C l i n i c a l G u i d e l i n e s

JOHN D. CHILDS, PT, PhD J05huA A. 6LLAN0, PT, PhD JAN5 N. LL|0II, PT, PhD 0Y0k 5. IYhN, PT, PhD
k08kI 5. wA|NNk, PT, PhD JuL| N. wh|INAN, PT, DSc 8kNAk0 J. 50PkY, MD
J05Ph J. 60065, DPT I|N0IhY w. FLYNN, PT, PhD
Neck Pain:
Clinical Practice Guidelines Linked to
the International Classication of
Functioning, Disability, and Health From
the Orthopaedic Section of the American
Physical Therapy Association
J Orthop Sports Phys Ther 2008;38(9):A1-A34. doi:10.2519/jospt.2008.0303
k|wk5: Anthony 0e|itto, PT, Ph0 Ceore V. 0yriW, 0PT Amanda ler|and, PT, le|ene learon, PT 1oy Vac0ermid, PT, Ph0
1ames \. Vatheson, 0PT Phi|ip VcC|ure, PT, Ph0 Pau| She|e||e, V0, Ph0 A. Russe|| Smith, 1r, PT, Ed0 les|ie Torburn, 0PT
lor author, coordinator, and revieWer aN|iations, see end ot tet. O2OO8 0rthopaedic Section American Physica| Therapy Association (APTA), lnc, and the 1ourna| ot
0rthopaedic Sports Physica| Therapy. The 0rthopaedic Section, APTA, lnc., and the 1ourna| ot 0rthopaedic Sports Physica| Therapy consent to the photocopyin ot
this uide|ine tor educationa| purposes. Address correspondence to. 1oseph 1. Codes, 0PT, lCl Practice Cuide|ines Coordinator, 0rthopaedic Section, APTA lnc., 292O
East Avenue South, Suite 2OO, la Crosse, \l 54GOI. Emai|. ict@orthopt.or
RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AZ
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4
CLINICAL GUIDELINES:
Impairment/Function-Based Diagnosis . . . . . . . . . . . . . . . . . . A9
CLINICAL GUIDELINES:
Examinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AI4
CLINICAL GUIDELINES:
Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AI9
SUMMARY OF RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AZ8
AUTHOR/REVIEWER AFFILIATIONS & CONTACTS . . . . . . . . . . AZ9
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A30
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a2 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
PAIh0ANAI0N|6AL FAIuk5: Although the cause of neck pain
may be associated with degenerative processes or pathology
identied during diagnostic imaging, the tissue that is causing
a patients neck pain is most often unknown. Thus, clinicians
should assess for impaired function of muscle, connective, and
nerve tissues associated with the identied pathological tissues
when a patient presents with neck pain. (Recommendation
based on theoretical/foundational evidence.)
k|5k FA6I0k5: 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 atti-
tude, poor quality of life, and less vitality as predisposing factors
for the development of chronic neck pain. (Recommendation
based on moderate evidence.)
0|A6N05|56LA55|F|6AI|0N: 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 ndings for classifying a
patient with neck pain into one of the following International
Statistical Classication of Diseases and Related Health Prob-
lems (ICD) categories: cervicalgia, pain in thoracic spine, head-
aches, cervicocranial syndrome, sprain and strain of cervical
spine, spondylosis with radiculopathy, and cervical disc disorder
with radiculopathy; and the associated International Classica-
tion of Functioning, Disability, and Health (ICF) impairment-
based category of neck pain with the following impairments of
body function:
Neck ain wilh mobiIily decils (b,1u1 MobiIily of
several joints)
Neck ain wilh headaches (28u1u Pain in head and neck)
Neck ain wilh movemenl coordinalion imairmenls
(b,6u1 ConlroI of comIex voIunlary movemenls)
Neck ain wilh radialing ain (b28u4 Radialing ain 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 decits and the associated ICD catego-
ries of cervicalgia or pain in thoracic spine. (Recommendation
based on moderate evidence.)
CervicaI aclive range of molion
CervicaI and lhoracic segmenlaI mobiIily
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.)
CervicaI aclive range of molion
CervicaI segmenlaI mobiIily
CraniaI cervicaI exion lesl
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.)
CraniaI cervicaI exion lesl
Dee neck exor endurance lesl
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.)
Uer Iimb lension lesl
SurIing`s lesl
Dislraclion lesl
0|FFkNI|AL 0|A6N05|5: Clinicians should consider diagnostic
classications associated with serious pathological conditions
or psychosocial factors when the patients reported activity
limitations or impairments of body function and structure are
not consistent with those presented in the diagnosis/classica-
tion section of this guideline, or, when the patients symptoms
are not resolving with interventions aimed at normalization of
the patients impairments of body function. (Recommendation
based on moderate evidence.)
XAN|NAI|0N - 0uI60N NA5uk5: Clinicians should use
validated self-report questionnaires, such as the Neck Disability
Index and the Patient-Specic Functional Scale for patients
with neck pain. These tools are useful for identifying a patients
baseline status relative to pain, function, and disability and for
monitoring a change in a patients status throughout the course
of treatment. (Recommendation based on strong evidence.)
XAN|NAI|0N - A6I||IY L|N|IAI|0N AN0 PAkI|6|PAI|0N k5Ik|6-
I|0N NA5uk5: Clinicians should utilize easily reproducible
activity limitation and participation restriction measures associ-
ated with their patients neck pain to assess the changes in the
patients level of function over the episode of care. (Recommen-
dation based on expert opinion.)
|NIkNI|0N5 - 6k|6AL N08|L|ZAI|0NNAN|PuLAI|0N:
Clinicians should consider utilizing cervical manipulation and
mobilization procedures, thrust and non-thrust, to reduce neck
pain and headache. Combining cervical manipulation and mo-
bilization with exercise is more efective for reducing neck pain,
headache, and disability than manipulation and mobilization
alone. (Recommendation based on strong evidence.)
|NIkNI|0N5 - Ih0kA6|6 N08|L|ZAI|0NNAN|PuLAI|0N:
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. (Recommen-
dation based on weak evidence.)
Recommendations*
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a3
A|N 0F Ih 6u|0L|N
The Orthopaedic Section of the American Physical Therapy As-
sociation (APTA) has an ongoing efort to create evidence-based
practice guidelines for orthopaedic physical therapy manage-
ment of patients with musculoskeletal impairments described
in the World Health Organizations International Classication
of Functioning, Disability, and Health (ICF).
86
The purposes of these clinical guidelines are to:
Describe evidence-based physical therapy practice including
diagnosis, prognosis, intervention, and assessment of outcome
for musculoskeletal disorders commonly managed by orthopae-
dic physical therapists
CIassify and dene common muscuIoskeIelaI condilions
using the World Health Organizations terminology related
to impairments of body function and body structure, activity
limitations, and participation restrictions
Idenlify inlervenlions suorled by currenl besl evidence lo
address impairments of body function and structure, activ-
ity limitations, and participation restrictions associated with
common musculoskeletal conditions
Idenlify aroriale oulcome measures lo assess changes
resulting from physical therapy interventions in body func-
tion and structure as well as in activity and participation of
the individual
Provide a descrilion lo oIicy makers, using inlernalionaIIy
accepted terminology, of the practice of orthopaedic physi-
cal therapists
Provide informalion for ayers and cIaims reviewers regard-
ing the practice of orthopaedic physical therapy for common
musculoskeletal conditions
Creale a reference ubIicalion for orlhoaedic hysicaI
therapy clinicians, academic instructors, clinical instructors,
students, interns, residents, and fellows regarding the best
current practice of orthopaedic physical therapy
5IAINNI 0F |NINI
This guideline is not intended to be construed or to serve as a
standard of medical care. Standards of care are determined on
the basis of all clinical data available for an individual patient
and are subject to change as scientic knowledge and technol-
ogy advance and patterns of care evolve. These parameters of
practice should be considered guidelines only. Adherence to
them will not ensure a successful outcome in every patient, nor
should they be construed as including all proper methods of care
or excluding other acceptable methods of care aimed at the same
results. The ultimate judgment regarding a particular clinical
procedure or treatment plan must be made in light of the clinical
data presented by the patient, the diagnostic and treatment op-
tions available, and the patients values, expectations, and prefer-
ences. However, we suggest that signicant departures from ac-
cepted guidelines should be documented in the patients medical
records at the time the relevant clinical decision is made.
Recommendations* (continued)
Introduction
|NIkNI|0N5 - 5IkI6h|N6 Xk6|55: Flexibility exercises
can be used for patients with neck symptoms. Examination
and largeled exibiIily exercises for lhe foIIowing muscIes are
suggested: anterior/medial/posterior scalenes, upper trapezius,
levator scapulae, pectoralis minor, and pectoralis major. (Rec-
ommendation based on weak evidence.)
|NIkNI|0N5 - 600k0|NAI|0N, 5IkN6IhN|N6, AN0 N0uk-
AN6 Xk6|55: Clinicians should consider the use of coor-
dination, strengthening, and endurance exercises to reduce
neck pain and headache. (Recommendation based on strong
evidence.)
|NIkNI|0N5 - 6NIkAL|ZAI|0N Pk060uk5 AN0 Xk6|55:
Specic repeated movements or procedures to promote cen-
tralization are not more benecial in reducing disability when
compared to other forms of interventions. (Recommendation
based on weak evidence.)
|NIkNI|0N5 - uPPk uAkIk AN0 Nk N08|L|ZAI|0N Pk0-
60uk5: 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.)
|NIkNI|0N5 - IkA6I|0N: 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 moder-
ate evidence.)
|NIkNI|0N5 - PAI|NI 0u6AI|0N AN0 60uN5L|N6: 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.)
`These recommendations and c|inica| practice uide|ines are based on the
scientihc |iterature pub|ished prior to 1une 2OO/.
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a4 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
Content experts were appointed by the Orthopaedic Section,
APTA as developers and authors of clinical practice guidelines
for musculoskeletal conditions of the cervical region that are
commonly treated by physical therapists. These content experts
were given the task to identify impairments of body function
and structure, activity limitations, and participation restric-
tions, described using ICF terminology, that could (1) categorize
patients into mutually exclusive impairment patterns upon
which to base intervention strategies, and (2) serve as measures
of changes in function over the course of an episode of care. The
second task given to the content experts was to describe inter-
ventions and supporting evidence for specic subsets of patients
based upon the previously chosen patient categories. It was also
acknowledged by the Orthopaedic Section, APTA content ex-
perts that a systematic search and review of the evidence solely
related to diagnostic categories based on International Statis-
tical Classication of Diseases and Health Related Problems
(ICD)
8,
terminology would not be useful for these ICF-based
clinical practice guidelines as most of the evidence associated
with changes in levels of impairment or function in homoge-
neous populations is not readily searchable using the ICD termi-
nology. Thus, the authors of this clinical practice guideline sys-
lemalicaIIy searched MEDLINE, CINAHL, and lhe Cochrane
Dalabase of Syslemalic Reviews (166 lhrough June 2uu,) for
any relevant articles related to classication, outcome measures,
and intervention strategies for musculoskeletal conditions of the
neck region commonly treated by physical therapists. Each con-
tent expert was assigned a specic subcategory (classication,
outcome measures, and intervention strategies for musculoskel-
etal conditions of the neck region) to search by the lead author
(JDC) based uon lheir secic area of exerlise. Two conlenl
experts were assigned to each subcategory and both individuals
performed a separate search, including but not limited to the
3 databases listed above, to identify articles to assure that no
studies of relevance were omitted. Additionally, when relevant
articles were identied, their reference lists were hand-searched
in an attempt to identify other articles that might have contrib-
uted to the outcome of these clinical practice guidelines.
This guideIine was issued in 2uu8 based uon ubIicalions in
lhe scienlic Iileralure rior lo June 2uu,. This guideIine wiII
be considered for review in 2012, or sooner if substantive new
evidence becomes available. Any updates to the guideline in the
interim period will be noted on the Orthopaedic Section of the
APTA website: www.orthopt.org
LL5 0F |0N6
Once the content experts of each subcategory had identied all
relevant articles, they independently graded each article accord-
ing lo crileria described by lhe Cenler for Evidence-Based Medi-
cine, Oxford, Uniled Kingdom (TabIe 1 beIow). If lhe 2 conlenl
experts did not agree on a grade of evidence for a particular
article, a third content expert was used to resolve the issue.
Methods
I
Evidence obtained trom hihqua|ity randomized contro||ed
tria|s, prospective studies, or dianostic studies
II
Evidence obtained trom |esserqua|ity randomized
contro||ed tria|s, prospective studies, or dianostic
studies (e, improper randomization, no b|indin, 8O%
to||oWup)
III Case contro||ed studies or retrospective studies
IV Case series
V
Epert opinion
6kA05 0F |0N6
The overall strength of the evidence supporting recom-
mendations made in this guideline will be graded accord-
ing to guidelines described by Guyatt et al,
,1
as modified by
MacDermid and adoled by lhe coordinalor and reviewers of
this project. In this modified system, the typical A, B, C, and
D grades of evidence have been modified to include the role
of consensus expert opinion and basic science research to
demonstrate biological or biomechanical plausibility (Table
2 below).
GRADES OF RECOMMENDATION STRENGTH OF EVIDENCE
A
Stron evidence A preponderance ot |eve| l and/or |eve|
ll studies support the recommendation.
This must inc|ude at |east I |eve| l study
B
Voderate evidence A sin|e hihqua|ity randomized con
tro||ed tria| or a preponderance ot |eve|
ll studies support the recommendation
C
\ea| evidence A sin|e |eve| ll study or a preponder
ance ot |eve| lll and lV studies inc|udin
statements ot consensus by content
eperts support the recommendation
D
Conhictin evidence liherqua|ity studies conducted on
this topic disaree With respect to their
conc|usions. The recommendation is
based on these conhictin studies
E
Theoretica|/
toundationa| evidence
A preponderance ot evidence trom
anima| or cadaver studies, trom
conceptua| mode|s/princip|es, or trom
basic sciences/bench research support
this conc|usion
F
Epert opinion Best practice based on the c|inica|
eperience ot the uide|ines deve|op
ment team
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a5
ICD-10 and ICF Codes Associated With Neck Pain
these clinical guidelines that provides a summary of symptoms,
impairment ndings, and matched interventions for each di-
agnostic category. This recommendation led the authors to add
Table 4 to these clinical guidelines.
6LA55|F|6AI|0N
The primary ICD-10 codes and conditions associated with neck
ain are: M4.2 CervicaIgia, M4.6 Pain in lhoracic sine, R1
Headache, M3.u CervicocraniaI syndrome, S13.4 Srain and
slrain of cervicaI sine, M4,.2 SondyIosis wilh radicuIoalhy,
and Mu.1 CervicaI disc disorder wilh radicuIoalhy.
8,
The
corresonding ICD- CM codes and condilions, which are used
in lhe USA, are ,23.1 CervicaIgia, ,24.1 Pain in lhoracic sine,
,84.u Headache, ,23.2 CervicocraniaI syndrome, 84,.u Srains
and slrains of lhe neck, and ,23.4 BrachiaI neurilis or radicu-
litis, not otherwise specied (Cervical radiculitis/Radicular
syndrome of upper limbs).
The primary ICF body function codes associated with the above
noted ICD-10 conditions are the sensory functions related to
pain and the movement functions related to joint motion and
control of voluntary movements. These body function codes are
b7I0I Nob|||ty oI severz| jo|ots, bZ80I0 Pz|o |o hezd zod oeck, b760I
6ootro| oI comp|ex vo|uotzry movemeots, zod bZ803 kzd|zt|og pz|o |o
z dermztome.
The primary ICF body structure codes associated with neck
pain are s7I03 Jo|ots oI hezd zod oeck reg|oo, s7I04 Nusc|es oI hezd
zod oeck reg|oo, s7I05 L|gzmeots zod Izsc|ze oI hezd zod oeck reg|oo,
s76000 6erv|cz| vertebrz| co|umo, zod sIZ0I 5p|oz| oerves.
The primary ICF activities and participation codes associated
with neck pain are d4I08 6hzog|og z bzs|c body pos|t|oo, d4I58
Nz|otz|o|og z body pos|t|oo, zod d445Z kezch|og.
The ICD-10 and primary and secondary ICF codes associated
with neck pain are provided in Table 3 (below).
k|w Pk0655
The Orthopaedic Section, APTA also selected consultants from
the following areas to serve as reviewers of the early drafts of
this clinical practice guideline:
CIaims review
Coding
EidemioIogy
MedicaI raclice guideIines
Orlhoaedic hysicaI lheray residency educalion
PhysicaI lheray academic educalion
Sorls hysicaI lheray residency educalion
Comments from these reviewers were utilized by the authors
to edit this clinical practice guideline prior to submitting it for
ubIicalion lo lhe JournaI of Orlhoaedic & Sorls PhysicaI
Therapy
In addition, several physical therapists practicing in orthopae-
dic and sports physical therapy settings were sent initial drafts
of this clinical practice guideline along with feedback forms
to determine its usefulness, validity, and impact. All returned
feedback forms from these practicing clinicians described this
clinical practice guideline as:
ModeraleIy usefuI" or exlremeIy usefuI"
An accurale reresenlalion of lhe eer-reviewed
Iileralure"
A guideIine lhal wiII have a subslanliaI osilive imacl on
orlhoaedic hysicaI lheray alienl care"
However, several reviewers noted that preliminary drafts of
this clinical guideline did not clearly link data gathered during
the patients subjective and physical examinations to diagnos-
tic classication and intervention. To assist in clarifying these
links, it was recommended that the authors add a table to
Methods (continued)
INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS
Neck Pz|o w|th Nob|||ty 0ehc|ts
Primary ICD-10 V54.2
V54.G
Cervica|ia
Pain in thoracic spine
Neck Pz|o w|th hezdzches
Primary ICD-10 R5I
V5J.O
leadache
Cervicocrania| syndrome
Neck Pz|o w|th Novemeot 6oord|ozt|oo |mpz|rmeots
Primary ICD-10 SIJ.4 Sprain and strain ot cervica| spine
Neck Pz|o w|th kzd|zt|og Pz|o
Primary ICD-10 V4/.2
V5O.I
Spondy|osis With radicu|opathy
Cervica| disc disorder With radicu|opathy
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a6 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH
PRIMARY ICF CODES
Neck Pz|o w|th Nob|||ty 0ehc|ts
Body functions b/IOI Vobi|ity ot severa| joints
Body structure s/GOOO Cervica| vertebra| co|umn
Activities and participation d4IO8 Chanin a basic body position, specihed as movin the head and nec| Whi|e |oo|
in to the |ett or to the riht
Neck Pz|o w|th hezdzches
Body functions b28OIO Pain in head and nec|
Body structure s/IOJ
s/IO4
1oints ot head and nec| reion
Vusc|es ot head and nec| reion
Activities and participation d4I58 Vaintainin a body position, specihed as maintainin the head in a heed position,
such as When readin a boo|, or, maintainin the head in an etended position, such
as When |oo|in up at a video monitor
Neck Pz|o w|th Novemeot 6oord|ozt|oo |mpz|rmeots
Body functions b/GOI Contro| ot comp|e vo|untary movements
Body structure s/IO5 liaments and tasciae ot head and nec| reion
Activities and participation d4I58 Vaintainin a body position, specihed as maintainin a|inment ot the head, nec|, and tho
ra such that the cervica| vertebra| sements tunction in a neutra|, or midrane, position
Neck Pz|o w|th kzd|zt|og Pz|o
Body functions b28O4 Radiatin pain in a sement or reion
Body structure sI2OI Spina| nerves
Activities and participation d4452 Reachin
SECONDARY ICF CODES
Neck Pz|o w|th Nob|||ty 0ehc|ts
Body functions b28OIO
b28OIJ
b28OI4
b/IOI
b/I5I
b/JO5
b/J5O
b/4OO
b/GOI
Pain in head and nec|
Pain in bac|
Pain in upper |imb
Vobi|ity ot severa| joints
Stabi|ity ot severa| joints
PoWer ot musc|es ot the trun|
Tone ot iso|ated musc|es and musc|e roups
Endurance ot iso|ated musc|es
Contro| ot comp|e vo|untary movements
Body structure sI2OOI
sIJO
s/IOJ
s/IO4
s/IO5
s/GOOO
s/GOOI
s/GOI
s/GO2
Thoracic spina| cord
Structure ot menines
1oints ot head and nec| reion
Vusc|es ot head and nec| reion
liaments and tasciae ot head and nec| reion
Cervica| vertebra| co|umn
Thoracic vertebra| co|umn
Vusc|es ot trun|
liaments and tasciae ot trun|
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a7
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED)
Activities and participation d2JO2
d24OO
d4IOO
d4IO5
d4I5O
d4/5O
Comp|etin the dai|y routine
land|in responsibi|ities
lyin doWn
Bendin
Vaintainin a |yin position
0rivin humanpoWered transportation
d4/5I
d4/52
d4554
dG4O9
d9IO9
d92O9
0rivin motorized vehic|es
0rivin anima|poWered transportation
SWimmin
0oin houseWor|, unspecihed
Community |ite, unspecihed
Recreation and |eisure, unspecihed
Neck Pz|o w|th hezdzches
Body functions b28OJ
b28O4
b/IOI
b/I5I
b/JO5
b/J5O
b/4OO
b/GOI
b2J59
b24O9
Radiatin pain in a dermatome
Radiatin pain in a sement or reion
Vobi|ity ot severa| joints
Stabi|ity ot severa| joints
PoWer ot musc|es ot the trun|
Tone ot iso|ated musc|es and musc|e roups
Endurance ot iso|ated musc|es
Contro| ot comp|e vo|untary movements
Vestibu|ar tunctions, unspecihed
Sensations associated With hearin and vestibu|ar tunction, unspecihed
Body structure sI2OOO
sI2OOI
sI2OI
sIJO
s/IO5
s/GOOI
s/GOOO
s/GOI
Cervica| spina| cord
Thoracic spina| cord
Spina| nerves
Structure ot menines
liaments and tasciae ot head and nec| reion
Thoracic vertebra| co|umn
Cervica| vertebra| co|umn
Vusc|es ot trun|
Activities and participation dIGJ
dIGG
d2JO2
d24OO
d4I5O
d4I5J
d4I54
d4/5O
d4/5I
d4/52
dG4O9
d9IO9
d92O9
Thin|in
Readin
Comp|etin the dai|y routine
land|in responsibi|ities
Vaintainin a |yin position
Vaintainin a sittin position
Vaintainin a standin position
0rivin humanpoWered transportation
0rivin motorized vehic|es
0rivin anima|poWered transportation
0oin houseWor|, unspecihed
Community |ite, unspecihed
Recreation and |eisure, unspecihed
Neck Pz|o w|th Novemeot 6oord|ozt|oo |mpz|rmeots
Body functions b28OIO
b28OIJ
b28OI4
b/I5I
b/JO5
b/4OO
b/GO2
Pain in head and nec|
Pain in bac|
Pain in upper |imb
Stabi|ity ot severa| joints
PoWer ot musc|es ot the trun|
Endurance ot iso|ated musc|es
Coordination ot vo|untary movements
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a8 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED)
Body structure s/IOJ
s/IO4
s/GOOO
s/GOOI
s/GOI
s/GO2
1oints ot head and nec| reion
Vusc|es ot head and nec| reion
Cervica| vertebra| co|umn
Thoracic vertebra| co|umn
Vusc|es ot trun|
liaments and tasciae ot trun|
Activities and participation d2JO2
d24OO
d4IO5
d4I5J
d4I54
d4/5O
d4/5I
d4/52
dG4O9
d9IO9
d92O9
Comp|etin the dai|y routine
land|in responsibi|ities
Bendin
Vaintainin a sittin position
Vaintainin a standin position
0rivin humanpoWered transportation
0rivin motorized vehic|es
0rivin anima|poWered transportation
0oin houseWor|, unspecihed
Community |ite, unspecihed
Recreation and |eisure, unspecihed
Neck Pz|o w|th kzd|zt|og Pz|o
Body functions b28OIJ
b28OI4
b28OJ
b/IOI
b/I5I
b/JO5
b/J5O
b/4OO
b/GOI
Pain in bac|
Pain in upper |imb
Radiatin pain in a dermatome
Vobi|ity ot severa| joints
Stabi|ity ot severa| joints
PoWer ot musc|es ot the trun|
Tone ot iso|ated musc|es and musc|e roups
Endurance ot iso|ated musc|es
Contro| ot comp|e vo|untary movements
Body structure sI2OOO
sI2OOI
sI2OI
sIJO
s/IO5
s/GOOO
s/GOOI
s/GOI
s/GO2
Cervica| spina| cord
Thoracic spina| cord
Spina| nerves
Structure ot menines
liaments and tasciae ot head and nec| reion
Cervica| vertebra| co|umn
Thoracic vertebra| co|umn
Vusc|es ot trun|
liaments and tasciae ot trun|
Activities and participation d2JO2
d24OO
d4I5O
d4I5J
d4I54
d4JOO
d4JOI
d4JO2
d4JOJ
d4JO4
d4JO5
d4/5O
d4/5I
d4/52
dG4O9
d9IO9
d92O9
Comp|etin the dai|y routine
land|in responsibi|ities
Vaintainin a |yin position
Vaintainin a sittin position
Vaintainin a standin position
littin
Carryin in the hands
Carryin in the arms
Carryin on shou|ders, hip, and bac|
Carryin on the head
Puttin doWn objects
0rivin humanpoWered transportation
0rivin motorized vehic|es
0rivin anima|poWered transportation
0oin houseWor|, unspecihed
Community |ite, unspecihed
Recreation and |eisure, unspecihed
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a9
PkALN6
Pain and impairment of the neck is common. It is esti-
maled lhal 22% lo ,u% of lhe ouIalion wiII have neck ain
some time in their lives.
1,2u,42,43,,11,12
In addition, it has been
suggested that the incidence of neck pain is increasing.
126,181
At any given time, 10% to 20% of the population reports neck
problems,
1,44,,8,16,
wilh 4% of individuaIs having exerienced
neck ain wilhin lhe Iasl 6 monlhs.
42
Prevalence of neck pain
increases with age and is most common in women around the
fth decade of life.
4,1,46,116,163
Although the natural history of neck pain appears to be fa-
vorable,
1,2
rates of recurrence and chronicity are high.
1,81
One study reported that 30% of patients with neck pain
will develop chronic symptoms, with neck pain of greater
lhan 6 monlhs duralion aecling 14% of aII individuaIs who
experience an episode of neck pain.
19
Additionally, a recent
survey demonslraled lhal 3,% of individuaIs who exeri-
ence neck pain will report persistent problems for at least
12 months.
44
Five percent of the adult population with neck
