Jospt 2008 0303

Clinical Guidelines
JOHN D. CHILDS, PT, PhD@EI>K77$9B;B7D:"PT, PhD@7C;IC$;BB?EJJ"PT, PhD:;O:H;I$J;O>;D"PT, PhD

HE8;HJI$M7?DD;H"PT, PhD@KB?;C$M>?JC7D"PT, DSc8;HD7H:@$IEFAO"MD
@EI;F>@$=E:=;I"DPTJ?CEJ>OM$<BODD"PT, PhD
Neck Pain:
Clinical Practice Guidelines Linked to
the International Classification of
Downloaded from www.jospt.org at on June 13, 2023. For personal use only. No other uses without permission.
Functioning, Disability, and Health From

the Orthopaedic Section of the American
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Physical Therapy Association

J Orthop Sports Phys Ther 2008;38(9):A1-A34. doi:10.2519/jospt.2008.0303
RECOMMENDATIONS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7(
INTRODUCTION$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7)
Journal of Orthopaedic & Sports Physical Therapy®
METHODS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7*
CLINICAL GUIDELINES:
Impairment/Function-Based Diagnosis$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7/
Examinations$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7'*
Interventions$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7'/
SUMMARY OF RECOMMENDATIONS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7(.
AUTHOR/REVIEWER AFFILIATIONS & CONTACTS$ $ $ $ $ $ $ $ $ $ 7(/

REFERENCES$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7)&
H;L?;M;HI07djêdo:[b_jje"FJ"F^:=[eh][C$:oh_m":FJ7cWdZW<[hbWdZ"FJ">[b[d[<[Whed"FJ@eoCWY:[hc_Z"FJ"F^:
@Wc[iM$CWj^[ied":FJF^_b_fCY9bkh["FJ"F^:FWkbI^[a[bb["C:"F^:7$Hkii[bbIc_j^"@h"FJ";Z:B[ib_[JehXkhd":FJ
<ehWkjêh"YeehZ_dWjeh"WdZh[l_[m[hWøb_Wj_edi"i[[[dZe\j[nj$(&&.EhjêfW[Z_YI[Yj_ed7c[h_YWdFôi_YWbJ^[hWfo7iieY_Wj_ed7FJ7"?dY"WdZj^[@ekhdWbe\
EhjêfW[Z_YIfehjiFôi_YWbJ^[hWfo$J^[EhjêfW[Z_YI[Yj_ed"7FJ7"?dY$"WdZj^[@ekhdWbe\EhjêfW[Z_YIfehjiFôi_YWbJ^[hWfoYedi[djjej^[fêjeYefo_d]e\
j^_i]k_Z[b_d[\eh[ZkYWj_edWbfkhfei[i$7ZZh[iiYehh[ifedZ[dY[je0@ei[f^@$=eZ][i":FJ"?9<FhWYj_Y[=k_Z[b_d[i9eehZ_dWjeh"EhjêfW[Z_YI[Yj_ed"7FJ7?dY$"(/(&
;Wij7l[dk[Iekj^"Ik_j[(&&1BW9heii["M?+*,&'$;cW_b0_Y\6ehjêfj$eh]
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Recommendations*
F7J>E7D7JEC?97B<;7JKH;I0 Although the cause of neck pain The following physical examination measures may be useful in
may be associated with degenerative processes or pathology classifying a patient in the ICF impairment-based category of
identified during diagnostic imaging, the tissue that is causing neck pain with movement coordination impairments and the
a patient’s neck pain is most often unknown. Thus, clinicians associated ICD category of sprain and strain of cervical spine.
should assess for impaired function of muscle, connective, and (Recommendation based on moderate evidence.)
nerve tissues associated with the identified pathological tissues <kZgbZe\^kob\Ze×^qbhgm^lm
when a patient presents with neck pain. (Recommendation =^îg^\d×^qhk^g]nkZg\^m^lm
based on theoretical/foundational evidence.)
The following physical examination measures may be useful in
H?IA<79JEHI0 Clinicians should consider age greater than 40, classifying a patient in the ICF impairment-based category of
coexisting low back pain, a long history of neck pain, cycling as neck pain with radiating pain and the associated ICD categories
a regular activity, loss of strength in the hands, worrisome atti- of spondylosis with radiculopathy or cervical disc disorder with
radiculopathy. (Recommendation based on moderate evidence.)
tude, poor quality of life, and less vitality as predisposing factors
Nii^kebf[m^glbhgm^lm
for the development of chronic neck pain. (Recommendation
Linkebg`Ílm^lm
based on moderate evidence.)
=blmkZ\mbhgm^lm
:?7=DEI?I%9B7II?<?97J?ED0 Neck pain, without symptoms or
:?<<;H;DJ?7B:?7=DEI?I0 Clinicians should consider diagnostic
signs of serious medical or psychological conditions, associated
classifications associated with serious pathological conditions
with (1) motion limitations in the cervical and upper thoracic or psychosocial factors when the patient’s reported activity
regions, (2) headaches, and (3) referred or radiating pain into limitations or impairments of body function and structure are
an upper extremity are useful clinical findings for classifying a not consistent with those presented in the diagnosis/classifica-
patient with neck pain into one of the following International tion section of this guideline, or, when the patient’s symptoms
Statistical Classification of Diseases and Related Health Prob- are not resolving with interventions aimed at normalization of
lems (ICD) categories: cervicalgia, pain in thoracic spine, head- the patient’s impairments of body function. (Recommendation
aches, cervicocranial syndrome, sprain and strain of cervical based on moderate evidence.)
spine, spondylosis with radiculopathy, and cervical disc disorder
with radiculopathy; and the associated International Classifica- ;N7C?D7J?EDÅEKJ9EC;C;7IKH;I0 Clinicians should use
tion of Functioning, Disability, and Health (ICF) impairment- validated self-report questionnaires, such as the Neck Disability
Index and the Patient-Specific Functional Scale for patients
based category of neck pain with the following impairments of