pain will be disabled by the pain, representing a serious
health concern.
1,88
In a survey of workers with injuries to
the neck and upper extremity, Pransky et al
13
reported that
42% missed more lhan 1 week of work and 26% exerienced
recurrence within 1 year. The economic burden due to dis-
orders of the neck is high, and includes costs of treatment,
lost wages, and compensation expenditures.
16,138
Neck pain is
second only to low back pain in annual workers compensa-
lion cosls in lhe Uniled Slales.
181
In Sweden, neck and shoul-
der robIems accounl for 18% of aII disabiIily aymenls.
126
Jelle el aI
91
reported that patients with neck pain make up
aroximaleIy 2% of alienls receiving oulalienl hysi-
cal therapy. Additionally, patients with neck pain frequently
are treated without surgery by primary care and physical
therapy providers.
1,,1,2
PAIh0ANAI0N|6AL FAIuk5
A variety of causes of neck pain have been described
and include osteoarthritis, discogenic disorders, trauma, tu-
mors, infection, myofascial pain syndrome, torticollis, and
whiplash.
121
UnforlunaleIy, cIearIy dened diagnoslic crileria
have not been established for many of these entities. Similar
to low back pain, a pathoanatomical cause is not identiable
in the majority of patients who present with complaints of
neck pain and neck related symptoms of the upper quarter.
1
Therefore, once serious medical pathology (such as cervical
fracture or myelopathy) has been ruled out, patients with
neck pain are often classied as having either a nerve root
comromise or a mechanicaI neck disorder."
In some conditions, particularly those that are de-
generative in nature or involve abnormalities of the
vertebral motion segment, abnormal ndings are
not always associated with symloms. Iourleen lo 18% of
people without neck pain demonstrate a wide range of ab-
normalities with imaging studies, including disc protrusion
or extrusion and impingement of the thecal sac on the nerve
root and spinal cord.
12
However, degenerative changes are
still suggested to be a possible cause of mechanical neck pain
in some cases,
109,130,131
despite the fact that these changes are
present in asymptomatic individuals, are non-specic, and
are highly prevalent in the elderly.
168
Disorders such as cervi-
cal radiculopathy and cervical compressive myelopathy are
reported to be caused by space-occupying lesions (osteophy-
tosis or herniated cervical disc). These may be secondary to
degenerative processes and can give rise to neck and/or up-
per quarter pain as well as neurologic signs and symptoms.
136
While cervical disc herniation and spondylosis are most com-
monly linked to cervical radiculopathy and myelopathy,
1u,136
the bony and ligamentous tissues afected 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.
13,40
Because most patients with neck pain usually lack
an identiable pathoanatomic cause for their prob-
lem, the majority are classied as having mechani-
cal neck disorders.
82
Although the cause of neck pain may be associ-
ated with degenerative processes or pathology
identified during diagnostic imaging, the tissue
that is causing a patients neck pain is most often un-
known. Thus, clinicians should assess for impaired func-
tion of muscle, connective, and nerve tissues associated
with the identified pathological tissues when a patient
presents with neck pain.
CLINICAL GUIDELINES
Impairment/Function-based
Diagnosis
II
II
E
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a10 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
k|5k FA6I0k5
Bot and colleagues
18
investigated the clini-
cal course and predictors of recovery for patients
with neck and shoulder pain. 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 recov-
ered. 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.
Hill and colleagues
,6
investigated the course of
neck pain in an adult population over a 12 month
period. Signicant baseline characteristics, which
redicled ersislenl neck ain were age (4- years), being
of work at the time of the baseline survey (odds ratio [OR]
= 1.6), comorbid Iow back ain (OR = 1.6), and bicycIing as a
regular activity (OR = 2.4).
In a prospective cohort study, Hoving et al
8u
ex-
amined the predictors of outcome in a patient
ouIalion wilh neck ain. A lolaI of 183 alienls
arlicialed in lhe sludy of which 63% had imroved al a
12-month follow-up. In the short term, older age (40),
concomitant low back pain, and headache were associated
with poor outcome. In the long-term, in addition to age and
concomitant low back pain, previous trauma, a long dura-
tion of neck pain, stable neck pain during the 2 weeks prior
to baseline measurement, and previous neck pain predicted
poor prognosis.
Clinicians should consider age greater than 40, co-
existing 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 vital-
ity as predisposing factors for the development of chronic
neck pain.
6L|N|6AL 60uk5
Approximately 44% of patients experiencing neck pain
will go on to develop chronic symptoms,
1
and many will con-
tinue to exhibit moderate disability at long-term follow-up.
66
A recent systematic review examined the outcomes of non-
treatment control groups in clinical trials for the conserva-
tive management of chronic mechanical neck pain - not due
to whiplash.
1,1
The outcomes of patients receiving a control
or placebo intervention were analyzed and efect 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 signicant.
1,1
Conversely, there is substantial evidence that favorable out-
comes are attained following treatment of patients with cer-
vical radiculopathy.
,,136
For example, Radhakrishnan and
colleagues
136
reported that nearly 90% of patients with cer-
vical radiculopathy presented with only mild symptoms at a
median follow-up of 4.9 years. Honet and Puri
,
found that
,u% of alienls wilh cervicaI radicuIoalhy exhibiled good or
excellent outcomes after a 2-year follow-up. Outcomes for the
patients in the aforementioned studies
,,136
appeared favor-
abIe and suggesl lhal ,u-u% of lhis ouIalion can exeri-
ence improvement without surgical intervention. In contrast,
the clinical prognosis of patients with whiplash-associated
disorder is Iess favorabIe. A survey of 1u8 alienls wilh a his-
tory of whiplash requiring care at an emergency department
found lhal % had residuaI ain]disabiIily referabIe lo lhe
originaI accidenl al a mean foIIow-u of 1, years Ialer. Neck
pain, radiating pain, and headache were the most common
symptoms. Thirty-three percent of the respondents with re-
sidual symptoms sufered from work disability, compared to
6% in lhe grou of alienls wilhoul residuaI disorders.
2
0|A6N05|56LA55|F|6AI|0N
Strategies for the classication of patients
with neck pain have been recently proposed by
Wang et al,
1,,
Childs et al,
2,
and Fritz and Bren-
nan.
62
The underlying premise is that classifying patients
into groups based on clinical characteristics and matching
these patient subgroups to management strategies likely to
benet them will improve the outcome of physical therapy
interventions.
2,
The classication system described by Wang
et al
1,,
categorized patients into 1 of 4 subgroups based on
the area of symptoms and the presumed source of the symp-
toms. The labels of these 4 categories were neck pain only,
headaches, referred arm pain and neck pain, and radicular
arm pain and neck pain. Distinct treatment approaches were
linked to each of the 4 categories. Wang et al
1,,
reported the
results of 30 patients treated using this classication strat-
egy as weII as 2, alienls who were nol lrealed. SlalislicaIIy
and clinically signicant reductions in pain and disability
were reported for the classication group only.
1,,
It is dif-
cult to draw conclusions regarding the potential usefulness
of the Wang et al
1,,
classication system because patients in
lhe conlroI grou were nol lrealed, which is nol reeclive of
physical therapy practice. The classication system described
by Childs et al
2,
and Fritz and Brennan
62
uses information
from the history and physical examination to place patients
inlo 1 of searale lrealmenl subgrous. The IabeIs of lhese
subgrous, which are mobiIily, cenlraIizalion, exercise and
II
II
II
B
III
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a11
conditioning, pain control, and headache, intend to capture
the primary focus or goal of treatment. Fritz and Brennan,
62
uliIizing a roseclive, observalionaI sludy of 2,4 alienls,
reported that patients who received interventions matched
with their treatment subgroup had better outcomes than pa-
tients who received interventions that were not matched with
their subgroup. The classication system described in this
practice guideline linked to the ICF, parallels the Childs et al
2,
and Fritz and Brennan
62
classication with 2 noteworthy dif-
ferences. The rst diference is that the labels in this clinical
practice guideline incorporate the following ICF impairments
of body functions terminology: Neck pain with mobility de-
cits, neck pain with headaches, neck pain with movement co-
ordination impairments, and neck pain with radiating pain.
The second diference is that Fritz and Brennans
62
ain con-
lroI" calegory, which was Iinked lo mobiIizalion and range
of motion exercises following an acute cervical sprain, was
divided inlo lhe neck ain wilh movemenl coordinalion im-
airmenls," and neck ain wilh mobiIily decils" calegories,
where the patient would receive interventions linked to the
most relevant impairment(s) exhibited at a given period dur-
ing the patients episode of care.
The ICD diagnosis of cervicalgia, or pain in thoracic
spine and the associated ICF diagnosis of neck pain
with mobility decits is made with a reasonable lev-
el of certainty when the patient presents with the following
clinical ndings
33,62,82,166
:
Younger individuaI (age <u years)
Acule neck ain (duralion <12 weeks)
Symloms isoIaled lo lhe neck
Reslricled cervicaI range of molion
The ICD diagnosis of headaches, or cervicocranial
syndrome and the associated ICF diagnosis of neck
pain with headaches is made with a reasonable lev-
el of certainty when the patient presents with the following
clinical ndings
6,62,,18
:
UniIaleraI headache associaled wilh neck]subocciilaI
area symptoms that are aggravated by neck movements or
positions
Headache roduced or aggravaled wilh rovocalion of lhe
ipsilateral posterior cervical myofascia and joints
Reslricled cervicaI range of molion
Reslricled cervicaI segmenlaI mobiIily
AbnormaI]subslandard erformance on lhe craniaI cervi-
caI exion lesl
The ICD diagnosis of sprain and strain of cervical
spine and the associated ICF diagnosis of neck pain
with movement coordination impairments is made
with a reasonable level of certainty when the patient presents
with the following clinical ndings
22,2,14,162,182,184
:
Longslanding neck ain (duralion >12 weeks)
AbnormaI]subslandard erformance on lhe craniaI cervi-
caI exion lesl
AbnormaI]subslandard erformance on lhe dee exor
endurance test
Coordinalion, slrenglh, and endurance decils of neck
and upper quarter muscles (longus colli, middle trapezius,
lower trapezius, serratus anterior)
IIexibiIily decils of uer quarler muscIes (anlerior]mid-
dle/posterior scalenes, upper trapezius, levator scapulae,
pectoralis minor, pectoralis major)
Ergonomic ineciencies wilh erforming reelilive
activities
The ICD diagnosis of spondylosis with radiculopa-
thy or cervical disc disorder with radiculopathy and
the associated ICF diagnosis of neck pain with radi-
ating pain is made with a reasonable level of certainty when
the patient presents with the following clinical ndings
1,
:
Uer exlremily symloms, usuaIIy radicuIar or referred
pain, that are produced or aggravated with Spurlings ma-
neuver and upper limb tension tests, and reduced with the
neck distraction test
Decreased cervicaI rolalion (<6u) loward lhe invoIved
side
Signs of nerve rool comression
Success wilh reducing uer exlremily symloms wilh ini-
tial examination and intervention procedures
Neck pain, without symptoms or signs of serious
medical or psychological conditions, associated
with (1) motion limitations in the cervical and up-
per thoracic regions, (2) headaches, and (3) referred or radi-
ating pain into an upper extremity are useful clinical ndings
for classifying a patient with neck pain into the following In-
ternational Statistical Classication of Diseases and Related
Health Problems (ICD) categories: cervicalgia, pain in tho-
racic spine, headaches, cervicocranial syndrome, sprain and
strain of cervical spine, spondylosis with radiculopathy, and
cervical disc disorder with radiculopathy; and the associated
International Classication of Functioning, Disability, and
Health (ICF) impairment-based category of neck pain with
the following impairments of body function:
Neck ain wilh mobiIily decils (b,1u1 MobiIily of severaI
joints)
Neck ain wilh headaches (28u1u Pain in head and neck)
Neck ain wilh movemenl coordinalion imairmenls
(b,6u1 ConlroI of comIex voIunlary movemenls)
Neck ain wilh radialing ain (b28u4 Radialing ain in a
segment or region)
The following physical examination measures may be useful
in classifying a patient in the ICF impairment-based category
II
II
B
I
I
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a12 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
of neck pain with mobility decits and the associated ICD
categories of cervicalgia or pain in thoracic spine:
CervicaI aclive range of molion
CervicaI and lhoracic segmenlaI mobiIily
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 catego-
ries of headaches or cervicocranial syndrome:
CervicaI aclive range of molion
CervicaI segmenlaI mobiIily
CraniaI cervicaI exion lesl
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:
CraniaI cervicaI exion lesl
Dee neck exor endurance
The following physical examination measures may be useful
in classifying a patient in the ICF impairment-based catego-
ry of neck pain with radiating pain and the associated ICD
categories of spondylosis with radiculopathy or cervical disc
disorder with radiculopathy:
Uer Iimb lension lesl
SurIing`s lesl
Dislraclion lesl
0|FFkNI|AL 0|A6N05|5
A primary goal of diagnosis is to match the pa-
tients clinical presentation with the most efcacious
treatment approach. A component of this decision
is determining whether the patient is, in fact, appropriate for
physical therapy management. In the vast majority of patients
with neck pain, symptoms can be attributed to mechanical
factors. However, in a much smaller percentage of patients,
the cause of neck pain may be something more serious, such as
cervical myelopathy, cervical instability,
49
fracture,
,,
neoplastic
conditions,
u,14u,12,14
vascular compromise,
11
or systemic dis-
ease.
8,24
Clinicians must be aware of the key signs and symp-
toms associated with serious pathological neck conditions,
continually screen for the presence of these conditions, and
initiate referral to the appropriate medical practitioner when
a potentially serious medical condition is suspected.
When a patient with neck pain reports a history of
trauma, the therapist needs to be particularly alert
for the presence of cervical instability, spinal frac-
ture, and the presence of or potential for spinal cord or brain
stem injury. A clinical prediction rule has been developed to
assist clinicians in determining when to order radiographs in
individuals who have experienced trauma.
1
In addition to medical conditions, clinicians should
be aware of psychosocial factors that may be con-
tributing to a patients persistent pain and dis-
ability, or that may contribute to the transition of an acute
condition to a chronic, disabling condition. Researchers have
recently shown that psychosocial factors are an important
prognostic indicator of prolonged disability.
63,64,114,1u
When
relevant psychosocial factors are identied, the rehabilitation
approach may need to be modied to emphasize active reha-
bilitation, graded exercise programs, positive reinforcement
of functional accomplishments, and/or graduated exposure
to specic activities that a patient fears as potentially painful
or difcult to perform.
6
Clinicians should consider diagnostic classications
associated with serious pathological conditions or
psychosocial factors when the patients reported ac-
tivity limitations or impairments of body function and struc-
ture are not consistent with those presented in the diagnosis/
classication section of this guideline, or, when the patients
symptoms are not resolving with interventions aimed at nor-
malization of the patients impairments of body function.
|NA6|N6 5Iu0|5
Adults with cervical pain precipitated by trauma
should be classied as low risk or high risk based on the Ca-
nadian Cervical Spine Rule (CCR) for radiography in alert
and stable trauma patients
1
and the 2001 American College
of Radiology (ACR) suspected Spine Trauma Appropriate-
ness Criteria.
3
According to the CCR, patients who (1) are
able to sit in the emergency department; or (2) have had a
simple rear-end motor vehicle collision; or (3) are ambula-
tory at any time; or (4) have had a delayed onset of neck pain;
or () do nol have midIine cervicaI sine lenderness; and (6)
are abIe lo acliveIy rolale lheir head 4 in each direclion, are
classied as low risk. Those who are classied as low risk do
not require imaging for acute conditions. Patients who are
(1) grealer lhan 6 years of age; or (2) have had a dangerous
mechanism of injury; or (3) have paresthesias in the extremi-
ties, are classied as high risk.
1
Those classied as high risk
should undergo cervical radiography.
,4,
There is a paucity of available literature regarding the pediat-
ric population to help guide decision making on the need for
imaging. Adult risk classication features should be applied
in children greater than age 14. Due to the added radiation
exposure of computed tomography the ACR recommends
Iain radiograhy (3 views) in lhose under 16 years of age
regardless of mental status.
3
III
I
II
B
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a13
There is no consensus for routine investigation of patients with
chronic neck pain with imaging beyond plain radiographs.
3,48
Routine use of ultrasonography, CT, and magnetic resonance
imaging (MRI) in alienls wilhoul neuroIogic insuIl or olher
disease has not been justied in view of the infrequency of
abnormalities detected, the lack of prognostic value, inacces-
sibility, and the high cost of the procedures.
14,,3,11,133,141,146,1,4
A
major limitation is the lack of specic ndings in patients
with neck disorder and no denite correlation between the
patients subjective symptoms and abnormal ndings seen on
imaging studies. As a result, debate continues as to whether
persistent pain is attributable to structural pathology or to
other underlying causes.
RecenlIy, Krisljansson
111
compared sagittal plane, rotational,
and translational cervical segmental motion in women with
(1) persistent whiplash-associated disorder (WAD) (grades I
and II), (2) persistent non-traumatic, insidious onset of neck
pain, and (3) normal values of rotational and translational
molion. LaleraI radiograhic anaIysis reveaIed signicanlIy
increased rolalionaI molion al C3-4 and C4- for individu-
als in the WAD and insidious groups, signicantly excessive
translational motion at C3-4 for individuals in the WAD and
insidious groups, and signicantly excessive translational
molion al C-6 for individuaIs in lhe WAD grou when com-
pared to normal subjects.
UIlrasonograhy has been used lo accuraleIy measure lhe
size of the cervical multidus muscle at the C4 level in as-
ymptomatic female subjects. For those with chronic WAD,
ultrasonography did not accurately measure the cervical
multidus because the fascial borders of the multidus were
largely indistinguishable, indicating possible pathological
conditions.
110
High resoIulion rolon densily-weighled MRI has recenlIy
demonstrated abnormal signal intensity (indicative of tissue
damage) in both the alar and transverse ligaments in some
subjects with chronic WAD.
1u8
Laler foIIow-u sludies indi-
cated a strong relationship between alar ligament damage,
head position (turned) at time of impact, and disability levels
(as measured with the Neck Disability Index).
1u1,1u2,1u,
Elliott et al
3
have demonslraled lhal femaIe alienls (18-4
years oId) wilh ersislenl WAD (grade II) show MRI changes
in the fat content of the cervical extensor musculature that
were not present in subjects with chronic insidious onset neck
pain or healthy controls. It is currently unclear whether the
patterns of fatty inltration are the result of local structural
lrauma causing a generaI inammalory resonse, a secic
nerve injury or insult, or a generalized disuse phenomenon.
Further, as the muscular changes were observed in the chron-
ic state, it is not yet known whether they occur uniformly in
all people who have sustained whiplash injury irrespective
of recovery or are unique to only those who develop chronic
symptoms.
In addition to fatty inltration, Elliott et al
4
have identied
changes in the relative cross-sectional area (rCSA) of the cer-
vical paraspinal musculature in patients with chronic WAD
relative to control subjects with no history of neck pain. Spe-
cically, the WAD group demonstrated a consistent pattern
of larger rCSA in the multidii muscles at each segment (C3-
C,). Inference can be drawn lhal lhe larger rCSAs recorded
in the multidii muscles of those with chronic WAD are the
result of larger amounts of fatty inltrate.
In summary, imaging studies often fail to identify any
structural pathology related to symptoms in patients with
neck disorder and in particular, whiplash injury. How-
ever, emerging evidence into upper cervical ligamentous
disruption, altered segmental motion, and muscular de-
generation has been demonstrated with radiographs, ul-
lrasonograhy, and MRI sludies. Il remains unknown if
(1) these ndings are unique to chronic WAD; (2) whether
they relate to patients physical signs and symptoms, and
(3) whether specic physical therapy intervention can alter
such degeneration. Such knowledge may ofer prognostic
information and provide the foundation for interventional
based studies.
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a14 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
0uI60N NA5uk5
The Neck Disability Index (NDI) is a commonly
utilized outcome measure to capture perceived dis-
ability in patients with neck pain.
134
The NDI con-
lains 1u ilems, , reIaled lo aclivilies of daiIy Iiving, 2 reIaled
to pain, and 1 related to concentration.
1,2
Each item is scored
from u- and lhe lolaI score is exressed as a ercenlage, wilh
higher scores corresponding to greater disability. Riddle and
Stratford
139
identied a signicant association between the
NDI and both the physical and mental health components
of lhe SI-36. The aulhors aIso idenlied lhal lhe NDI os-
sesses adequate sensitivity as compared to the magnitude of
change that occurred for patients reaching their functional
goals, work status, and if the patient was currently in litiga-
tion.
139
Jelle and Jelle
92
further substantiated the sensitivity
to change by calculating the efect sizes for change scores of
bolh lhe NDI and SI-36.
Two studies
161,1,
with small sample sizes have identied the
minimal detectable change, or the amount of change that
must be observed before the change can be considered to
exceed the measurement error, for the NDI. Westaway
1,
idenlied lhe minimaI deleclabIe change as (1u ercenlage
points) in a group of 31 patients with neck pain. Stratford
and colleagues
161
identied the minimal detectable change
aIso lo be (1u ercenlage oinls) in a grou of 48 alienls
with neck pain. However, the minimum clinically important
diference, the smallest diference which patients perceive as
benecial, may be more useful to clinicians.
8
Stratford and
colleagues
161
identied the minimal clinically important dif-
ference as oinls (1u ercenlage oinls). More recenlIy,
Cleland and colleagues,
3
described the minimum clinically
imorlanl dierence for lhe NDI lo be . (1 ercenlage
points) for patients with mechanical neck disorders.
The NDI has demonstrated moderate test re-test reliability
and has been shown to be a valid health outcome measure
in a patient population with cervical radiculopathy.
3,
In this
group, the intraclass correlation coefcient (ICC) for test re-
lesl reIiabiIily was u.68 for lhe NDI and lhe minimum cIini-
caIIy imorlanl dierence was , (14 ercenlage oinls).
3,
The Patient-Specic Functional Scale (PSFS) is a
practical alternative or supplement to generic and
condition-specic measures.
1,
The PSFS asks pa-
tients to list 3 activities that are difcult as a result of their
symptoms, injury, or disorder. The patient rates each activity
on a 0-10 scale, with 0 representing the inability to perform
the activity, and 10 representing the ability to perform the ac-
tivity as well as they could prior to the onset of symptoms.
16u
The nal PSFS score is the average of the 3 activity scores.
The PSFS was developed by Stratford et al
16u
in an attempt
to present a standardized measure for recording a patients
perceived level of disability across a variety of conditions.
The PSFS has been evaluated for reliability and validity in
patients with neck pain.
1,
The ICC value for test retest reli-
abiIily in alienls wilh cervicaI radicuIoalhy was u.82.
3,
The
minimal detectable change in that population was identied
to be 2.1 points with a minimum clinically important difer-
ence of 2.0.
3,
Clinicians should use validated self-report ques-
tionnaires, such as the Neck Disability Index and
the Patient-Specic Functional Scale for patients
with neck pain. These tools are useful for identifying a pa-
tients baseline status relative to pain, function, and disability
and for monitoring a change in patients status throughout
the course of treatment.
A6I||IY L|N|IAI|0N AN0 PAkI|6|PAI|0N k5Ik|6-
I|0N NA5uk5
There are no activity limitation and partici-
pation restriction measures specically reported in
the literature associated with neck pain - other than
those that are part of the self-report questionnaire noted in
lhis guideIine`s seclion on Oulcome Measures. However, lhe
following measures are options that a clinician may use to
assess changes in a patients level of function over an episode
of care.
Pain IeveI al end ranges of Iooking over shouIder
Pain IeveI al end ranges of Iooking down
Pain IeveI al end ranges of Iooking u
Pain IeveI afler silling for 2 hours
Number of limes er nighl lhal ain disruls sIee
Deskwork loIerance (in number of minules or hours)
Percenl of lime exeriencing neck ain over lhe revious
24 hours
Percenl of lime exeriencing headache(s) over lhe revi-
ous month
CLINICAL GUIDELINES
Examination
I
I
A
V
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a15
In addition, the Patient-Specific Functional Scale is a
questionnaire that can be used to quantify changes in
activity limitations and participation restrictions for pa-
tients with neck pain.
16u
This scale enables the clinician to
collect measures related to function that may be different
then the measures that are components of the region-
specific outcome measures section such as the Neck Dis-
ability Index.
1,
Clinicians should utilize easily reproducible activ-
ity limitation and participation restriction mea-
sures associated with their patients neck pain to
assess the changes in the patients level of function over the
episode of care.
Cervical Active Range of Motion
ICF category Veasurement ot impairment ot body tunction - mobi|ity ot severa| joints
Description The amount ot active nec| heion, etension, rotation, and sidebendin motion measured usin an inc|inometer
Measurement method A|| cervica| rane ot motion (R0V) measures are pertormed in the upriht sittin position. Care shou|d be ta|en to ensure the
patient maintains an upriht sittin position throuhout the eamination and durin subsequent to||oWup eaminations. The
to||oWin procedures are used to measure the R0V tor the cervica| spine.
Neck F|ex|ooxteos|oo: lor nec| heion, the inc|inometer is p|aced on the top ot the patient's head a|ined With the eterna|
auditory meatus and then zeroed. The patient is as|ed to he the head torWard as tar as possib|e, brinin the chin to the chest.
The amount ot nec| heion is recorded trom the inc|inometer. lor etension R0V, the inc|inometer is positioned in the same
manner, and the patient is as|ed to etend the nec| bac|Wards as tar as possib|e. The amount ot nec| etension is recorded With
the inc|inometer.
Neck 5|debeod|og: The inc|inometer is positioned in the tronta| p|ane on the top ot the patient's head in a|inment With the eterna|
auditory meatus. To measure riht sidebendin, the patient is as|ed to move the riht ear to the riht shou|der. The amount ot
sidebendin is recorded With the inc|inometer. The opposite is pertormed to measure |ett sidebendin. Care shou|d be ta|en to
avoid concomitant rotation or heion With the sidebendin movement.
Neck kotzt|oo: Rotation can be measured With a universa|/standard oniometer. The patient is seated, |oo|in direct|y torWard
With the nec| in neutra| position. The tu|crum ot the oniometer is p|aced over the top ot the head With the stationary arm a|ined
With the acromion process ot the shou|der, and the moveab|e arm bisectin the patient's nose. The patient is as|ed to rotate in each
direction as tar as possib|e.
Nature of variable Continuous
Units of measurement 0erees
Measurement properties Cervica| R0V measurements tor heion, etension, and sidebendin usin a bubb|e inc|inometer have ehibited re|iabi|ity
coeNcients ranin trom O.GG to O.84 (lCC
2,I
).
J2,I/5
Instrument variations ln addition to usin an inc|inometer,
5,8J,I28,I8O
cervica| R0V can a|so be measured tor c|inica| purposes usin a cervica| rane ot motion
(CR0V) device
IIJ,IG5
or a tape measure. A|| methods are moderate|y corre|ated With more dehnitive radioraphic and J0 |inematic
measurement.
4,5
F
PhY5|6AL |NPA|kNNI NA5uk5
Cervical And Thoracic Segmental Mobility
ICF category Veasurement ot impairment ot body tunction - mobi|ity ot sin|e joints
Description \ith the patient prone, cervica| and thoracic spine sementa| movement and pain response are assessed
Measurement method The patient is prone. The eaminer contacts each cervica| spinous process With the thumbs. The |atera| nec| muscu|ature is ent|y
pu||ed s|iht|y posterior With the hners. The eaminer shou|d be direct|y over the contact area |eepin e|boWs etended, then he/
she uses the upper trun| to impart a posterior to anterior torce in a proressive osci||atory tashion over the spinous process. This
is repeated tor each cervica| sement. The eaminer then chanes his/her contact position and p|aces the hypothenar eminence
(just dista| to the pisitorm) ot one hand over the spinous process ot each thoracic spinous process and repeats the same posterior
to anterior torces in a proressive osci||atory tashion. The test resu|t is considered to be positive it the patient reports reproduction
ot pain. The mobi|ity ot the sement is juded to be norma|, hypermobi|e, or hypomobi|e. lnterpretation ot mobi|ity is based on the
eaminer's perception ot the mobi|ity at each spina| sement re|ative to those above and be|oW the tested sement, and based on
the eaminer's eperience and perception ot norma| mobi|ity.
Nature of variable |omina| (pain response) and ordina| (mobi|ity judment)
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a16 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
Cervical And Thoracic Segmental Mobility (continued)
Units of measurement None
Diagnostic accuracy and
measurement properties
0ianostic Accuracy
I44
.
Pain durin sementa| testin associated With reports ot nec| pain.
Sensitivity - O.82, neative |i|e|ihood ratio (lR) - O.2J
Specihcity - O./9, positive |i|e|ihood ratio (+lR) - J.9
Re|iabi|ity tor cervica| spine assessment.
lappa - O.I4 to O.J/ (pain)
IG9
lCC - O.42 to O./9 (pain)
II
lCC - O./8 to I.O (presence ot joint dystunction in upper J cervica| spine sements)
IOO
\eihted |appa. O.2G to O./4 (mobi|ity), O.52 to O.9O (pain)
J2
Re|iabi|ity tor thoracic spine assessment.
\eihted |appa. O.IJ to O.82 (mobi|ity), O.II to O.9O (pain)
J2
Cranial Cervical Flexion Test
ICF category Veasurement ot impairment ot body tunction - contro| ot simp|e vo|untary movements and endurance ot iso|ated musc|es
Description ln supine, the abi|ity to initiate and maintain iso|ated crania| and cervica| heion
Measurement method Patient is positioned supine in hoo| |yin and the head and nec| in midrane neutra| (imainary |ine betWeen torehead and chin and
imainary |ine betWeen the traus ot the ear and the nec| |onitudina||y shou|d be para||e| to each other and the surtace ot the
treatment tab|e). ToWe|s may be needed under the occiput to achieve this neutra| position. A pneumatic pressure device, such as a
pressure bioteedbac| unit, is inhated to 2O mml to h|| the space betWeen the cervica| |ordotic curve and the surtace ot the tab|e
(behind the suboccipita| reion, not be|oW the |oWer cervica| area).
\hi|e |eepin the posterior head/occiput stationary (do not |itt, do not push doWn), the patient pertorms crania| cervica| heion
(CCl) in a raded tashion in 5 increments (22, 24, 2G, 28, and JO mml) and aims to ho|d each position tor IO seconds. Ten seconds
rest is provided betWeen staes. To pertorm CCl, the patient is instructed to ent|y nod the head as thouh they Were sayin "yes
With the upper nec|. This motion Wi|| hatten the cervica| |ordosis, thus chanin the pressure in the pneumatic pressure device. \hi|e
the patient is pertormin the test movement, the therapist pa|pates the nec| to monitor tor unWanted activation ot the superhcia|
cervica| musc|es, such as the sternoc|eidomastoid. The patient can p|ace his/her tonue on the root ot the mouth, With |ips toether
but the teeth s|iht|y separated, to he|p decrease p|atysma and/or hyoid activation. The test is raded accordin to the pressure |eve|
the patient can achieve With concentric contractions and accurate|y sustain isometrica||y. The test is terminated When the pressure
is decreased by more than 2O% or When the patient cannot pertorm the proper CCl movement Without substitution strateies.
A norma| response is tor the pressure to increase to betWeen 2GJO mml and be maintained tor IO seconds Without uti|izin
superhcia| cervica| musc|e substitution strateies.
An abnorma| response is Where the patient.
I. ls unab|e to enerate an increase in pressure ot at |east G mml,
2. ls unab|e to ho|d the enerated pressure tor IO seconds,
J. uses superhcia| nec| musc|es to accomp|ish the cervica| heion motion, or
4. uses a sudden movement ot the chin or pushin (etendin) the nec| torcetu||y aainst the pressure device
Scorin.
Activation Score. Pressure achieved and he|d tor IO second
Pertormance lnde. lncrease in Pressure number ot repetitions
Nature of variable Continuous
Units of measurement mml tor the activation score
Measurement properties Re|iabi|ity assessment tor 5O asymptomatic subjects, tested tWice (I Wee| apart). Activation score. lCC-O.8I, Pertormance lnde. lCC-.9J
9G
Neck Flexor Muscle Endurance Test
ICF category Veasurement ot impairment ot body tunction - endurance ot iso|ated musc|es
Description ln supine, the abi|ity to |itt the head and nec| aainst ravity tor an etended period
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a17
Neck Flexor Muscle Endurance Test ( continued)
Measurement method The test is pertormed in a supine, hoo||yin position. \ith the chin maima||y retracted and maintained isometrica||y, the patient
|itts the head and nec| unti| the head is approimate|y 2.5 cm (I in) above the p|inth Whi|e |eepin the chin retracted to the chest.
The c|inician tocuses on the s|in to|ds a|on the patient's nec| and p|aces a hand on the tab|e just be|oW the occipita| bone ot the
patient's head. Verba| commands (ie, "Tuc| your chin or "lo|d your head up) are iven When either the s|in to|d(s) beins to
separate or the patient's occiput touches the c|inician's hand. The test is terminated it the s|in to|d(s) is separated due to |oss ot
chin tuc| or the patient's head touches the c|inician's hand tor more than I second.
/5
Nature of variable Continuous
Units of measurement Seconds
Measurement properties ln a study by larris et a|,
/5
4I subjects With and Without nec| pain pertormed this test. TWo raters tested a|| subjects at base|ine, and
subjects Without nec| pain Were tested aain I Wee| |ater.
Re|iabi|ity.
Subjects Without nec| pain.
lCC (J,I) - O.82 to O.9I, SEV 8.O II.O seconds
lCC (2,I) - O.G/ to O./8, SEV I2.G I5.J seconds
Subjects With nec| pain.
lCC (2,I) - O.G/, SEV II.5 seconds
Test resu|ts.
Subjects Without nec| pain. Vean J8.95 seconds (S0-2G.4)
Subjects With nec| pain. Vean 24.I seconds (S0-I2.8)
Upper Limb Tension Test
ICF category Veasurement ot impairment ot structure ot the nervous system, other specihed
Description ln nonWeiht bearin, the amount ot mobi|ity ot the neura| e|ements ot the upper |imb are assessed Whi|e determinin Whether the
patient's upper quarter symptoms are e|icited durin pertormance ot the test
Measurement method upper |imb tension tests are pertormed With the patient supine. 0urin pertormance ot the upper |imb tension test that p|aces a
bias toWard testin the patient's response to tension p|aced on the median nerve, the eaminer sequentia||y introduces the
to||oWin movements to the symptomatic upper etremity.
Scapu|ar depression
Shou|der abduction to about 9O With the e|boW heed
lorearm supination, Wrist and hner etension
Shou|der |atera| rotation
E|boW etension
Contra|atera| then ipsi|atera| cervica| sidebendin
A positive test occurs When any ot the to||oWin hndins are present.
I. reproduction ot a|| or part ot the patient's symptoms
2. sidetoside diterences ot reater than IO ot e|boW etension or Wrist etension
J. on the symptomatic side, contra|atera| cervica| sidebendin increases the patient's symptoms, or ipsi|atera| sidebendin
decreases the patient's symptoms
Nature of variable |omina|
Units of measurement None
Diagnostic accuracy indices for
the upper limb tension test, based
on the study by Wainner et al
175
95% Conhdence lnterva|
lappa O./G O.5II.O
Sensitivity O.9/ O.9OI.O
Specihcity O.22 O.I2O.JJ
Positive |i|e|ihood ratio I.JO I.IOI.5
|eative |i|e|ihood ratio O.I2 O.OII.9
Spurling s Test
ICF category Veasurement ot impairment ot structure ot the nervous system, other specihed
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a18 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
Distraction Test
ICF category Veasurement ot impairment ot structure ot the nervous system, other specihed
Description 0istraction ot the cervica| spine to maimize the diameter ot the neura| toramen and reduce or e|iminate the patient's symptoms
Measurement method The distraction test is used to identity cervica| radicu|opathy and is pertormed With the patient supine. The eaminer rasps under
the chin and occiput, hees the patient's nec| to a position ot comtort, and radua||y app|ies a distraction torce ot up to
approimate|y I4 |. A positive test occurs With the reduction or e|imination ot the patient's upper etremity or scapu|ar symptoms.
This test is not indicated it the patient has no upper etremity or scapu|ar reion symptoms.
Nature of variable |omina|
Units of measurement None
Diagnostic accuracy indices for
the upper limb tension test, based
on the study by Wainner et al
175
95% Conhdence lnterva|
lappa O.88 O.G4 I.O
Sensitivity O.44 O.2I O.G/
Specihcity O.9O O.82 O.98
Positive |i|e|ihood ratio 4.4O I.8O II.I
|eative |i|e|ihood ratio O.G2 O.4O O.9O
Spurling s Test ( continued)
Description Combination ot sidebendin to the symptomatic side coup|ed With compression to reduce the diameter ot the neura| toramen and
e|icit the patient's symptoms
Measurement method The patient is seated and is as|ed to sidebend and s|iht|y rotate the head to the paintu| side. The eaminer p|aces a compression torce
ot approimate|y / | throuh the top ot the head in an etort to turther narroW the intervertebra| toramen. The test is considered positive
When it reproduces the patient's symptoms. The test is not indicated it the patient has no upper etremity or scapu|ar reion symptoms.
Nature of variable |omina|/dichotomous
Units of measurement None
Diagnostic accuracy indices for
Spurlings test, based on the
study by Wainner et al
175
95% Conhdence lnterva|
lappa O.GO O.J2 O.8/
Sensitivity O.5O O.2/ O./J
Specihcity O.8G O.// O.94
Positive |i|e|ihood ratio J.5O I.GO /.5O
|eative |i|e|ihood ratio O.58 O.JG O.94
Valsalva Test
ICF category Veasurement ot impairment ot structure ot the nervous system, other specihed
Description Vaneuver in Which the patient bears doWn Without eha|in to increase intratheca| pressure and e|icit upper quarter symptoms
Measurement method The patient is seated and instructed to ta|e a deep breath and ho|d it Whi|e attemptin to eha|e tor 2J seconds. A positive
response occurs With reproduction ot symptoms.
Nature of variable |omina|/dichotomous
Units of measurement None
Diagnostic accuracy indices for
the valsalva test, based on the
study by Wainner et al
175
95% Conhdence lnterva|
lappa O.G9 O.JG I.O
Sensitivity O.22 O.OJ O.4I
Specihcity O.94 O.88 I.O
Positive |i|e|ihood ratio J.5O O.9/ I2.G
|eative |i|e|ihood ratio O.8J O.G4 I.I
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a19
A variety of interventions have been described for the treat-
ment of neck pain and there is good evidence from high-
quality randomized, controlled trials and systematic reviews
to support the benets of physical therapy intervention in
these patients.
6k|6AL N08|L|ZAI|0NNAN|PuLAI|0N
The most recent Cochrane Collaboration
Review
6
of mobilization and manipulation for
mechanical neck disorders included 33 randomized
controlled trials of which 42% were considered high qual-
ity. They concluded that the most benecial manipulative
interventions for patients with mechanical neck pain with
or without headaches should be combined with exercise to
reduce ain and imrove alienl salisfaclion. ManiuIalion
(thrust) and mobilization (non-thrust manipulation) inter-
vention alone were determined to be less efective than when
combined with exercise (combined intervention).
6
A recently
published clinical practice guideline concluded that the evi-
dence for combined intervention was relatively strong, while
the evidence for the efectiveness of thrust or non-thrust ma-
nipulation in isolation was weaker.
68
The recommendations of the Cochrane Review
6
and the re-
cently published clinical practice guideline
68
were based on
key ndings that warrant further discussion. Studies cited
included patients with both acute
82
and chronic neck pain
22
and interventions consisted of soft-tissue mobilization and
manual stretching procedures, as well as thrust,
1,,83
and non-
thrust manipulative procedures
82
directed at spinal motion
segmenls. Number of visils ranged from 6 over a 3 week
period
82
to 20 over an 11 week period
22
and the duration of
sessions ranged from 30 minutes
99
lo 6u minules.
22
Com-
bined intervention was compared with various competing
interventions that included manipulation alone,
22,99
various
non-manual physical therapy interventions,
82
high-tech and
low-tech exercises,
22,82,
general practitioner care (medica-
tion, advice, education),
82
and no treatment.
99
The majority
of studies report either clinically or statistically important
diferences in pain in favor of combined intervention when
compared to competing single interventions.
6
Diferences in
muscle performance
22,99
as well as patient satisfaction have
also been reported for both short-term
22,82,
as well as long-
term outcomes 1
22
and 2 years later.
8
When compared to care
rendered by a general practitioner and non-manual physical
therapy interventions, the combination of manipulation and
exercise resuIled in signicanl cosl-savings of u lo 68%.
1u6
Although many patients experience a signicant
benet when treated with thrust manipulation, it
is still unclear which patients benet most. Tseng
et al
166
reorled 6 rediclors for alienls who exerienced an
immediate improvement in either pain, satisfaction, or per-
ception of condition following manipulation of the cervical
spine. These predictors included
166
:
IniliaI scores on Neck DisabiIily Index Iess lhan 11.
Having biIaleraI invoIvemenl allern
Nol erforming sedenlary work more lhan hours er
day
IeeIing beller whiIe moving lhe neck
Did nol feeI worse whiIe exlending lhe neck
The diagnosis of sondyIosis wilhoul radicuIoalhy
The presence of 4 or more of these predictors increased the
robabiIily of success wilh maniuIalion from 6u% lo 8%.
166
Predictors of which patients respond best to combined inter-
vention have not been reported.
Nilsson et al
12
conducted a randomized, clinical tri-
aI (n=3) in individuaIs wilh cervicogenic headache.
Subjects were randomized to receive high velocity
low amplitude spinal manipulation or low level laser and
deep friction massage. The use of analgesics were reduced
by 36% in lhe maniuIalion grou bul were unchanged in
the laser/massage group. The number of headache hours per
day decreased by 6% for lhe individuaIs in lhe maniuIalion
grou and 3,% in lhe Iaser]massage grou. Headache inlen-
sily er eisode decreased by 36% for lhose in lhe maniuIa-
lion grou and 1,% in lhe Iaser]massage grou.
A systematic review by Vernon et al,
1,1
which includ-
ed sludies ubIished lhrough 2uu, concIuded lhal
there is moderate- to high-quality evidence that sub-
jects with chronic neck pain and headaches show clinically im-
portant improvements from a course of spinal mobilization or
maniuIalion al 6, 12, and u lo 1u4 weeks osl-lrealmenl.
Despite good evidence to support the benets of cervical
mobilization/manipulation, it is important that physical
CLINICAL GUIDELINES
Interventions
I
I
II
II
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a20 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
therapists be aware of the potential risks in using these tech-
niques.
68,6
However, it is impossible to determine the pre-
cise risk because (1) it is extremely difcult to quantify the
number of cervical spine mobilization/manipulative inter-
ventions performed each year, and (2) not all adverse events
occurring after mobilization/manipulation interventions are
published in the peer-reviewed literature, and there is no ac-
cepted standard for reporting these injuries. Reported risk
factors include hypertension, migraines, oral contraceptive
use, and smoking.
,2
However, the prevalence of these factors
in the study by Haldeman et al
,2
is largely the same or lower
than that which occurs in the general population.
Although the true risk for complications remains unknown,
lhe risk for serious comIicalions is eslimaled lo be 6 in 1u
miIIion (u.uuuu6%) maniuIalions, wilh lhe risk of dealh be-
ing 3 in 10 million (0.000003%). Importantly, these rates are
adjusted assuming that only 1 in 10 complications is actually
reported in the literature.
84
Gross et al
,u
recently reported,
in a clinical practice guideline on the use of mobilization/
manipulation in patients with mechanical neck pain, that
estimates for serious complication for manipulation ranged
from 1 in 2u,uuu (u.u1%) lo in 1u miIIion (u.uuu%).
,u
The risk estimate for patients experiencing non-serious
side efects such as increased symptoms, ranges from 1% to
2%.
149
The most common side efects included local discom-
forl (3%), IocaI headache (12%), faligue (11%), or radialing
discomforl (1u%). Palienls characlerized 8% of lhese com-
Iainls as miId or moderale, wilh 64% of side eecls aear-
ing within 4 hours after manipulation. Within 24 hours after
maniuIalion, ,4% of lhe comIainls had resoIved. Less lhan
% of side eecls were characlerized as dizziness, nausea, hol
skin, or other complaints. Side efects were rarely still noted
on the day after manipulation, and very few patients reported
the side efects as being severe.
Due the potential risk of serious adverse efects associated
with cervical manipulation, such as vertebrobasilar artery
stroke,
6
it has been recommended that non-thrust cervi-
cal mobilization/manipulation be utilized in favor of thrust
manipulation.
u,8
However, information regarding the risk/
benet ratio of providing cervical thrust manipulation to
patients with impairments of body function purported to
benet from cervical mobilization/manipulation, such as cer-
vical segmental mobility decits, has not been reported. In
addition, the case reports in the literature describing serious
adverse efects associated with cervical thrust manipulation
do not provide information regarding either the presence of
imairmenls of body funclions, or lhe resence of red ags
for vertebrobasilar insufciency,
,
prior to the application of
the manipulative procedure suspected to be linked with the
reported harmful efects.
Recommendation: Clinicians should consider utiliz-
ing cervical manipulation and mobilization proce-
dures, thrust and non-thrust, to reduce neck pain and
headache. Combining cervical manipulation and mobilization
with exercise is more efective for reducing neck pain, headache,
and disability than manipulation and mobilization alone.
Th0kA6|6 N08|L|ZAI|0NNAN|PuLAI|0N
A survey among clinicians that practice manual physi-
cal therapy reported that the thoracic spine is the region of
the spine most often manipulated, despite the fact that more
patients complain of neck pain.
1
While several randomized
clinical trials have examined the efectiveness of thoracic
sine lhrusl maniuIalion (TSM) for alienls wilh neck
pain, patients in these studies also received cervical manipu-
lation.
2,22,,
The rationale to include thoracic spine mobiliza-
tion/manipulation in the treatment of patients with neck
pain stems from the theory that disturbances in joint mobil-
ity in the thoracic spine may be an underlying contributor to
musculoskeletal disorders in the neck.
4,1u
Cleland et al
34
comared lhe eecliveness of TSM in
a trial in which patients were randomized to either a
singIe session of TSM or sham maniuIalion. Palienls
who received TSM exerienced a cIinicaIIy meaningfuI and sla-
tistically signicant reduction in pain on the visual analogue
scale (VAS) compared to patients who received the sham inter-
vention (P.001).
34
A similar nding (reduction of pain) was
aIso reorled in a randomized lriaI lhal comared TSM inler-
vention to an active exercise program.
14,
A subsequent random-
ized trial by Cleland et al
38
which comared TSM lo non-lhrusl
manipulation (mobilization) found signicant diferences in fa-
vor of lhe TSM grou in ain, disabiIily, and alienl erceived
imrovemenl uon re-evaIualion 48 hours Ialer.
While preliminary reports indicate that patients
with complaints of primary neck pain experience a
signicanl benel when lrealed wilh TSM, il is sliII
unclear which patients benet most. Cleland et al
33
reported a
preliminary clinical prediction rule for patients with primary
neck pain who experience short-term improvement (1-week)
wilh TSM. Each subjecl received a lolaI of 3 lhoracic maniu-
lations directed at the upper and middle thoracic spine for up
lo 2 sessions. Using a gIobaI raling of change score as a
reference crilerion, 6 variabIes were reorled as rediclors of
improvement and included
33
:
Symlom duralion of Iess lhan 3u days
No symloms dislaI lo lhe shouIder
Subjecl reorls lhal Iooking u does nol aggravale
symptoms
Iear-avoidance BeIiefs Queslionnaire-PhysicaI Aclivily
Scale score less than 12
A
I
II
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a21
Diminished uer lhoracic sine kyhosis (T3-T)
CervicaI exlension of Iess lhan 3u
Interestingly, the lack of symptom aggravation with looking
up was also one of the predictors reported by Tseng et al
166
in
the cervical manipulation clinical prediction rule. Validation
of bolh lhe cervicaI and TSM cIinicaI ruIes is required before
they can be recommended for widespread clinical use.
In a randomized clinical trial Fernndez de las Pe-
as et al