body function: with neck pain. These tools are useful for identifying a patient’s
G^\diZbgpbmafh[bebmr]^Ö\bml![0*)*Fh[bebmrh_ baseline status relative to pain, function, and disability and for
several joints) monitoring a change in a patient’s status throughout the course
G^\diZbgpbmaa^Z]Z\a^l!+1)*)IZbgbga^Z]Zg]g^\d" of treatment. (Recommendation based on strong evidence.)
G^\diZbgpbmafho^f^gm\hhk]bgZmbhgbfiZbkf^gml
![0/)*<hgmkheh_\hfie^qohengmZkrfho^f^gml" ;N7C?D7J?EDÅ79J?L?JOB?C?J7J?ED7D:F7HJ?9?F7J?EDH;IJH?9-
G^\diZbgpbmakZ]bZmbgìZbg![+1)-KZ]bZmbgìZbgbgZ J?EDC;7IKH;I0 Clinicians should utilize easily reproducible
activity limitation and participation restriction measures associ-
segment or region)
ated with their patient’s neck pain to assess the changes in the
patient’s level of function over the episode of care. (Recommen-
The following physical examination measures may be useful in
dation based on expert opinion.)
classifying a patient in the ICF impairment-based category of
neck pain with mobility deficits and the associated ICD catego-
?DJ;HL;DJ?EDIÅ9;HL?97BCE8?B?P7J?ED%C7D?FKB7J?ED0
ries of cervicalgia or pain in thoracic spine. (Recommendation
Clinicians should consider utilizing cervical manipulation and
based on moderate evidence.) mobilization procedures, thrust and non-thrust, to reduce neck
<^kob\ZeZ\mbo^kZg`^h_fhmbhg pain and headache. Combining cervical manipulation and mo-
<^kob\ZeZg]mahkZ\b\l^`f^gmZefh[bebmr bilization with exercise is more effective for reducing neck pain,
headache, and disability than manipulation and mobilization
The following physical examination measures may be useful in alone. (Recommendation based on strong evidence.)
classifying a patient in the ICF impairment-based category of
neck pain with headaches and the associated ICD categories ?DJ;HL;DJ?EDIÅJ>EH79?9CE8?B?P7J?ED%C7D?FKB7J?ED0
of headaches or cervicocranial syndrome. (Recommendation Thoracic spine thrust manipulation can be used for patients
based on moderate evidence.) with primary complaints of neck pain. Thoracic spine thrust
<^kob\ZeZ\mbo^kZg`^h_fhmbhg manipulation can also be used for reducing pain and disability
<^kob\Zel^`f^gmZefh[bebmr in patients with neck and neck-related arm pain. (Recommen-
<kZgbZe\^kob\Ze×^qbhgm^lm dation based on weak evidence.)
a2 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
Recommendations* (continued)
?DJ;HL;DJ?EDIÅIJH;J9>?D=;N;H9?I;I0 Flexibility exercises and nerve mobilization procedures to reduce pain and disability
can be used for patients with neck symptoms. Examination in patients with neck and arm pain. (Recommendation based
Zg]mZk`^m^]×^qb[bebmr^q^k\bl^l_hkma^_heehpbg`fnl\e^lZk^ on moderate evidence.)
suggested: anterior/medial/posterior scalenes, upper trapezius,
levator scapulae, pectoralis minor, and pectoralis major. (Rec- ?DJ;HL;DJ?EDIÅJH79J?ED0 Clinicians should consider the use
ommendation based on weak evidence.) of mechanical intermittent cervical traction, combined with
other interventions such as manual therapy and strengthening
?DJ;HL;DJ?EDIÅ9EEH:?D7J?ED"IJH;D=J>;D?D="7D:;D:KH- exercises, for reducing pain and disability in patients with neck
7D9;;N;H9?I;I0 Clinicians should consider the use of coor- and neck-related arm pain. (Recommendation based on moder-
dination, strengthening, and endurance exercises to reduce ate evidence.)
neck pain and headache. (Recommendation based on strong
evidence.) ?DJ;HL;DJ?EDIÅF7J?;DJ;:K97J?ED7D:9EKDI;B?D=0 To
improve recovery in patients with whiplash-associated disorder,
?DJ;HL;DJ?EDIÅ9;DJH7B?P7J?EDFHE9;:KH;I7D:;N;H9?I;I0 clinicians should (1) educate the patient that early return to
Specific repeated movements or procedures to promote cen- normal, non-provocative pre-accident activities is important,
tralization are not more beneficial in reducing disability when and (2) provide reassurance to the patient that good prognosis
compared to other forms of interventions. (Recommendation and full recovery commonly occurs. (Recommendation based
based on weak evidence.) on strong evidence.)
?DJ;HL;DJ?EDIÅKFF;HGK7HJ;H7D:D;HL;CE8?B?P7J?EDFHE- J^[i[h[Yecc[dZWj_ediWdZYb_d_YWbfhWYj_Y[]k_Z[b_d[iWh[XWi[Zedj^[
9;:KH;I0 Clinicians should consider the use of upper quarter iY_[dj_ÓYb_j[hWjkh[fkXb_i^[Zfh_ehje@kd[(&&-$
Introduction
7?CE<J>;=K?:;B?D; Ikhob]^Z]^l\kbimbhgmhiheb\rfZd^kl%nlbg`bgm^kgZmbhgZeer
The Orthopaedic Section of the American Physical Therapy As- accepted terminology, of the practice of orthopaedic physi-
sociation (APTA) has an ongoing effort to create evidence-based cal therapists
practice guidelines for orthopaedic physical therapy manage-