demonstrated that patients with neck

pain related to a whiplash-associated disorder re-
ceiving TSM exerienced a signicanlIy grealer (P<.uu3)
reduction in pain as measured by the visual analogue scale,
than those who did not receive the thoracic manipulation.
The mean change in ain IeveIs in lhe grou receiving TSM
was 4.1 mm (SD 18.8 mm) comared lo a mean change of
13.4 mm (SD 8. mm) in lhe grou nol receiving lhoracic ma-
nipulation. The length of follow-up was not clearly dened.
Self-reported levels of pain and cervical active
ROM were assessed before and immedialeIy afler
TSM in 26 alienls wilh a rimary comIainl of
neck pain. The mean reduction in pain on an 11-point nu-
meric pain rating scale was approximately 2 points (P.01),
which has been shown to indicate that a clinically meaningful
improvement has occurred. Signicant increases in cervical
aclive ROM were aIso observed in aII direclions excel exlen-
sion (P<.uu1). This sludy did nol incIude a conlroI grou and
only consisted of an immediate follow-up, but the immediate
imrovemenls in ain and cervicaI aclive ROM suggesl lhal
TSM may have some meril in alienls wilh neck ain.
61
There have been 4 case series that have incorpo-
rated thoracic spine thrust manipulation in the
multi-modal management of patients with cervi-
cal radiculopathy.
23,3,12u,1,6
In the rst case series,
39
10 of the
11 patients (91%) demonstrated a clinically meaningful im-
rovemenl in ain and funclion al lhe 6-monlh foIIow-u
afler a mean of ,.1 hysicaI lheray visils. In lhe second case
series
1,6
all patients except for 1 exhibited a signicant reduc-
tion in disability. In the third case series,
120
full resolution of
ain was reorled in 8 of 1 (3%) alienls, where aII 6 of lhe
patients receiving mobilization and manipulation achieved
full resolution of pain. In addition, there has been 1 case se-
ries
23
that included thoracic spine thrust manipulation in the
managemenl of , alienls wilh grade I cervicaI comressive
myelopathy. All patients exhibited a reduction in pain and
improvement in function at the time of discharge.
Recommendation: Thoracic spine thrust ma-
nipulation can be used for patients with primary
complaints of neck pain. Thoracic spine thrust ma-
nipulation can also be used for reducing pain and disability
in patients with neck and neck-related arm pain.
5IkI6h|N6 Xk6|55
In a randomized controlled trial, Ylinen et
al
183
assessed the efectiveness of manual therapy
procedures implemented twice a week compared
wilh a slrelching regimen erformed limes a week in lhose
with non-specic neck pain. At the 4 and 12 week follow-up
both groups improved but there were no signicant diferenc-
es between the groups related to pain. Neck pain and disabil-
ity outcome measures, shoulder pain and disability outcome
measures, and neck stifness were reduced signicantly more
in those receiving manual therapy, but the clinical diference
was minimal. The authors concluded that the low-cost of
stretching exercises should be included in the initial treat-
ment plan for patients with neck pain.
The authors of this clinical practice guideline have
observed that patients with neck pain often pres-
enl wilh imairmenls of exibiIily of key muscIes
related to the lower cervical and upper thoracic spine, such
as the anterior, medial, and posterior scalenes, upper trape-
zius, levator scapulae, pectoralis minor, and pectoralis major,
that should be addressed with stretching exercises. One study
reorled lhal uer quarler muscIe exibiIily decils were
common in dental hygienists,

an occupation that requires

frequent repetitive activities involving the shoulders, arms,
and hands. Although research generally does not support the
efectiveness of interventions that focus on stretching and
exibiIily, cIinicaI exerience suggesls lhal addressing se-
cic impairments of muscle length for an individual patient
may be a benecial addition to a comprehensive treatment
program.
Recommendation: Flexibility exercises can be used
for patients with neck symptoms. Examination and
largeled exibiIily exercises for lhe foIIowing mus-
cles are suggested: anterior/medial/posterior scalenes, upper
trapezius, levator scapulae, pectoralis minor, and pectoralis
major.
600k0|NAI|0N, 5IkN6IhN|N6, AN0 N0ukAN6
Xk6|55
Jull et al
99
conducted a multi-centered,
randomized clinical trial (n=200) in participants
who met the diagnostic criteria for cervicogenic
headache. The inclusion criteria were unilateral or unilateral
dominant side-consistent headache associated with neck pain
and aggravated by neck postures or movement, joint tender-
ness in at least 1 of the upper 3 cervical joints as detected by
I
I
I
V
IV
IV
C
C
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a22 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
manual palpation, and a headache frequency of at least 1 per
week over a period of 2 months to 10 years. Subjects were
randomized into 4 groups: mobilization/manipulation group,
exercise therapy group, combined mobilization/manipulation
and exercise group, and a control group. The primary out-
come was a change in headache frequency. At the 12-month
follow-up, the mobilization/manipulation, combined mobi-
lization/manipulation and exercise, and the specic exercise
groups had signicantly reduced headache frequency and in-
tensity. Additionally 10% more patients experienced a com-
plete reduction in headache frequency when treated with
mobilization/manipulation and exercise than those treated
with the alternative approaches.
99
The exercise rogram in lhis cIinicaI lriaI by JuII el aI
99
used
low load endurance exercises to train muscle control of the
cervicoscapular region. The rst stage consisted of specic
craniocervicaI exion exercises, erformed in suine Iying,
aimed lo largel lhe dee neck exor muscIes, which are lhe
longus capitis and longus colli. Subsequently, isometric exer-
cises using a low level of rotatory resistance were used to train
lhe co-conlraclion of lhe neck exors and exlensors. The ex-
ercise groups had signicantly reduced headache frequency
and intensity when compared to the controls.
Chiu et al
28
assessed the benets of an exercise pro-
gram that focused both on motor control training of
lhe dee neck exors and dynamic slrenglhening. A
lolaI of 14 alienls wilh chronic neck ain were randomized
to either an exercise or a non-exercise control group. At week
6, lhe exercise grou had signicanlIy beller imrovemenls
in disability scores, pain levels, and isometric neck muscle
strength. However, signicant diferences between the 2
groups were found only in pain and patient satisfaction at
lhe 6-monlh foIIow-u.
In a randomized, cIinicaI lriaI, YIinen el aI
184
dem-
onstrated the efectiveness of both strengthening
exercises and endurance training of the deep neck
exor muscIes in reducing ain and disabiIily al lhe 1-year
foIIow-u in women (n = 18u) wilh chronic, nonsecic neck
pain. The endurance training group performed dynamic neck
exercises, which included lifting the head up from the supine
and prone positions. The strength training group performed
high-intensity isometric neck strengthening and stabiliza-
tion exercises with an elastic band. Both training groups
performed dynamic exercises for the shoulders and upper
extremities with dumbbells. Both groups were advised to
also do aerobic and stretching exercises 3 times a week. In a
3-year foIIow-u sludy, YIinen el aI
182
found that women (n =
118) in bolh lhe slrenglhening exercise and endurance lrain-
ing groups achieved long-term benets from the 12-month
programs.
O`Leary el aI
12,
compared the efect of 2 specic
cervicaI exor muscIe exercise rolocoIs on im-
mediate pain relief in the cervical spine of people
with chronic neck pain. They found that those performing
lhe secic craniocervicaI exion exercise demonslraled
greater improvements in pressure pain thresholds, me-
chanical hyperalgesia, and perceived pain relief during ac-
tive movement.
In a cross-sectional comparative study, Chiu et al
29
compared the performance of the deep cervical
exor muscIes on lhe craniocervicaI exion lesl in
individuals with (n = 20) and without (n = 20) chronic neck
pain. Those with chronic neck pain had signicantly poorer
erformance on lhe craniocervicaI exion lesl (median res-
sure achieved, 24 mmHg when starting at 20 mmHg) when
compared with those in the asymptomatic group (median
ressure achieved, 28 mmHg when slarling al 2u mmHg).
JuII el aI
,
compared the efects of conventional
roriocelive lraining and craniocervicaI exion
training on cervical joint position error in people
with persistent neck pain. The aim was to evaluate whether
proprioceptive training was superior in improving proprio-
ceptive acuity compared to a form of exercise that has been
shown to be efective in reducing neck pain. Sixty-four female
subjects with persistent neck pain and decits in cervical
joint position error were randomized into 2 exercise groups:
roriocelive lraining or craniocervicaI exion lraining.
Exercise regimens were conducled over a 6-week eriod.
The results demonstrated that both proprioceptive training
and craniocervicaI exion lraining have a demonslrabIe ben-
et on impaired cervical joint position error in people with
neck pain, with marginally more benet gained from prop-
rioceptive training. The results suggest that improved prop-
rioceptive acuity following intervention with either exercise
protocol may occur through an improved quality of cervical
aferent input or by addressing input through direct training
of relocation sense.
,
In a randomized, clinical trial, Taimela et al
162
com-
pared the efcacy of a multimodal treatment em-
phasizing proprioceptive training in patients with
non-secic chronic neck ain (n = ,6). The roriocelive
treatment, which consisted of exercises, relaxation, and be-
havioral support was more efcacious than comparison in-
terventions that consisted of (1) attending a lecture on the
neck and 2 sessions of practical training for a home exercise
program, and (2) a lecture regarding care of the neck with a
recommendation to exercise. Specically, the proprioceptive
treatment group had greater reductions in neck symptoms,
improvements in general health, and improvements in the
ability to work.
III
III
I
I
I
I
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a23
In a randomized clinical trial, Viljanen et al
1,3
as-
sessed the efectiveness of dynamic muscle training
(n= 13), reIaxalion lraining (n = 128), or ordinary
aclivily (n = 13) for femaIe oce workers wilh chronic neck
pain. Dynamic muscle training and relaxation training did
not lead to better improvements in neck pain compared with
ordinary activity.
In a randomized clinical trial, Bronfort et al
22
found
that a combined program of strengthening and en-
durance exercises combined with manual therapy
resulted in greater gains in strength, endurance, range of mo-
tion, and long-term patient pain ratings in those with chron-
ic neck pain than programs that only incorporated manual
therapy. Additionally, Evans et al
8
found that these results
were maintained at a 2-year follow-up.
In a prospective case series, Nelson et al
124
followed
patients with cervical and lumbar pain and found
that an aggressive strengthening program was able
lo revenl surgery in 3 of lhe 6u alienls (46 of lhe 6u com-
Ieled lhe rogram, 38 were avaiIabIe for foIIow-u, and onIy
3 reported having surgery). Despite the methodological limi-
tations of this study, some patients that were originally given
the option of surgery were able to successfully avoid surgery
in the short term following participation in an aggressive
strengthening exercise program.
In a systematic review of 9 randomized clinical tri-
aIs and , comaralive lriaIs wilh moderale melhod-
ological quality for patients with mechanical neck
disorders, Sarig-Bahat
14
reported relatively strong evidence
supporting the efectiveness of proprioceptive exercises and
dynamic resisted strengthening exercises of the neck-shoul-
der musculature for patients with chronic or frequent neck
disorders. The evidence identied could not support the ef-
fectiveness of group exercise, neck schools, or single sessions
of extension-retraction exercises.
In a randomized clinical trial, Chiu et al
30
found
in alienls wilh chronic neck ain (n = 218), lhal
a 6-week lrealmenl of lransculaneous eIeclri-
cal nerve stimulation or exercise had a better and clinically
relevant improvement in disability, isometric neck muscle
strength, and pain compared to a control group. All the im-
provements in the intervention groups were maintained at
lhe 6-monlh foIIow-u.
Hammill et al
,4
used a combination of postural
education, stretching, and strengthening exercises
to reduce the frequency of headaches and improve
disability in a series of 20 patients, with results being main-
tained at a 12-month follow-up.
In a syslemalic review, Kay el aI
103
concluded that
specic exercises may be efective for the treatment
of acute and chronic mechanical neck pain, with or
without headache.
A recent Cochrane review
6
concluded that mo-
bilization and/or manipulation when used with
exercise are benecial for patients with persistent
mechanical neck disorders with or without headache. How-
ever, manual therapy without exercise or exercise alone were
not superior to one another.
Although evidence is generally lacking, postural
correction and body mechanics education and
training may also be indicated if clinicians identify
ergonomic inefciencies during either the examination or
treatment of patients with motor control, movement coordi-
nation, muscle power, or endurance impairments.
Recommendation: Clinicians should consider the
use of coordination, strengthening, and endurance
exercises to reduce neck pain and headache.
6NIkAL|ZAI|0N Pk060uk5 AN0 Xk6|55
Kjellman and colleagues
104
randomly assigned
,, alienls wilh neck ain (2 of which resenled
with cervical radiculopathy) to general exercise,
McKenzie melhod of examinalion and lrealmenl, or a conlroI
grou (Iow inlensily uIlrasound and educalion). The McKen-
zie method of treatment consists of patient positioning, spe-
cic repeated movements, manual procedures, and patient
education in self management in case of recurrence.
1u4,118
The
reealed secic movemenls wilh lhe McKenzie melhod in-
tend to centralize (promote the migration of symptoms from
an area more distal to location more proximal) or reduce
pain.
118
At the 12 month follow-up all groups showed signi-
cant reductions in pain intensity and disability but no signi-
cant diference between groups existed. Seventy-nine percent
of patients reported that they were better or completely re-
slored afler lrealmenl, aIlhough 1% reorled conslanl]daiIy
pain. All 3 groups had similar recurrence rates.
Murhy el aI
122
incororaled McKenzie rocedures
to promote centralization in the management of a
cohort of 31 patients with cervical radiculopathy.
These patients also received cervical manipulation or muscle
energy techniques and neural mobilization. Seventy-seven
percent of patients at the short-term follow-up and 93% of
patients at the long-term follow-up exhibited a clinically im-
portant improvement in disability. However, specic details
regarding the number of patients receiving procedures to
promote centralization was not reported.
III
A
I I
I
I
I
I
II
V
IV
IV
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a24 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
There has not been a clinical trial that recruited patients with
only cervical radiculopathy. Therefore, it is not possible to
commenl on lhe ecacy of lhe McKenzie melhod or lhe use
of centralization procedures and exercises for this particular
subgroup of patients.
31
Recommendation: Specic repeated movements or
procedures to promote centralization are not more
benecial in reducing disability when compared to
other forms of interventions.
uPPk uAkIk AN0 Nk N08|L|ZAI|0N
Pk060uk5
Allison et al
2
examined the efectiveness of
2 diferent manual therapy techniques (neural
mobilization and cervical/upper quadrant mobi-
lization) in the management of cervico-brachial syndrome.
AII alienls received lrealmenl for 8 weeks in addilion lo
a home exercise program. The results demonstrated that
both manual therapy groups exhibited improvements in
pain and function. At the nal data collection there ex-
isted no diference between the manual therapy groups
for function but a signicant diference between groups
for reduction in pain was identied in favor of the neural
mobilization group.
In a randomized clinical trial, Coppieters et al
41
assigned 20 patients with cervico-brachial pain to
receive either cervical mobilization with the upper
extremity in an upper limb neurodynamic position or thera-
peutic ultrasound. The group receiving the mobilizations
exhibited signicantly greater improvements in elbow range
of motion during neurodynamic testing as well as greater re-
ductions in pain compared to the ultrasound group.
Murhy el aI
122
incorporated neural mobilization in
the management of a cohort of patients with cervi-
cal radiculopathy. Seventy seven percent of patients
at the short-term follow-up and 93% of patients at the long
term follow-up exhibited a clinically important decrease in
disability. However, no specics were provided relative to
which patients received neural mobilization procedures.
Cleland et al
39
described the outcomes of a con-
secutive series of patients presenting to physical
therapy who received cervical mobilization (cer-
vical lateral glides) with the upper extremity in a neuro-
dynamic position as well as thoracic spine manipulation,
cervical traction, and strengthening exercises. Ten of the
11 patients (91%) demonstrated a clinically meaningful
imrovemenl in ain and funclion foIIowing a mean of ,.1
physical therapy visits.
Recommendation: Clinicians should consider the
use of upper quarter and nerve mobilization proce-
dures to reduce pain and disability in patients with
neck and arm pain.
IkA6I|0N
A systematic review by Graham and col-
leagues
6,
reported that there is moderate evidence
to support the use of mechanical intermittent cervi-
cal traction.
Taghi Joghalaei el aI
93
randomly assigned 30 pa-
tients to receive a treatment program consisting
of ultrasound and exercise with or without me-
chanical intermittent cervical traction for 10 sessions. The
group receiving traction exhibited greater improvements
in gri slrenglh, lhe rimary oulcome measure, afler ses-
sions. However, no statistically signicant diference be-
tween groups existed at the time of discharge from physical
therapy.
93
Saal et al
143
invesligaled lhe oulcomes of 26 con-
secutive patients who t the diagnostic criteria for
herniated cervical disc with radiculopathy who re-
ceived a rehabilitation program consisting of cervical traction
and exercise. Twenty-four patients avoided surgical interven-
tion and 20 exhibited good or excellent outcomes.
In a prospective cohort design Cleland et al
36
iden-
tied predictor variables of short-term success for
patients presenting to physical therapy with cervi-
cal radiculopathy. One of the predictor variables for patients
who exhibited a short-term success included a multimodal
physical therapy approach consisting of manual or mechani-
cal traction, manual therapy (cervical or thoracic mobiliza-
lion]maniuIalion), and dee neck exor slrenglhening. The
pretest probability for the likelihood of short-term success
was 3%. The mean duralion of mechanicaI lraclion used on
alienls in lhis sludy was 1,.8 minules wilh an average force
of pull of 11 kg (24.3 pounds). The positive likelihood ratio
for patients receiving the multimodal treatment approach
(excluding other predictor variables) was 2.2, resulting in a
osl-lesl robabiIily of success of ,1%.
36
Raney et al
13,
recently developed a clinical predic-
tion rule to identify patients with neck pain likely
to benet from cervical mechanical traction. Sixty-
eighl alienls (38 femaIe) were incIuded in dala anaIysis of
which 3u had a successfuI oulcome. AII alienls received 6
sessions of mechanical intermittent cervical traction start-
ing wilh a force of uII belween 4.-.4 kg (1u-12 ounds)
for a duralion of 1 minules. The force of uII rogressiveIy
I
III
III
II
II
II
II
II
IV
C
B
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a25
increased based on centralization of symptoms at each sub-
sequenl session. A cIinicaI rediclion ruIe wilh variabIes
was identied:
Palienl reorled eriheraIizalion wilh Iower cervicaI sine
(C4-,) mobiIily lesling
Posilive shouIder abduclion sign
Age years
Posilive uer Iimb lension lesl (median nerve bias uliIiz-
ing shouIder abduclion lo u)
ReIief of symloms wilh manuaI dislraclion lesl
Having al Ieasl 3 oul of variabIes resenl resuIled in a
osilive IikeIihood ralio equaI lo 4.81 (% CI = 2.1,-11.4),
increasing the likelihood of success with cervical traction
from 44% lo ,.2%. If al Ieasl 4 oul of variabIes were res-
enl, lhe osilive IikeIihood ralio was equaI lo 11., (% CI
= 2.u-6.8), increasing lhe osl-lesl robabiIily of having
improvement with cervical traction to 90.2%.
Three separate case series
3,12u,1,6
describe the man-
agement of patients with cervical radiculopathy,
where the interventions included traction. In these
case series, the patients were treated with a multimodal treat-
ment approach and the vast majority of patients exhibited
improved outcomes. In the rst report, Cleland et al
39
de-
scribed the outcomes of a consecutive series of 11 patients
presenting to physical therapy with cervical radiculopathy
and managed with the use of manual physical therapy, cervi-
caI lraclion, and slrenglhening exercises. Al 6 monlh foIIow-
up, 91% demonstrated a clinically meaningful improvement
in ain and funclion foIIowing a mean of ,.1 hysicaI lheray
visits. Similarly, Waldrop
1,6
lrealed 6 alienls wilh cervicaI
radiculopathy with mechanical intermittent cervical traction,
thoracic thrust joint manipulation, and range of motion and
slrenglhening exercises for lhe cervicaI sine. Uon discharge
(mean lrealmenl 1u visils, range -18 visils; duralion 33 days,
range 1-6 days), lhere was a reduclion in disabiIily belween
13% and 88%. In lhe lhird case series, Moeli and Marchelli
120
investigated the outcomes associated with cervical traction,
neck retraction exercises, scapular muscle strengthening,
and mobilization/manipulation techniques (used for some
alienls) for 1 alienls wilh cervicaI radicuIoalhy. These
aulhors reorled fuII resoIulion of ain in 3% of alienls al
the time of discharge.
Browder and colleagues
23
investigated the efec-
tiveness of a multimodal treatment approach in
lhe managemenl of , femaIe alienls wilh grade I
cervical compressive myelopathy. Patients were treated with
intermittent mechanical cervical traction and thoracic ma-
niuIalion for a median of sessions over a median of 6
days. The median decrease in ain scores was from a base-
Iine of 6 (using a u-1u ain scaIe), and median imrovemenl
in IunclionaI Raling Index scores was 26% from a baseIine
of 44%.
Recommendation: Clinicians should consider
the use of mechanical intermittent cervical trac-