Ikhob]^bg_hkfZmbhg_hkiZr^klZg]\eZbflkôb^p^klk^`Zk]-
ment of patients with musculoskeletal impairments described
ing the practice of orthopaedic physical therapy for common
in the World Health Organization’s International Classification
musculoskeletal conditions
of Functioning, Disability, and Health (ICF).1/
<k^Zm^Zk^_^k^g\în[eb\Zmbhg_hkhkmahiZ^]b\iarlb\Ze
The purposes of these clinical guidelines are to: therapy clinicians, academic instructors, clinical instructors,
students, interns, residents, and fellows regarding the best
Describe evidence-based physical therapy practice including current practice of orthopaedic physical therapy
diagnosis, prognosis, intervention, and assessment of outcome
IJ7J;C;DJE<?DJ;DJ
for musculoskeletal disorders commonly managed by orthopae-
This guideline is not intended to be construed or to serve as a
dic physical therapists
standard of medical care. Standards of care are determined on
<eZllb_rZg]]^Ög^\hffhgfnl\nehldê^mZe\hg]bmbhgl the basis of all clinical data available for an individual patient
using the World Health Organization’s terminology related and are subject to change as scientific knowledge and technol-
to impairments of body function and body structure, activity ogy advance and patterns of care evolve. These parameters of
limitations, and participation restrictions practice should be considered guidelines only. Adherence to
them will not ensure a successful outcome in every patient, nor
B]^gmb_rbgm^ko^gmbhgllniihkm^][r\nkk^gm[^lmôb]^g\^mh should they be construed as including all proper methods of care
address impairments of body function and structure, activ- or excluding other acceptable methods of care aimed at the same
ity limitations, and participation restrictions associated with results. The ultimate judgment regarding a particular clinical
common musculoskeletal conditions procedure or treatment plan must be made in light of the clinical
data presented by the patient, the diagnostic and treatment op-
B]^gmb_rZiikhikbZm^hnm\hf^f^Zlnk^lmhZll^ll\aZg`^l tions available, and the patient’s values, expectations, and prefer-
resulting from physical therapy interventions in body func- ences. However, we suggest that significant departures from ac-
tion and structure as well as in activity and participation of cepted guidelines should be documented in the patient’s medical
the individual records at the time the relevant clinical decision is made.
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a3
Methods
Content experts were appointed by the Orthopaedic Section,