tion, 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.
PAI|NI 0u6AI|0N AN0 60uN5L|N6
There is a paucity of high quality evidence
surrounding efcacy of treatments for whiplash-
associated disorder (WAD). However, existing re-
search supports instructing patients in active interventions,
such as exercises, and early return to regular activities as a
means of pain control. Rosenfeld et al
142
compared the long-
term efcacy of active intervention with that of standard in-
tervention and the efect of early versus delayed initiation
of intervention. Patients were randomized to an interven-
tion using frequent active cervical rotation range of motion
exercises complemented by assessment and treatment ac-
cording lo McKenzie`s rinciIes or lo an inlervenlion lhal
promoted initial rest, soft collar utilization, and gradual self-
mobilization. In patients with WAD, early active interven-
tion was more efective in reducing pain intensity and sick
leave, and in retaining/regaining total range of motion than
intervention that promoted rest, collar usage, and gradual
self-mobilization. Patient education promoting an active ap-
proach can be carried out as home exercises and progressive
return to activities initiated and supported by appropriately
trained health professionals.
An often prescribed intervention for acute whiplash
injury is the use of a soft cervical collar. Crawford
et al
4
rosecliveIy invesligaled 1u8 conseculive
patients following a soft tissue injury of the neck that result-
ed from motor vehicle accidents. Each patient was random-
ized to a group instructed to engage in early mobilization
using an exercise regime or to a group that was instructed to
utilize a soft cervical collar for 3 weeks followed by the same
exercise regime. Patients were assessed clinically at 3, 12,
and 2 week inlervaIs from injury. Inlervenlion lhal uliIized
a soft collar was found to have no obvious benet in terms
of functional recovery after neck injury and was associated
with a prolonged time period of work. Other investigations
have reported similar results.
148,1,u
Interventions that instruct
patients to perform exercises early in their recovery from
whiplash type injuries have been reported to be more ef-
fective in reducing pain intensity and disability following
whiplash injury than interventions that instruct patients to
use cervical collars.
148,1,u
I
I
IV
IV
B
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a26 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
Existing research supports active interventions and
early return to regular activities but it has largely
been unknown as to which type of active interven-
tion would yield the most benet. Brison et al
21
assessed the
efcacy of an educational video in the prevention of persis-
tent WAD symptoms following rear-end motor vehicle colli-
sions. The video provided reassurance, and education about
posture, return to regular activities, specic exercises, and
pain management. Patients were randomized to receive ei-
ther an educational video plus usual care or usual care alone.
The primary outcome was presence of persistent WAD symp-
toms at 24 weeks post injury, based on the frequency and
severity of neck, shoulder, or upper back pain. The group re-
ceiving the instructional video demonstrated a trend toward
less severe WAD symptoms suggesting that the act as usual
recommendation that is often prescribed as a management
strategy for patients with WAD is not sufcient and, in fact,
may exacerbate their symptoms if such activities are provoca-
tive of pain.
21
A reduction in pain alone is not sufcient to ad-
dress the neuromuscular control decits in patients
with chronic symptoms,
1,
as these decits require
specic rehabilitation techniques.
99
For example, persistent
sensory and motor decits may render the patient at risk for
symptom persistence.
1,16
Support for specicity in reha-
bilitation can be indirectly found from a recent population-
based, incidence cohort study evaluating a government policy
of funding community and hospital-based tness training and
multidisciplinary rehabilitation for whiplash.
26
No supportive
evidence was found for the efectiveness of this general reha-
bilitation approach. Therefore, only addressing the lack of
tness and conditioning in this patient population may not
be the most efcacious approach to treatment.
Ferrari et al
6u
studied whether an educational in-
tervention using a pamphlet provided to patients
in the acute stage of whiplash injury might im-
prove the recovery rate. One hundred twelve consecutive
subjects were randomized to 1 of 2 treatment groups: edu-
cational intervention or usual care. The education interven-
tion group received an educational pamphlet based on the
current evidence, whereas the control group only received
usual emergency department care and a standard non-di-
rected discharge information sheet. Both groups underwent
follow-up by telephone interview at 2 weeks and 3 months.
The primary outcome measure of recovery was the patients
resonse lo lhe queslion, How weII do you feeI you are recov-
ering from your injuries?" Al 3 monlhs osl coIIision, 21.8%
in the education intervention group reported complete recov-
ery compared with 21.0% in the control group (absolute risk
dierence, u.8%; % CI = -14.4% lo 16.u%). Al 3 monlhs,
there were no clinically or statistically signicant diferences
between groups in severity of remaining symptoms, limita-
tions in daily activities, therapy use, medications used, lost
time from work, or litigation. This study concluded that an
evidence-based educational pamphlet provided to patients at
discharge from the emergency department is no more efec-
tive than usual care for patients with grade I or II WAD.
6u
JuII el aI
99
conducted a preliminary randomized
conlroIIed lriaI wilh ,1 arlicianls wilh ersislenl
neck pain following a motor vehicle accident to ex-
plore whether a multimodal program of physical therapies
was an appropriate management strategy compared to a self-
management approach. Participants were randomly allocated
to receive either a multimodal physical therapy program or
a self-management program (advice and exercise). Further-
more, participants were stratied according to the presence
or absence of widespread mechanical or cold hyperalgesia.
The intervention period was 10 weeks and outcomes were as-
sessed immediately following treatment. Even with the pres-
ence of sensory hyersensilivily in ,2.% of subjecls, bolh
groups reported some relief of neck pain and disability, mea-
sured using Neck Disability Index scores, and it was superior
in the group receiving multimodal physical therapy (P=.04).
However, the overall efects of both programs were mitigated
in the group presenting with both widespread mechanical
and cold hyperalgesia. Further research aimed at testing the
validity of this sub-group observation is warranted.
8
A comprehensive review
11,
of the available scientic
evidence produced a set of unambiguous patient
centered messages that challenge unhelpful beliefs
about whiplash, promoting an active approach to recovery.
The use of this rigorously developed educational booklet
(The Whiplash Book) was capable of improving beliefs about
whiplash and its management for patients with whiplash-
associated disorders.
11,
In a smaII case series, SoderIund and Lindberg
13
reported that physical therapy integrated with
cognitive behavioral components decreased pain
intensity in problematic daily activities in 3 individuals with
chronic WAD.
Predictors of outcome following whiplash injury
have been limited to socio-demographic and fac-
tors of symptom location and severity, which are
not readily amenable to intervention. However, evidence
exists to demonstrate that psychological factors are pres-
ent soon following injury and play a role in recovery from
whiplash injury.
8,1,18
These factors can be as diverse as
the physical presentation and can include afective distur-
bances, anxiety, depression, and fear of movement.
123,132,1,8
Furthermore, post-traumatic stress disorder
112
has also been
I
I
III
I
II
II
IV
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a27
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
observed in both the acute
2
and chronic conditions and has
been shown to be prognostic.
1,1
Identifying these factors in
patients may assist in the development of relevant subgroups
and appropriately matched education and counseling strate-
gies that practitioners should utilize in management of pa-
tients with WAD.
Recommendation: To improve the recovery in pa-
tients 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 progno-
sis and full recovery commonly occurs.
A
IA8L 4
Neck Pain Impairment/Function-based Diagnosis, Examination and
Intervention Recommended Classification Criteria*
|mpz|rmeot8zsed 6ztegory
(w|th |60I0 Assoc|zt|oos) 5ymptoms |mpz|rmeots oI 8ody Fuoct|oo |oterveot|oos
|ec| pain With mobi|ity dehcit
Cervica|ia
Pain in thoracic spine
uni|atera| nec| pain
|ec| motion |imitations
0nset ot symptoms is otten
|in|ed to a recent unuarded /
aW|Ward movement or position
Associated (reterred) upper
etremity pain may be present
limited cervica| rane ot motion
|ec| pain reproduced at end
ranes ot active and passive
motions
Restricted cervica| and thoracic
sementa| mobi|ity
|ec| and nec|re|ated upper
etremity pain reproduced With
provocation ot the invo|ved cervica|
or upper thoracic sements
Cervica| mobi|ization /
manipu|ation
Thoracic mobi|ization /
manipu|ation
Stretchin eercises
Coordination, strenthenin, and
endurance eercises
|ec| Pain With leadache
leadache
Cervicocrania| syndrome
|oncontinuous, uni|atera| nec|
pain and associated (reterred)
headache
leadache is precipitated or
aravated by nec| movements or
sustained positions
leadache reproduced With
provocation ot the invo|ved upper
cervica| sements
limited cervica| rane ot motion
Restricted upper cervica| sementa|
mobi|ity
Strenth and endurance dehcits ot
the deep nec| heor musc|es
Cervica| mobi|ization /
manipu|ation
Stretchin eercises
Coordination, strenthenin, and
endurance eercises
|ec| Pain With Vovement
Coordination lmpairments
Sprain and strain ot cervica| spine
|ec| pain and associated (reterred)
upper etremity pain
Symptoms are otten |in|ed to a
precipitatin trauma/Whip|ash
and may be present tor an etended
period ot time
Strenth, endurance, and
coordination dehcits ot the deep
nec| heor musc|es
|ec| pain With midrane motion
that Worsens With end rane
movements or positions
|ec| and nec|re|ated upper
etremity pain reproduced With
provocation ot the invo|ved cervica|
sement(s)
Cervica| instabi|ity may be present
(note that musc|e spasm adjacent
to the invo|ved cervica| sement(s)
may prohibit accurate testin)
Coordination, strenthenin,
and endurance eercises
Patient education and counse|in
Stretchin eercises
|ec| Pain With Radiatin Pain
Spondy|osis With radicu|opathy
Cervica| disc disorder With
radicu|opathy
|ec| pain With associated radiatin
(narroW band ot |ancinatin) pain in
the invo|ved upper etremity
upper etremity paresthesias,
numbness, and Wea|ness may be
present
|ec| and nec|re|ated radiatin
pain reproduced With.
I. Cervica| etension, sidebendin,
and rotation toWard the invo|ved
side (Spur|in's test)
2. upper |imb tension testin
|ec| and nec|re|ated radiatin
pain re|ieved With cervica|
distraction
Vay have upper etremity sensory,
strenth, or rehe dehcits
associated With the invo|ved nerve(s)
upper quarter and nerve
mobi|ization procedures
Traction
Thoracic mobi|ization /
manipu|ation
* Recommendation based on expert opinion.
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a28 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
E PAIh0ANAI0N|6AL FAIuk5
A|thouh the cause ot nec| pain may be associated With deenera
tive processes or patho|oy identihed durin dianostic imain, the
tissue that is causin a patient's nec| pain is most otten un|noWn.
Thus, c|inicians shou|d assess tor impaired tunction ot musc|e, con
nective, and nerve tissues associated With the identihed patho|oica|
tissues When a patient presents With nec| pain.
B k|5k FA6I0k5
C|inicians shou|d consider ae reater than 4O, coeistin |oW bac|
pain, a |on history ot nec| pain, cyc|in as a reu|ar activity, |oss ot
strenth in the hands, Worrisome attitude, poor qua|ity ot |ite, and
|ess vita|ity as predisposin tactors tor the deve|opment ot chronic
nec| pain.
B 0|A6N05|56LA55|F|6AI|0N
|ec| pain, Without symptoms or sins ot serious medica| or psycho
|oica| conditions, associated With (I) motion |imitations in the cervi
ca| and upper thoracic reions, (2) headaches, and (J) reterred or
radiatin pain into an upper etremity are usetu| c|inica| hndins tor
c|assityin a patient into one ot the to||oWin lnternationa| Statistica|
C|assihcation ot 0iseases and Re|ated lea|th Prob|ems (lC0) cat
eories. cervica|ia, pain in thoracic spine, headaches, cervicocrania|
syndrome, sprain and strain ot cervica| spine, spondy|osis With
radicu|opathy, and cervica| disc disorder With radicu|opathy, and the
associated lnternationa| C|assihcation ot lunctionin, 0isabi|ity, and
lea|th (lCl) impairmentbased cateory nec| pain With the to||oWin
impairments ot body tunction.
|ec| pain With mobi|ity impairments (b/IOI Vobi|ity ot severa| joints)
|ec| pain With headaches (28OIO Pain in head and nec|)
|ec| pain With movement coordination impairments (b/GOI Contro|
ot comp|e vo|untary movements)
|ec| pain With radiatin pain (b28O4 Radiatin pain in a sement or reion)
The to||oWin physica| eamination measures may be usetu| in c|as
sityin a patient in the lCl impairmentbased cateory ot nec| pain
With mobi|ity impairments and the associated lC0 cateories ot cer
vica|ia or pain in thoracic spine.
Cervica| active rane ot motion
Cervica| and thoracic sementa| mobi|ity
The to||oWin physica| eamination measures may be usetu| in c|as
sityin a patient in the lCl impairmentbased cateory ot nec| pain
With headaches and the associated lC0 cateories ot headaches or
cervicocrania| syndrome.
Cervica| active rane ot motion
Cervica| sementa| mobi|ity
Crania| cervica| heion test
The to||oWin physica| eamination measures may be usetu| in c|as
sityin a patient in the lCl impairmentbased cateory ot nec| pain
With movement coordination impairments and the associated lC0
cateory ot sprain and strain ot cervica| spine.
Crania| cervica| heion test
0eep nec| heor endurance
The to||oWin physica| eamination measures may be usetu| in c|as
sityin a patient in the lCl impairmentbased cateory ot nec| pain
With radiatin pain and the associated lC0 cateories ot spondy|osis
With radicu|opathy or cervica| disc disorder With radicu|opathy.
upper |imb tension test
Spur|in's test
0istraction test
B 0|FFkNI|AL 0|A6N05|5
C|inicians shou|d consider dianostic c|assihcations associated With
serious patho|oica| conditions or psychosocia| tactors When the
patient's reported activity |imitations or impairments ot body tunc
tion and structure are not consistent With those presented in the di
anosis/c|assihcation section ot this uide|ine, or, When the patient's
symptoms are not reso|vin With interventions aimed at norma|iza
tion ot the patient's impairments ot body tunction.
A XAN|NAI|0N - 0uI60N NA5uk5
C|inicians shou|d use va|idated se|treport questionnaires, such as
the |ec| 0isabi|ity lnde and the PatientSpecihc lunctiona| Sca|e
tor patients With nec| pain. These too|s are usetu| tor identityin a
patient's base|ine status re|ative to pain, tunction, and disabi|ity and
tor monitorin a chane in patient's status throuhout the course ot
treatment.
F XAN|NAI|0N - A6I||IY L|N|IAI|0N NA5uk5
C|inicians shou|d uti|ize easi|y reproducib|e activity |imitation and
participation restriction measures associated With their patient's
nec| pain to assess the chanes in the patient's |eve| ot tunction over
the episode ot care.
A |NIkNI|0N5 - 6k|6AL N08|L|ZAI|0N
NAN|PuLAI|0N
C|inicians shou|d consider uti|izin cervica| manipu|ation and mobi
|ization procedures, thrust and nonthrust, to reduce nec| pain and
headache. Combinin cervica| manipu|ation and mobi|ization With
eercise is more etective tor reducin nec| pain, headache, and dis
abi|ity than manipu|ation and mobi|ization a|one.
C |NIkNI|0N5 - Ih0kA6|6 N08|L|ZAI|0N
NAN|PuLAI|0N
Thoracic spine thrust manipu|ation can be used tor patients With
primary comp|aints ot nec| pain. Thoracic spine thrust manipu|ation
can a|so be used tor reducin pain and disabi|ity in patients With
nec| and nec|re|ated arm pain.
CLINICAL GUIDELINES
Summary of Recommendations
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a29
C |NIkNI|0N5 - 5IkI6h|N6 Xk6|55
l|eibi|ity eercises can be used tor patients With nec| symptoms. E
amination and tareted heibi|ity eercises tor the to||oWin musc|es
are suested by the authors. anterior/media|/posterior sca|enes, up
per trapezius, |evator scapu|ae, pectora|is minor, and pectora|is major.
A |NIkNI|0N5 - 600k0|NAI|0N, 5IkN6IhN|N6,
AN0 N0ukAN6 Xk6|55
C|inicians shou|d consider the use ot coordination, strenthenin,
and endurance eercises to reduce nec| pain and headache.
C |NIkNI|0N5 - 6NIkAL|ZAI|0N Pk060uk5 AN0
Xk6|55
Specihc repeated movements or procedures to promote centra|iza
tion are not more benehcia| in reducin disabi|ity When compared to
other torms ot interventions.
B |NIkNI|0N5 - uPPk uAkIk AN0 Nk N08|L|ZA-
I|0N Pk060uk5
C|inicians shou|d consider the use ot upper quarter and nerve mobi|i
zation procedures to reduce pain and disabi|ity in patients With nec|
and arm pain.
B |NIkNI|0N5 - IkA6I|0N
C|inicians shou|d consider the use ot mechanica| intermittent cervi
ca| traction, combined With other interventions such as manua|
therapy and strenthenin eercises, tor reducin pain and disabi|ity
in patients With nec| and nec|re|ated arm pain.
A |NIkNI|0N5 - PAI|NI 0u6AI|0N AN0
60uN5L|N6
To improve the recovery in patients With Whip|ashassociated dis
order, c|inicians shou|d (I) educate the patient that ear|y return to
norma|, nonprovocative preaccident activities is important, and
(2) provide reassurance to the patient that ood pronosis and tu||
recovery common|y occurs.
Summary of
Recommendations (continued)
AuIh0k5
Joho 0. 6h||ds, PT, PhD
Associate Protessor 0irector ot
Research
uS ArmyBay|or university 0octora|
Proram in Physica| Therapy
San Antonio, Teas
chi|dsjd@sbc|oba|.net
Joshuz A. 6|e|zod, PT, PhD
Associate Protessor
lran||in Pierce university
Concord, |eW lampshire
joshc|e|and@comcast.net
Jzmes N. |||ott, PT, PhD
Post0octora| Research le||oW
Centre tor C|inica| Research Ece|
|ence in Spina| Pain, lnjury and
lea|th
The university ot ueens|and
Brisbane, Austra|ia
j.e||iott2@uq.edu.au
8erozrd J. 5opky, MD
0epartment ot lami|y Vedicine
Ca|itornia Permanente Vedica| Croup
Rosevi||e, Ca|itornia
Bernard.Sop|y@|p.or
0eydre Ieyheo, PT, PhD
Associate Protessor
uS ArmyBay|or university 0octora|
Proram in Physica| Therapy
San Antonio, Teas
dteyhen@sbc|oba|.net
kobert 5. wz|ooer, PT, PhD
Associate Protessor
0epartment ot Physica| Therapy
Teas State university
Vice President and 0irector ot
Research and Practice
Teas Physica| Therapy Specia|ists
|eW Brante|s, Teas
rob@tepts.com
Ju||e N. wh|tmzo, PT, DSc
Assistant Protessor
Schoo| ot Physica| Therapy
Reis university
0enver, Co|orado
0irector ot the Vanua| Physica| Ther
apy le||oWship Proram, Evidence
in Motion
jWhitman@reis.edu
Joseph J. 6odges, DPT
lCl Practice Cuide|ines Coordinator
0rthopaedic Section APTA, lnc.
la Crosse, \isconsin
ict@orthopt.or
I|mothy w. F|yoo, PT, PhD
Associate Protessor Vanua| Thera
py le||oWship Coordinator
0epartment ot Physica| Therapy
Reis university
0enver, Co|orado
thynn@reis.edu
k|wk5
Aothooy 0e||tto, PT, PhD
Protessor and Chair
Schoo| ot lea|th Rehabi|itation Sciences
university ot Pittsburh
Pittsburh, Pennsy|vania
de|ittoa@upmc.edu
6eorge N. 0yr|w, DPT
C|inica| lacu|ty
0rthopaedic Physica| Therapy and Sports
Physica| Therapy Residency Prorams
The 0hio State university Sports
Vedicine Center
Co|umbus, 0hio
eore.dyriW@osumc.edu
Amzodz Fer|zod, PT
C|inic 0irector
VVP Physica| Therapy
ledera| \ay, \ashinton
ater|and@mvppt.com
he|eoe Fezroo, PT
Principa| and Consu|tant
Rehabi|itation Consu|tin Resource
lnstitute
Phoeni, Arizona
htearonI2J@mac.com
Joy Nzc0erm|d, PT, PhD
Associate Protessor
Schoo| ot Rehabi|itation Science
VcVaster university
lami|ton, 0ntario, Canada
macderj@mcmaster.ca
Jzmes w. Nzthesoo, DPT
C|inica| Research 0irector
Therapy Partners, lnc
Burnsvi||e, Vinnesota
jmatheson@therapypartners.com
Ph|||p Nc6|ure, PT, PhD
Protessor
0epartment ot Physica| Therapy
Arcadia university
C|enside, Pennsy|vania
mcc|ure@arcadia.edu
Pzu| 5heke||e, MD, PhD
0irector
Southern Ca|itornia EvidencedBased
Practice Center
Rand Corporation
Santa Vonica, Ca|itornia
she|e||e@rand.or
A. kusse|| 5m|th, Jr, PT, Ed0
Chair
Ath|etic Trainin Physica| Therapy
university ot |orth l|orida
1ac|sonvi||e, l|orida
arsmith@unt.edu
Les||e Iorburo, DPT
Principa| and Consu|tant
Si|houette Consu|tin, lnc.
San Car|os, Ca|itornia
torburn@yahoo.com
AFF|L|AI|0N5 & 60NIA6I5
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a30 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
disorders to||oWin rearend motor vehic|e co||isions. Spine. 2OO5,JO.I/99
I8O/.
ZZ. Brontort C, Evans R, |e|son B, A|er P0, Co|dsmith Cl, Vernon l. A ran
domized c|inica| tria| ot eercise and spina| manipu|ation tor patients With
chronic nec| pain. Spine. 2OOI,2G./88/9/, discussion /98/89.
Z3. BroWder 0A, Erhard RE, Piva SR. lntermittent cervica| traction and thoracic
manipu|ation tor manaement ot mi|d cervica| compressive mye|opathy
attributed to cervica| herniated disc. a case series. J Orthop Sports Phys
Ther. 2OO4,J4./OI/I2. http.//d.doi.or/IO.25I9/jospt.2OO4.I5I9
Z4. Bruce VC, Rosenstein |E, Cappare||a 1V, Shutt lA, Per|ins BA, Co||ins
V. Ris| tactors tor meninococca| disease in co||ee students. JAMA.
2OOI,28G.G88G9J.
Z5. Bun|etorp l, |ordho|m l, Car|sson 1. A descriptive ana|ysis ot disor
ders in patients I/ years to||oWin motor vehic|e accidents. Eur Spine J.
2OO2,II.22/2J4. http.//d.doi.or/IO.IOO//sOO58GOO2OJ9Jy
Z6. Cassidy 10, Carro|| l1, Cote P, lran| 1. 0oes mu|tidiscip|inary rehabi|ita
tion beneht Whip|ash recovery7. resu|ts ot a popu|ationbased incidence
cohort study. Spine. 2OO/,J2.I2GIJI. http.//d.doi.or/IO.IO9//OI.
brs.OOOO24952G./G/88.e8
Z7. Chi|ds 10, lritz 1V, Piva SR, \hitman 1V. Proposa| ot a c|assihcation sys
tem tor patients With nec| pain. J Orthop Sports Phys Ther. 2OO4,J4.G8G
G9G, discussion G9//OO. http.//d.doi.or/IO.25I9/jospt.2OO4.I45I
Z8. Chiu TT, lam Tl, led|ey A1. A randomized contro||ed tria| on the eNcacy
ot eercise tor patients With chronic nec| pain. Spine. 2OO5,JO.EI/.
Z9. Chiu TT, laW EY, Chiu Tl. Pertormance ot the craniocervica| heion test in
subjects With and Without chronic nec| pain. J Orthop Sports Phys Ther.
2OO5,J5.5G/5/I. http.//d.doi.or/IO.25I9/jospt.2OO5.2O55
30. Chiu TT, Sin ll. Eva|uation ot cervica| rane ot motion and isometric nec|
musc|e strenth. re|iabi|ity and va|idity. Clin Rehabil. 2OO2,IG.85I858.
3I. C|are lA, Adams R, Vaher CC. A systematic revieW ot eNcacy ot Vclenzie
therapy tor spina| pain. Aust J Physiother. 2OO4,5O.2O92IG.
3Z. C|e|and 1A, Chi|ds 10, lritz 1V, \hitman 1V. lnterrater re|iabi|ity ot the
history and physica| eamination in patients With mechanica| nec| pain.
Arch Phys Med Rehabil. 2OOG,8/.IJ88IJ95. http.//d.doi.or/IO.IOIG/j.
apmr.2OOG.OG.OII
33. C|e|and 1A, Chi|ds 10, lritz 1V, \hitman 1V, Eberhart Sl. 0eve|opment ot a
c|inica| prediction ru|e tor uidin treatment ot a subroup ot patients With
nec| pain. use ot thoracic spine manipu|ation, eercise, and patient educa
tion. Phys Ther. 2OO/,8/.92J. http.//d.doi.or/IO.2522/ptj.2OOGOI55
34. C|e|and 1A, Chi|ds 10, VcRae V, Pa|mer 1A, StoWe|| T. lmmediate et
tects ot thoracic manipu|ation in patients With nec| pain. a randomized
c|inica| tria|. Man Ther. 2OO5,IO.I2/IJ5. http.//d.doi.or/IO.IOIG/j.
math.2OO4.O8.OO5
35. C|e|and 1A, Chi|ds 10, \hitman 1V. Psychometric properties ot the |ec|
0isabi|ity lnde and |umeric Pain Ratin Sca|e in patients With mechani
ca| nec| pain. Arch Phys Med Rehabil. 2OO8,89.G9/4. http.//d.doi.
or/IO.IOIG/j.apmr.2OO/.O8.I2G
36. C|e|and 1A, lritz 1V, \hitman 1V, leath R. Predictors ot shortterm out
come in peop|e With a c|inica| dianosis ot cervica| radicu|opathy. Phys
Ther. 2OO/,8/.IGI9IGJ2. http.//d.doi.or/IO.2522/ptj.2OOGO28/
37. C|e|and 1A, lritz 1V, \hitman 1V, Pa|mer 1A. The re|iabi|ity and construct
va|idity ot the |ec| 0isabi|ity lnde and patient specihc tunctiona| sca|e in
patients With cervica| radicu|opathy. Spine. 2OOG,JI.598GO2. http.//d.doi.
or/IO.IO9//OI.brs.OOOO2OI24I.9O9I4.22
38. C|e|and 1A, C|ynn P, \hitman 1V, Eberhart Sl, Vac0ona|d C, Chi|ds 10.
Shortterm etects ot thrust versus nonthrust mobi|ization/manipu|ation
directed at the thoracic spine in patients With nec| pain. a randomized
c|inica| tria|. Phys Ther. 2OO/,8/.4JI44O. http.//d.doi.or/IO.2522/
I. Adams C, Sim 1. A survey ot ul manua| therapists' practice ot and at
titudes toWards manipu|ation and its comp|ications. Physiother Res Int.
I998,J.2OG22/.
Z. A||ison CT, |ay BV, la|| T. A randomized c|inica| tria| ot manua| therapy
tor cervicobrachia| pain syndrome a pi|ot study. Man Ther. 2OO2,/.95
IO2.
3. American Co||ee ot Radio|oy Epert Pane| on Vuscu|os|e|eta| lmain.
ACR Appropriateness Criteria. Suspected Cervica| Spine Trauma. Reston,
VA. American Co||ee ot Radio|oy, 2OOI.
4. Andersson ll. The epidemio|oy ot chronic pain in a SWedish rura| area.
Qual Life Res. I994,J Supp| I.SI92G.
5. Antonaci l, Chirmai S, Bono C, |appi C. Current methods tor cervica| spine
movement eva|uation. a revieW. Clin Exp Rheumatol. 2OOO,I8.S4552.
6. Antonaci l, Chirmai S, Bono C, Sandrini C, |appi C. Cervicoenic
headache. eva|uation ot the oriina| dianostic criteria. Cephalalgia.
2OOI,2I.5/J58J.
7. Asavasopon S, 1an|os|i 1, Codes 11. C|inica| dianosis ot vertebrobasi
|ar insuNciency. resident's case prob|em. J Orthop Sports Phys Ther.
2OO5,J5.G45G5O. http.//d.doi.or/IO.25I9/jospt.2OO5.I/J2
8. Attia 1, lata|a R, Coo| 01, \on 1C. The rationa| c|inica| eamination. 0oes
this adu|t patient have acute meninitis7 JAMA. I999,282.I/5I8I.
9. Berne 10, |orWood Sl, VcAu|ey CE, Vi||area| 0l. le|ica| computed tomo
raphic anioraphy. an ece||ent screenin test tor b|unt cerebrovascu|ar
injury. J Trauma. 2OO4,5/.III/, discussion I/I9.
I0. Bernhardt V, lynes RA, B|ume l\, \hite AA, Jrd. Cervica| spondy|otic
mye|opathy. J Bone Joint Surg Am. I99J,/5.II9I28.
II. Berti|son BC, Crunnesjo V, Strender lE. Re|iabi|ity ot c|inica| tests
in the assessment ot patients With nec|/shou|der prob|emsimpact
ot history. Spine. 2OOJ,28.222222JI. http.//d.doi.or/IO.IO9//OI.
BRS.OOOOO89G85.55G29.2E
IZ. Boden S0, 0avis 00, 0ina TS, Patronas |1, \iese| S\. Abnorma| manetic
resonance scans ot the |umbar spine in asymptomatic subjects. A prospec
tive investiation. J Bone Joint Surg Am. I99O,/2.4OJ4O8.
I3. Bodu| |, Vars|and A. The cervica| zyapophysia| joints as a source ot
nec| pain. Spine. I988,IJ.GIOGI/.
I4. Borchrevin| C, Smevi| 0, laave l, lara|dseth 0, |ordby A, lereim l. VRl
ot cerebrum and cervica| co|umna Within tWo days atter Whip|ash nec|
sprain injury. Injury. I99/,28.JJIJJ5.
I5. Borhouts 1A, loes B\, Bouter lV. The c|inica| course and pronostic tac
tors ot nonspecihc nec| pain. a systematic revieW. Pain. I998,//.IIJ.
I6. Borhouts 1A, loes B\, Vonde|in l, Bouter lV. Costoti||ness ot nec|
pain in The |ether|ands in I99G. Pain. I999,8O.G29GJG.
I7. Bot S0, van der \aa| 1V, TerWee CB, et a|. lncidence and preva|ence ot
comp|aints ot the nec| and upper etremity in enera| practice. Ann Rheum
Dis. 2OO5,G4.II8I2J. http.//d.doi.or/IO.IIJG/ard.2OOJ.OI9J49
I8. Bot S0, van der \aa| 1V, TerWee CB, et a|. Predictors ot outcome in
nec| and shou|der symptoms. a cohort study in enera| practice. Spine.
2OO5,JO.E4594/O.
I9. Bovim C, Schrader l, Sand T. |ec| pain in the enera| popu|ation. Spine.
I994,I9.IJO/IJO9.
Z0. Brattber C, Thors|und V, \i|man A. The preva|ence ot pain in a enera|
popu|ation. The resu|ts ot a posta| survey in a county ot SWeden. Pain.
I989,J/.2I5222.
ZI. Brison R1, lart|in l, 0osta|er S, et a|. A randomized contro||ed tria| ot an
educationa| intervention to prevent the chronic pain ot Whip|ash associated
kFkN65
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a31
ptj.2OOGO2I/
39. C|e|and 1A, \hitman 1V, lritz 1V, Pa|mer 1A. Vanua| physica| therapy,
cervica| traction, and strenthenin eercises in patients With cervica|
radicu|opathy. a case series. J Orthop Sports Phys Ther. 2OO5,J5.8O28II.
http.//d.doi.or/IO.25I9/jospt.2OO5.2O//
40. C|oWard RB. Cervica| dis|oraphy. A contribution to the etio|oy and mech
anism ot nec|, shou|der and arm pain. Ann Surg. I959,I5O.IO52IOG4.
4I. Coppieters V\, Stappaerts ll, \outers ll, 1anssens l. The immediate
etects ot a cervica| |atera| |ide treatment technique in patients With neuro
enic cervicobrachia| pain. J Orthop Sports Phys Ther. 2OOJ,JJ.JG9J/8.
4Z. Cote P, Cassidy 10, Carro|| l. The tactors associated With nec| pain and its
re|ated disabi|ity in the Sas|atcheWan popu|ation. Spine. 2OOO,25.IIO9
III/.
43. Cote P, Cassidy 10, Carro|| l. The Sas|atcheWan lea|th and Bac| Pain
Survey. The preva|ence ot nec| pain and re|ated disabi|ity in Sas|atcheWan
adu|ts. Spine. I998,2J.IG89IG98.
44. Cote P, Cassidy 10, Carro|| l1, lristman V. The annua| incidence and course
ot nec| pain in the enera| popu|ation. a popu|ationbased cohort study.
Pain. 2OO4,II2.2G/2/J. http.//d.doi.or/IO.IOIG/j.pain.2OO4.O9.OO4
45. CraWtord 1R, lhan R1, Var|ey C\. Ear|y manaement and outcome to||oW
in sott tissue injuries ot the nec|a randomised contro||ed tria|. Injury.
2OO4,J5.89I895. http.//d.doi.or/IO.IOIG/j.injury.2OO4.OI.OII
46. Crott PR, leWis V, Papaeoriou AC, et a|. Ris| tactors tor nec| pain. a
|onitudina| study in the enera| popu|ation. Pain. 2OOI,9J.JI/J25.
47. 0atner Rl. Cervica| radioraphy tor trauma patients. a timeetective tech
nique7 AJR Am J Roentgenol. 2OOO,I/5.IJO9IJII.
48. 0atner Rl, 0a|in|a Vl, A|azra|i |, et a|. Chronic nec| pain. American
Co||ee ot Radio|oy. ACR Appropriateness Criteria. Radiology. 2OOO,2I5
Supp|.J45J5G.
49. 0e|hni R, 0orizzi A, lacchinetti C, laccio|i l, Ca|zio R, Vane|ista T. 0e|ayed
posttraumatic cervica| instabi|ity. Surg Neurol. I999,5I.588594, discus
sion 594585.
50. 0i labio RP. Vanipu|ation ot the cervica| spine. ris|s and benehts. Phys
Ther. I999,/9.5OG5.
5I. 0i labio RP, Boissonnau|t \. Physica| therapy and hea|thre|ated outcomes
tor patients With common orthopaedic dianoses. J Orthop Sports Phys
Ther. I998,2/.2I92JO.
5Z. 0rottnin V, Stat P, levin l, Va|t u. Acute emotiona| response to common
Whip|ash predicts subsequent pain comp|aints. a prospective study ot IO/
subjects sustainin Whip|ash injury. Nordic J Psych. I995,49.29J299.
53. E||iott 1, 1u|| C, |oteboom 1T, 0arne|| R, Ca||oWay C, Cibbon \\. latty inh|
tration in the cervica| etensor musc|es in persistent Whip|ashassociated
disorders. a manetic resonance imain ana|ysis. Spine. 2OOG,JI.E84/
855. http.//d.doi.or/IO.IO9//OI.brs.OOOO24O84I.O/O5O.J4
54. E||iott 1, 1u|| C, |oteboom 1T, Ca||oWay C. VRl study ot the crosssectiona|
area tor the cervica| etensor muscu|ature in patients With persistent
Whip|ash associated disorders (\A0). Man Ther. 2OO8,IJ.2582G5. http.//
d.doi.or/IO.IOIG/j.math.2OO/.OI.OI2
55. E|naar lV, |ordin V, Shei|hzadeh A, Parnianpour V, lahanovitz |. Et
tects ot spina| heion and etension eercises on |oWbac| pain and spina|
mobi|ity in chronic mechanica| |oWbac| pain patients. Spine. I99I,IG.9G/
9/2.
56. Ernst E. Vanipu|ation ot the cervica| spine. a systematic revieW ot case re
ports ot serious adverse events, I9952OOI. Med J Aust. 2OO2,I/G.J/GJ8O.
57. Evans 0\. Vechanisms and etects ot spina| hihve|ocity, |oWamp|itude
thrust manipu|ation. previous theories. J Manipulative Physiol Ther.
2OO2,25.25I2G2.
58. Evans R, Brontort C, |e|son B, Co|dsmith Cl. TWoyear to||oWup ot a ran
domized c|inica| tria| ot spina| manipu|ation and tWo types ot eercise tor
patients With chronic nec| pain. Spine. 2OO2,2/.2J8J2J89. http.//d.doi.
or/IO.IO9//OI.BRS.OOOOOJOI92.J9J2G.ll
59. lernandez de |as Penas C, lernandez Carnero 1, P|aza lernandez A, lomas
Vea R, Viano|arra Pae 1C. 0orsa| manipu|ation in Whip|ash injury treat
ment. a randomized contro||ed tria|. Whiplash Rel Dis. 2OO4,J.55/2.
60. lerrari R, RoWe Bl, Vajumdar SR, et a|. Simp|e educationa| intervention to
improve the recovery trom acute Whip|ash. resu|ts ot a randomized, con
tro||ed tria|. Acad Emerg Med. 2OO5,I2.G99/OG. http.//d.doi.or/IO.II9//j.
aem.2OO5.OJ.5JI
6I. l|ynn T\, \ainner RS, \hitman 1V, Chi|ds 10. The immediate etect ot tho
racic spine manipu|ation on cervica| rane ot motion and pain in patients
With a primary comp|aint ot nec| pain, a technica| note. Orthop Div Rev.
2OO/,Varch/Apri|.
6Z. lritz 1V, Brennan CP. Pre|iminary eamination ot a proposed treatment
based c|assihcation system tor patients receivin physica| therapy
interventions tor nec| pain. Phys Ther. 2OO/,8/.5IJ524. http.//d.doi.
or/IO.2522/ptj.2OOGOI92
63. lritz 1V, Ceore SZ. ldentityin psychosocia| variab|es in patients With
acute Wor|re|ated |oW bac| pain. the importance ot tearavoidance be|iets.
Phys Ther. 2OO2,82.9/J98J.
64. lritz 1V, Ceore SZ, 0e|itto A. The ro|e ot tearavoidance be|iets in acute
|oW bac| pain. re|ationships With current and tuture disabi|ity and Wor|
status. Pain. 2OOI,94./I5.
65. Ceore SZ, lritz 1V, Erhard RE. A comparison ot tearavoidance be
|iets in patients With |umbar spine pain and cervica| spine pain. Spine.
2OOI,2G.2IJ92I45.
66. Core 0R, Sepic SB, Cardner CV, Vurray VP. |ec| pain. a |onterm to||oW
up ot 2O5 patients. Spine. I98/,I2.I5.
67. Craham |, Cross AR, Co|dsmith C. Vechanica| traction tor mechanica|
nec| disorders. a systematic revieW. J Rehabil Med. 2OOG,J8.I45I52.
http.//d.doi.or/IO.IO8O/IG5OI9/OGOO58JO29
68. Cross AR, Co|dsmith C, lovin 1l, et a|. Conservative manaement ot me
chanica| nec| disorders. a systematic revieW. J Rheumatol. 2OO/,J4.IO8J
IIO2.
69. Cross AR, lovin 1l, laines TA, et a|. A Cochrane revieW ot manipu|ation
and mobi|ization tor mechanica| nec| disorders. Spine. 2OO4,29.I54II548.
70. Cross AR, lay TV, lennedy C, et a|. C|inica| practice uide|ine on the use
ot manipu|ation or mobi|ization in the treatment ot adu|ts With mechanica|
nec| disorders. Man Ther. 2OO2,/.I9J2O5.
7I. Cuyatt Cl, Sac|ett 0l, Sinc|air 1C, layWard R, Coo| 01, Coo| R1. users'
uides to the medica| |iterature. lX. A method tor radin hea|th care
recommendations. EvidenceBased Vedicine \or|in Croup. JAMA.
I995,2/4.I8OOI8O4.
7Z. la|deman S, loh|bec| l1, VcCreor V. Ris| tactors and precipitatin nec|
movements causin vertebrobasi|ar artery dissection atter cervica| trauma
and spina| manipu|ation. Spine. I999,24./85/94.
73. la||ren RC, Creenman PE, Rechtien 11. Atrophy ot suboccipita| musc|es
in patients With chronic pain. a pi|ot study. J Am Osteopath Assoc.
I994,94.IOJ2IOJ8.
74. lammi|| 1V, Coo| TV, Rosecrance 1C. Etectiveness ot a physica|
therapy reimen in the treatment ot tensiontype headache. Headache.
I99G,JG.I49I5J.
75. larris l0, leer 0V, Roy TC, Santos 0V, \hitman 1V, \ainner RS. Re|i
abi|ity ot a measurement ot nec| heor musc|e endurance. Phys Ther.
2OO5,85.IJ49IJ55.
76. li|| 1, leWis V, Papaeoriou AC, 0ziedzic l, Crott P. Predictin persistent
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a32 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
nec| pain. a Iyear to||oWup ot a popu|ation cohort. Spine. 2OO4,29.IG48
IG54.
77. lotman 1R, VoWer \R, \o|tson AB, Todd ll, Zuc|er Vl. Va|idity ot a set ot
c|inica| criteria to ru|e out injury to the cervica| spine in patients With b|unt
trauma. |ationa| Emerency XRadioraphy uti|ization Study Croup. N Engl
J Med. 2OOO,J4J.9499.
78. lo|mstrom EB, linde|| 1, Voritz u. loW bac| and nec|/shou|der pain in
construction Wor|ers. occupationa| Wor||oad and psychosocia| ris| tactors.
Part 2. Re|ationship to nec| and shou|der pain. Spine. I992,I/.G/2G//.
79. lonet 1C, Puri l. Cervica| radicu|itis. treatment and resu|ts in 82 patients.
Arch Phys Med Rehabil. I9/G,5/.I2IG.
80. lovin 1l, de Vet lC, TWis| 1\, et a|. Pronostic tactors tor nec| pain in
enera| practice. Pain. 2OO4,IIO.GJ9G45. http.//d.doi.or/IO.IOIG/j.
pain.2OO4.O5.OO2
8I. lovin 1l, Cross AR, Casner 0, et a|. A critica| appraisa| ot revieW artic|es
on the etectiveness ot conservative treatment tor nec| pain. Spine.
2OOI,2G.I9G2O5.
8Z. lovin 1l, loes B\, de Vet lC, et a|. Vanua| therapy, physica| therapy,
or continued care by a enera| practitioner tor patients With nec| pain. A
randomized, contro||ed tria|. Ann Intern Med. 2OO2,IJG./IJ/22.
83. lovin 1l, Poo| 11, van Vameren l, et a|. Reproducibi|ity ot cervica|
rane ot motion in patients With nec| pain. BMC Musculoskelet Disord.
2OO5,G.59. http.//d.doi.or/IO.II8G/I4/I24/4G59
84. lurWitz El, A|er P0, Adams Al, Vee|er \C, She|e||e PC. Vanipu|ation
and mobi|ization ot the cervica| spine. A systematic revieW ot the |iterature.
Spine. I99G,2I.I/4GI/59, discussion I/59I/GO.
85. lurWitz El, Vorenstern l, Vassi|a|i V, Chian lV. lrequency and c|inica|
predictors ot adverse reactions to chiropractic care in the uClA nec| pain
study. Spine. 2OO5,JO.I4//I484.
86. lnternationa|. lnternationa| C|assihcation ot lunctionin, 0isabi|ity and
lea|th. lCl. Ceneva, SWitzer|and. \orth lea|th 0ranization, 2OOI.
87. lnternationa| Statistica| C|assihcation ot 0iseases and lea|th Re|ated Prob
|ems lC0IO. Cenera SWitzer|and. \or|d lea|th 0ranization, 2OO5.
88. 1acobsson l, lindarde l, Vanthorpe R. The commonest rheumatic com
p|aints ot over si Wee|s' duration in a tWe|vemonth period in a dehned
SWedish popu|ation. Preva|ences and re|ationships. Scand J Rheumatol.
I989,I8.J5JJGO.
89. 1aesch|e R, Siner 1, Cuyatt Cl. Veasurement ot hea|th status. Ascer
tainin the minima| c|inica||y important diterence. Control Clin Trials.
I989,IO.4O/4I5.
90. 1ett 1R. Superior su|cus tumors and Pancoast's syndrome. Lung Cancer.
2OOJ,42 Supp| 2.SI/2I.
9I. 1ette AV, Smith l, la|ey SV, 0avis l0. Physica| therapy episodes ot care
tor patients With |oW bac| pain. Phys Ther. I994,/4.IOIIIO, discussion IIO
IO5.
9Z. 1ette 0u, 1ette AV. Physica| therapy and hea|th outcomes in patients With
spina| impairments. Phys Ther. I99G,/G.9JO94I, discussion 9429J5.
93. 1ohataei VT, Arab AV, lha|sar l. The etect ot cervica| traction combined
With conventiona| therapy on rip strenth on patients With cervica| radicu|
opathy. Clin Rehabil. 2OO4,I8.8/988/.
94. 1ohansson l, Soj|a P. Pathophysio|oica| mechanisms invo|ved in en
esis and spread ot muscu|ar tension in occupationa| musc|e pain and in
chronic muscu|os|e|eta| pain syndromes. a hypothesis. Med Hypotheses.
I99I,J5.I9G2OJ.
95. 1ohnson EC, Codes 11, lohman EB, Stephens 1A, Zimmerman C1, An
derson SP. 0isabi|ity se|tassessment and upper quarter musc|e ba|ance
betWeen tema|e denta| hyienists and nondenta| hyienists. J Dent Hyg.
2OOJ,//.2I/22J.
96. 1u|| C, Barrett C, Vaee R, lo P. lurther c|inica| c|arihcation ot the musc|e
dystunction in cervica| headache. Cephalalgia. I999,I9.I/9I85.
97. 1u|| C, la||a 0, Tre|eaven 1, lodes P, Vicenzino B. Retrainin cervica|
joint position sense. the etect ot tWo eercise reimes. J Orthop Res.
2OO/,25.4O44I2. http.//d.doi.or/IO.IOO2/jor.2O22O
98. 1u|| C, Ster|in V, lenardy 1, Be||er E. 0oes the presence ot sensory
hypersensitivity inhuence outcomes ot physica| rehabi|itation tor chronic
Whip|ash7A pre|iminary RCT. Pain. 2OO/,I29.28J4. http.//d.doi.
or/IO.IOIG/j.pain.2OOG.O9.OJO
99. 1u|| C, Trott P, Potter l, et a|. A randomized contro||ed tria| ot eercise and
manipu|ative therapy tor cervicoenic headache. Spine. 2OO2,2/.I8J5
I84J, discussion I84J.
I00. 1u|| C, Zito C, Trott P, Potter l, Shir|ey 0. lntereaminer re|iabi|ity to detect
paintu| upper cervica| joint dystunction. Aust J Physiother. I99/,4J.I25I29.
I0I. laa|e BR, lra|enes 1, A|bre|tsen C, \ester l. lead position and impact
direction in Whip|ash injuries. associations With VRlverihed |esions ot
|iaments and membranes in the upper cervica| spine. J Neurotrauma.
2OO5,22.I294IJO2. http.//d.doi.or/IO.IO89/neu.2OO5.22.I294
I0Z. laa|e BR, lra|enes 1, A|bre|tsen C, \ester l. \hip|ashassociated
disorders impairment ratin. nec| disabi|ity inde score accordin to
severity ot VRl hndins ot |iaments and membranes in the upper cervi
ca| spine. J Neurotrauma. 2OO5,22.4GG4/5. http.//d.doi.or/IO.IO89/
neu.2OO5.22.4GG
I03. lay TV, Cross A, Co|dsmith C, Santauida Pl, lovin 1, Brontort C.
Eercises tor mechanica| nec| disorders. Cochrane Database Syst Rev.
2OO5,C0OO425O. http.//d.doi.or/IO.IOO2/I4G5I858.C0OO425O.pubJ
I04. lje||man C, 0ber B. A randomized c|inica| tria| comparin enera| eer
cise, Vclenzie treatment and a contro| roup in patients With nec| pain. J
Rehabil Med. 2OO2,J4.I8JI9O.
I05. lnutson CA. Sinihcant chanes in systo|ic b|ood pressure post vectored
upper cervica| adjustment vs restin contro| roups. a possib|e etect ot
the cervicosympathetic and/or pressor rehe. J Manipulative Physiol Ther.
2OOI,24.IOIIO9. http.//d.doi.or/IO.IOG//mmt.2OOI.II25G4
I06. lortha|sde Bos lB, lovin 1l, van Tu|der V\, et a|. Cost etectiveness
ot physiotherapy, manua| therapy, and enera| practitioner care tor nec|
pain. economic eva|uation a|onside a randomised contro||ed tria|. BMJ.
2OOJ,J2G.9II. http.//d.doi.or/IO.IIJG/bmj.J2G./J95.9II
I07. lra|enes 1, laa|e BR. Vanetic resonance imain assessment ot
craniovertebra| |iaments and membranes atter Whip|ash trauma. Spine.
2OOG,JI.282O282G. http.//d.doi.or/IO.IO9//OI.brs.OOOO2458/I.I5G9G.It
I08. lra|enes 1, laa|e BR, Voen C, |ord|i l, Ci|hus |E, Rorvi| 1. VRl assess
ment ot the a|ar |iaments in the |ate stae ot Whip|ash injurya study
ot structura| abnorma|ities and observer areement. Neuroradiology.
2OO2,44.GI/G24. http.//d.doi.or/IO.IOO//sOO2J4OO2O/99G
I09. lriss TC, lriss VV. |ec| pain. Primary care Wor|up ot acute and chronic
symptoms. Geriatrics. 2OOO,55.4/48, 5I44, 5/.
II0. lristjansson E. Re|iabi|ity ot u|trasonoraphy tor the cervica| mu|tihdus
musc|e in asymptomatic and symptomatic subjects. Man Ther. 2OO4,9.8J
88. http.//d.doi.or/IO.IOIG/SIJ5GG89X(OJ)OOO59G
III. lristjansson E, leivseth C, Brinc|mann P, lrobin \. lncreased saitta|
p|ane sementa| motion in the |oWer cervica| spine in Women With chronic
Whip|ashassociated disorders, rades lll. a casecontro| study usin
a neW measurement protoco|. Spine. 2OOJ,28.22I5222I. http.//d.doi.
or/IO.IO9//OI.BRS.OOOOO89525.59G84.49
IIZ. luch l, Co B1, Evans R1, Shu|man l. Phobias, panic, and pain in 55 survi
vors ot road vehic|e accidents. J Anxiety Disord. I994,8.I8II8/.
II3. lWa| S, |ieder||ein R, Tarcha R, luhes C. Re|ationship betWeen active
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a33
cervica| rane ot motion and perceived nec| disabi|ity in community dWe||
in e|der|y individua|s. J Geriatr Phys Ther. 2OO5,28.545G.
II4. linton S1. A revieW ot psycho|oica| ris| tactors in bac| and nec| pain.
Spine. 2OOO,25.II48II5G.
II5. linton S1, Ryber V. 0o epidemio|oica| resu|ts rep|icate7 The preva|ence
and hea|theconomic consequences ot nec| and bac| pain in the en
era| popu|ation. Eur J Pain. 2OOO,4.J4/J54. http.//d.doi.or/IO.IO5J/
eujp.2OOO.OI9O
II6. Va|e|a V, le|iovaara V, Sievers l, lmpivaara 0, lne|t P, Aromaa A. Preva
|ence, determinants, and consequences ot chronic nec| pain in lin|and.
Am J Epidemiol. I99I,IJ4.IJ5GIJG/.
II7. VcC|une T, Burton Al, \adde|| C. Eva|uation ot an evidence based patient
educationa| boo||et tor manaement ot Whip|ash associated disorders.
Emerg Med J. 2OOJ,2O.5I45I/.
II8. Vclenzie RA. The Cervical and Thoracic Spine: Mechanical Diagnosis and
Therapy. \ai|anae, |eW Zea|and. Spina| Pub|ications, 2OO9.
II9. VcPart|and 1V, Brodeur RR, la||ren RC. Chronic nec| pain, standin
ba|ance, and suboccipita| musc|e atrophya pi|ot study. J Manipulative
Physiol Ther. I99/,2O.2429.
IZ0. Voeti P, Varchetti C. C|inica| outcome trom mechanica| intermittent cervi
ca| traction tor the treatment ot cervica| radicu|opathy. a case series. J
Orthop Sports Phys Ther. 2OOI,JI.2O/2IJ.
IZI. Vos|ovich R. |ec| pain in the e|der|y. common causes and manaement.
Geriatrics. I988,4J.G5/O, //, 8IG2 passim.
IZZ. Vurphy 0R, lurWitz El, Creory A, C|ary R. A nonsurica| approach to the
manaement ot patients With cervica| radicu|opathy. a prospective obser
vationa| cohort study. J Manipulative Physiol Ther. 2OOG,29.2/928/. http.//
d.doi.or/IO.IOIG/j.jmpt.2OOG.OJ.OO5
IZ3. |ederhand V1, ljzerman V1, lermens l1, Tur| 0C, Zi|vo|d C. Predic
tive va|ue ot tear avoidance in deve|opin chronic nec| pain disabi|ity.
consequences tor c|inica| decision ma|in. Arch Phys Med Rehabil.
2OO4,85.49G5OI.
IZ4. |e|son B\, Carpenter 0V, 0reisiner TE, Vitche|| V, le||y CE, \ener 1A.
Can spina| surery be prevented by aressive strenthenin eercises7 A
prospective study ot cervica| and |umbar patients. Arch Phys Med Rehabil.
I999,8O.2O25.
IZ5. |i|sson |, Christensen l\, lartvisen 1. The etect ot spina| manipu|ation
in the treatment ot cervicoenic headache. J Manipulative Physiol Ther.
I99/,2O.J2GJJO.
IZ6. |yren A, Ber|und A, von loch V. |ec|andshou|der pain, an increasin
prob|em. Strateies tor usin insurance materia| to to||oW trends. Scand J
Rehabil Med Suppl. I995,J2.IO/II2.
IZ7. 0'leary S, la||a 0, lodes P\, 1u|| C, Vicenzino B. Specihc therapeutic e
ercise ot the nec| induces immediate |oca| hypoa|esia. J Pain. 2OO/,8.8J2
8J9. http.//d.doi.or/IO.IOIG/j.jpain.2OO/.O5.OI4
IZ8. 0sterbauer P1, lon l, Ribaudo TA, et a|. Threedimensiona| head |inemat
ics and cervica| rane ot motion in the dianosis ot patients With nec|
trauma. J Manipulative Physiol Ther. I99G,I9.2JI2J/.
IZ9. Pa|mer lT, \a||erBone l, CriNn V1, et a|. Preva|ence and occupationa|
associations ot nec| pain in the British popu|ation. Scand J Work Environ
Health. 2OOI,2/.495G.
I30. Payne R. |ec| pain in the e|der|y. a manaement revieW. Part l. Geriatrics.
I98/,42.59G2, G5.
I3I. Payne R. |ec| pain in the e|der|y. a manaement revieW. Part ll. Geriatrics.
I98/,42./I/J.
I3Z. Peeb|es 1E, Vc\i||iams lA, Vaclennan R. A comparison ot symptom
chec||ist 9Orevised proh|es trom patients With chronic pain trom Whip|ash
and patients With other muscu|os|e|eta| injuries. Spine. 2OOI,2G./GG//O.
I33. Pettersson l, li|dinsson C, Too|anen C, laer|und V, Bjornebrin| 1. VRl
and neuro|oy in acute Whip|ash trauma. |o corre|ation in prospective
eamination ot J9 cases. Acta Orthop Scand. I994,G5.525528.
I34. Pietrobon R, Coeytau RR, Carey TS, Richardson \1, 0eVe||is Rl. Standard
sca|es tor measurement ot tunctiona| outcome tor cervica| pain or dys
tunction. a systematic revieW. Spine. 2OO2,2/.5I5522.
I35. Prans|y C, Benjamin l, li||lotouhi C, et a|. 0utcomes in Wor|re|ated
upper etremity and |oW bac| injuries. resu|ts ot a retrospective study.
Am J Ind Med. 2OOO,J/.4OO4O9. http.//d.doi.or/IO.IOO2/(SlCl)IO9/
O2/4(2OOOO4)J/.44OO..Al0A1lVIO>J.O.C0,2C [pii|
I36. Radha|rishnan l, litchy \1, 0'la||on \V, lur|and lT. Epidemio|oy ot cer
vica| radicu|opathy. A popu|ationbased study trom Rochester, Vinnesota,
I9/G throuh I99O. Brain. I994,II/ ( Pt 2).J25JJ5.
I37. Raney |l, Petersen E1, Smith TA, et a|. 0eve|opment ot a c|inica| prediction
ru|e to identity patients With nec| pain |i|e|y to beneht trom cervica| trac
tion and eercise. Eur Spine J. ln press,
I38. Rempe| 0V, larrison R1, Barnhart S. \or|re|ated cumu|ative trauma
disorders ot the upper etremity. JAMA. I992,2G/.8J8842.
I39. Ridd|e 0l, Strattord P\. use ot eneric versus reionspecihc tunctiona|
status measures on patients With cervica| spine disorders. Phys Ther.
I998,/8.95I9GJ.
I40. Robinson 0, la|perin |, Aar C, A|| 0, Rami l. Shou|der ird|e neop|asms
mimic|in trozen shou|der syndrome. J Shoulder Elbow Surg. 2OOJ,I2.45I
455. http.//d.doi.or/IO.IOIG/SIO582/4GOJOOO922
I4I. Ronnen lR, de lorte P1, Brin| PR, van der Bij| l1, Tonino A1, lran|e Cl.
Acute Whip|ash injury. is there a ro|e tor VR imain7a prospective study
ot IOO patients. Radiology. I99G,2OI.9J9G.
I4Z. Rosente|d V, Seteriadis A, Car|sson 1, Cunnarsson R. Active intervention in
patients With Whip|ashassociated disorders improves |onterm pronosis.
a randomized contro||ed c|inica| tria|. Spine. 2OOJ,28.249I2498. http.//
d.doi.or/IO.IO9//OI.BRS.OOOOO9O822.9G8I4.IJ
I43. Saa| 1S, Saa| 1A, Yurth El. |onoperative manaement ot herniated cervica|
intervertebra| disc With radicu|opathy. Spine. I99G,2I.I8//I88J.
I44. Sandmar| l, |ise|| R. Va|idity ot hve common manua| nec| pain provo|in
tests. Scand J Rehabil Med. I995,2/.IJIIJG.
I45. SariBahat l. Evidence tor eercise therapy in mechanica| nec| disorders.
Man Ther. 2OOJ,8.IO2O.
I46. Sasso RC, Vacadae l, |ordmann 0, Smith V. Se|ective nerve root
injections can predict surica| outcome tor |umbar and cervica| radicu|
opathy. comparison to manetic resonance imain. J Spinal Disord Tech.
2OO5,I8.4/I4/8.
I47. Savo|ainen A, Ah|ber 1, |ummi|a l, |issinen V. Active or passive treat
ment tor nec|shou|der pain in occupationa| hea|th care7 A randomized
contro||ed tria|. Occup Med (Lond). 2OO4,54.422424. http.//d.doi.
or/IO.IO9J/occmed/|qhO/O
I48. Schnabe| V, lerrari R, Vassi|iou T, la|uza C. Randomised, contro||ed
outcome study ot active mobi|isation compared With co||ar therapy tor
Whip|ash injury. Emerg Med J. 2OO4,2I.JOGJIO.
I49. Senstad 0, leboeutYde C, Borchrevin| C. lrequency and characteristics
ot side etects ot spina| manipu|ative therapy. Spine. I99/,22.4J544O,
discussion 44O4JI.
I50. Sieben 1V, V|aeyen 1\, Porteijs P1, et a|. A |onitudina| study on the
predictive va|idity ot the tearavoidance mode| in |oW bac| pain. Pain.
2OO5,II/.IG2I/O. http.//d.doi.or/IO.IOIG/j.pain.2OO5.OG.OO2
I5I. Si|bert Pl, Vo|ri B, Schievin| \l. leadache and nec| pain in spontaneous in
terna| carotid and vertebra| artery dissections. Neurology. I995,45.I5I/I522.
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a34 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
I5Z. Snyder l, Robinson l, Shah 0, Brennan R, landrian V. Sins and symp
toms ot patients With brain tumors presentin to the emerency depart
ment. J Emerg Med. I99J,II.25J258.
I53. Soder|und A, lindber P. An interated physiotherapy/conitivebehavioura|
approach to the ana|ysis and treatment ot chronic Whip|ash associated
disorders, \A0. Disabil Rehabil. 2OOI,2J.4JG44/.
I54. Spen|er 0V, lirsh VV, lauter l. 0rthopaedic aspects and ear|y dia
nosis ot superior su|cus tumor ot |un (Pancoast). J Bone Joint Surg Am.
I9/J,55.IG45IG5O.
I55. Ster|in V, 1u|| C, lenardy 1. Physica| and psycho|oica| tactors maintain
|onterm predictive capacity postWhip|ash injury. Pain. 2OOG,I22.IO2IO8.
http.//d.doi.or/IO.IOIG/j.pain.2OOG.OI.OI4
I56. Ster|in V, 1u|| C, Vicenzino B, lenardy 1. Sensory hypersensitivity occurs
soon atter Whip|ash injury and is associated With poor recovery. Pain.
2OOJ,IO4.5O95I/.
I57. Ster|in V, 1u|| C, Vicenzino B, lenardy 1, 0arne|| R. 0eve|opment ot motor
system dystunction to||oWin Whip|ash injury. Pain. 2OOJ,IOJ.G5/J.
I58. Ster|in V, lenardy 1, 1u|| C, Vicenzino B. The deve|opment ot psycho|oi
ca| chanes to||oWin Whip|ash injury. Pain. 2OOJ,IOG.48I489.
I59. Stie|| lC, \e||s CA, Vandemheen ll, et a|. The Canadian Cspine ru|e tor ra
dioraphy in a|ert and stab|e trauma patients. JAMA. 2OOI,28G.I84II848.
I60. Strattord P\, Ci|| C, \estaWay V0, Bin||ey 1V. Assessin disabi|ity and
chane on individua| patients. a report ot a patientspecihc measure. Phys-
iother Can. I995,4/.258.
I6I. Strattord P\, Ridd|e 0l, Bin||ey 1V, Spadoni C, \estaWay V0, Padhe|d
B. usin the nec| disabi|ity inde to ma|e decisions concernin individua|
patients. Physiother Can. I999,5I.IO/II2.
I6Z. Taime|a S, Ta|a|a EP, As||ot T, Seppa|a l, Parviainen S. Active treatment
ot chronic nec| pain. a prospective randomized intervention. Spine.
2OOO,25.IO2IIO2/.
I63. Ta|a|a EP, Vii|ari1untura E, Tyn||ynen EV. 0oes roup ymnastics at the
Wor|p|ace he|p in nec| pain7 A contro||ed study. Scand J Rehabil Med.
I994,2G.I/2O.
I64. Ton lC, lai A1, Yama|aWa l. The Spur|in test and cervica| radicu|opa
thy. Spine. 2OO2,2/.I5GI59.
I65. Tousinant V, Smeesters C, Breton AV, Breton E, Corriveau l. Criterion
va|idity study ot the cervica| rane ot motion (CR0V) device tor rota
tiona| rane ot motion on hea|thy adu|ts. J Orthop Sports Phys Ther.
2OOG,JG.242248. http.//d.doi.or/IO.25I9/jospt.2OOG.2I48
I66. Tsen Yl, \an \T, Chen \Y, lou T1, Chen TC, lieu ll. Predictors tor the
immediate responders to cervica| manipu|ation in patients With nec| pain.
Man Ther. 2OOG,II.JOGJI5. http.//d.doi.or/IO.IOIG/j.math.2OO5.O8.OO9
I67. van der 0on| 1, Schouten 1S, Passchier 1, van Romunde ll, Va||enbur
lA. The associations ot nec| pain With radio|oica| abnorma|ities ot the
cervica| spine and persona|ity traits in a enera| popu|ation. J Rheumatol.
I99I,I8.I884I889.
I68. van Saase 1l, van Romunde ll, Cats A, Vandenbrouc|e 1P, Va||enbur
lA. Epidemio|oy ot osteoarthritis. Zoetermeer survey. Comparison ot
radio|oica| osteoarthritis in a 0utch popu|ation With that in IO other popu
|ations. Ann Rheum Dis. I989,48.2/I28O.
I69. Van Suij|e|om lA, 0e Vet lC, Van 0en Ber SC, \eber \E. lnterobserver
re|iabi|ity in physica| eamination ot the cervica| spine in patients With
headache. Headache. 2OOO,4O.58I58G.
I70. Vassi|iou T, la|uza C, Putz|e C, \u|t l, Schnabe| V. Physica| therapy and
active eercisesan adequate treatment tor prevention ot |ate Whip|ash
syndrome7 Randomized contro||ed tria| in 2OO patients. Pain. 2OOG,I24.G9
/G. http.//d.doi.or/IO.IOIG/j.pain.2OOG.OJ.OI/
I7I. Vernon l, lumphreys Bl, laino C. The outcome ot contro| roups in
c|inica| tria|s ot conservative treatments tor chronic mechanica| nec| pain.
a systematic revieW. BMC Musculoskelet Disord. 2OOG,/.58. http.//d.doi.
or/IO.II8G/I4/I24/4/58
I7Z. Vernon l, Vior S. The |ec| 0isabi|ity lnde. a study ot re|iabi|ity and va|id
ity. J Manipulative Physiol Ther. I99I,I4.4O94I5.
I73. Vi|janen V, Va|mivaara A, uitti 1, Rinne V, Pa|mroos P, laippa|a P. Etec
tiveness ot dynamic musc|e trainin, re|aation trainin, or ordinary activity
tor chronic nec| pain. randomised contro||ed tria|. BMJ. 2OOJ,J2/.4/5.
http.//d.doi.or/IO.IIJG/bmj.J2/./4IJ.4/5
I74. Voyvodic l, 0o|inis 1, Voore VV, et a|. VRl ot car occupants With Whip|ash
injury. Neuroradiology. I99/,J9.J54O.
I75. \ainner RS, lritz 1V, lrran 11, Boniner Vl, 0e|itto A, A||ison S. Re|i
abi|ity and dianostic accuracy ot the c|inica| eamination and patient se|t
report measures tor cervica| radicu|opathy. Spine. 2OOJ,28.52G2. http.//
d.doi.or/IO.IO9//OI.BRS.OOOOOJ88/J.OI855.5O
I76. \a|drop VA. 0ianosis and treatment ot cervica| radicu|opathy usin
a c|inica| prediction ru|e and a mu|timoda| intervention approach. a
case series. J Orthop Sports Phys Ther. 2OOG,JG.I52I59. http.//d.doi.
or/IO.25I9/jospt.2OOG.2O5G
I77. \an \T, 0|son Sl, Campbe|| Al, lanten \P, C|eeson PB. Etectiveness
ot physica| therapy tor patients With nec| pain. an individua|ized approach
usin a c|inica| decisionma|in a|orithm. Am J Phys Med Rehabil.
2OOJ,82.2OJ2I8, quiz 2I922I.
I78. \enze| lC, lau TT, Vy||etun A, 0ah| AA. A popu|ation study ot aniety
and depression amon persons Who report Whip|ash traumas. J Psycho-
som Res. 2OO2,5J.8JI8J5.
I79. \estaWay V0, Strattord P\, Bin||ey 1V. The patientspecihc tunctiona|
sca|e. va|idation ot its use in persons With nec| dystunction. J Orthop
Sports Phys Ther. I998,2/.JJIJJ8.
I80. \o|tenberer VA, Bui , Batenchu| CB. A comparison ot methods ot eva|u
atin cervica| rane ot motion. J Manipulative Physiol Ther. 2OO2,25.I54
IGO.
I8I. \riht A, Vayer TC, Catche| R1. 0utcomes ot disab|in cervica| spine
disorders in compensation injuries. A prospective comparison to ter
tiary rehabi|itation response tor chronic |umbar spina| disorders. Spine.
I999,24.I/8I8J.
I8Z. Y|inen 1, la||inen A, |y|anen V, lautiainen l, Ta|a|a EP. |ec| musc|e
trainin in the treatment ot chronic nec| pain. a threeyear to||oWup study.
Eura Medicophys. 2OO/,4J.IGIIG9.
I83. Y|inen 1, lautiainen l, \iren l, la||inen A. Stretchin eercises vs
manua| therapy in treatment ot chronic nec| pain. a randomized, con
tro||ed crossover tria|. J Rehabil Med. 2OO/,J9.I2GIJ2. http.//d.doi.
or/IO.2J4O/IG5OI9//OOI5
I84. Y|inen 1, Ta|a|a EP, |y|anen V, et a|. Active nec| musc|e trainin in the
treatment ot chronic nec| pain in Women. a randomized contro||ed tria|.
JAMA. 2OOJ,289.25O925IG. http.//d.doi.or/IO.IOOI/jama.289.I9.25O9
I85. Zito C, 1u|| C, Story l. C|inica| tests ot muscu|os|e|eta| dystunction in the
dianosis ot cervicoenic headache. Man Ther. 2OOG,II.II8I29. http.//
d.doi.or/IO.IOIG/j.math.2OO5.O4.OO/
@
N0k |NF0kNAI|0N
WWW.JOSPT.ORG
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.
CORRECTIONS
I
n the September 2008 issue of
Journal of Orthopaedic & Sports
Physical Therapy, we make the fol-
lowing corrections to the Neck Pain:
Clinical Practice Guidelines:
Under Primary ICI Codes" on age
A6, lhe ICI code for Pain in head and
neck," rinled as 28u1u," shouId be
b28u1u.
Under Secondary ICI Codes on
ages A, and A8, lhe ICI code for
Driving molorized vehicIes," rinl-
ed in 4 inslances as d4,u," shouId
be d4,1.
Under Secondary ICI Codes on ages
A, and A8, lhe ICI code for Driv-
ing animaI-owered lransorlalion,"
rinled in 4 inslances as d4,u,"
shouId be d4,2.
Under Secondary ICI codes on ages
A, and A8, lhe ICI Code for Main-
laining a slanding osilion," rinled
in 2 inslances as d41u," shouId be
d414.
PIease accel our aoIogy for lhese
errors. Correcled rerinls of lhe Guide-
Iines are avaiIabIe for downIoad on lhe
JOSPT web sile (www.josl.org).
ERRATA
journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | 297
EARN CEUs With JOSPTs Read for Credit Program
JOSPTs Read for Credit (RFC) program invites Journal readers to study and
analyze selected JOSPT articles and successfully complete online quizzes
about them for continuing education credit. To participate in the
program:
1. Go to www.jospt.org and click the link in the Read for Credit box in
the right-hand column of the home page.
2. Choose an article to study and when ready, click Take Exam for
that article.
3. Login and pay for the quiz by credit card.
4. Take the quiz.
5. Evaluate the RFC experience and receive a personalized certicate of
continuing education credits.
The RFC program ofers you 2 opportunities to pass the quiz. You may
review all of your answersincluding the questions you missed. You
receive 0.2 CEUs for each quiz passed, and the Journal website maintains a
history of the quizzes you have taken and the credits and certicates you
have been awarded in the My CEUs section of your My JOSPT account.
J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

D
o
w
n
l
o
a
d
e
d

f
r
o
m

w
w
w
.
j
o
s
p
t
.
o
r
g

a
t

o
n

J
u
l
y

5
,

2
0
1
4
.

F
o
r

p
e
r
s
o
n
a
l

u
s
e

o
n
l
y
.

N
o

o
t
h
e
r

u
s
e
s

w
i
t
h
o
u
t

p
e
r
m
i
s
s
i
o
n
.


C
o
p
y
r
i
g
h
t

2
0
0
8

J
o
u
r
n
a
l

o
f

O
r
t
h
o
p
a
e
d
i
c

&

S
p
o
r
t
s

P
h
y
s
i
c
a
l

T
h
e
r
a
p
y

.

A
l
l

r
i
g
h
t
s

r
e
s
e
r
v
e
d
.