;l_Z[dY[eXjW_d[Z\hec^_]^#gkWb_johWdZec_p[ZYedjhebb[Z
APTA as developers and authors of clinical practice guidelines I
jh_Wbi"fheif[Yj_l[ijkZ_[i"ehZ_W]deij_YijkZ_[i
for musculoskeletal conditions of the cervical region that are
commonly treated by physical therapists. These content experts ;l_Z[dY[eXjW_d[Z\hecb[ii[h#gkWb_johWdZec_p[Z
were given the task to identify impairments of body function Yedjhebb[Zjh_Wbi"fheif[Yj_l[ijkZ_[i"ehZ_W]deij_Y
II
and structure, activity limitations, and participation restric- ijkZ_[i[]"_cfhef[hhWdZec_pWj_ed"deXb_dZ_d]"2.&
tions, described using ICF terminology, that could (1) categorize \ebbem#kf
patients into mutually exclusive impairment patterns upon III 9Wi[Yedjhebb[ZijkZ_[iehh[jheif[Yj_l[ijkZ_[i
which to base intervention strategies, and (2) serve as measures
of changes in function over the course of an episode of care. The IV 9Wi[i[h_[i
second task given to the content experts was to describe inter- V ;nf[hjef_d_ed
ventions and supporting evidence for specific subsets of patients
based upon the previously chosen patient categories. It was also
acknowledged by the Orthopaedic Section, APTA content ex-
=H7:;IE<;L?:;D9;
perts that a systematic search and review of the evidence solely
The overall strength of the evidence supporting recom-
related to diagnostic categories based on International Statis-

mendations made in this guideline will be graded accord-
tical Classification of Diseases and Health Related Problems
ing to guidelines described by Guyatt et al,0* as modified by
(ICD)10 terminology would not be useful for these ICF-based
FZ\=^kfb]Zg]Z]him^][rma^\hhk]bgZmhkZg]kôb^p^klh_
clinical practice guidelines as most of the evidence associated
this project. In this modified system, the typical A, B, C, and
with changes in levels of impairment or function in homoge-
D grades of evidence have been modified to include the role
neous populations is not readily searchable using the ICD termi-

of consensus expert opinion and basic science research to
nology. Thus, the authors of this clinical practice guideline sys-
demonstrate biological or biomechanical plausibility (Table
m^fZmb\Zeerl^Zk\a^]F>=EBG>%<BG:AE%Zg]ma^<h\akZg^
2 below).
=ZmZ[Zl^h_Lrlm^fZmb\Kôb^pl!*2//makhnàCng^+))0"_hk
any relevant articles related to classification, outcome measures,
and intervention strategies for musculoskeletal conditions of the
neck region commonly treated by physical therapists. Each con- GRADES OF RECOMMENDATION STRENGTH OF EVIDENCE
tent expert was assigned a specific subcategory (classification,
outcome measures, and intervention strategies for musculoskel- Ijhed][l_Z[dY[ 7fh[fedZ[hWdY[e\b[l[b?WdZ%ehb[l[b
etal conditions of the neck region) to search by the lead author A ??ijkZ_[iikffehjj^[h[Yecc[dZWj_ed$
!C=<"[Zl^]nihgma^bkli^\bÖ\Zk^Zh_^qi^kmbl^'Mph\hgm^gm J^_ickij_dYbkZ[Wjb[Wij'b[l[b?ijkZo
experts were assigned to each subcategory and both individuals CeZ[hWj[[l_Z[dY[ 7i_d]b[^_]^#gkWb_johWdZec_p[ZYed#
performed a separate search, including but not limited to the B jhebb[Zjh_WbehWfh[fedZ[hWdY[e\b[l[b
3 databases listed above, to identify articles to assure that no ??ijkZ_[iikffehjj^[h[Yecc[dZWj_ed
studies of relevance were omitted. Additionally, when relevant
articles were identified, their reference lists were hand-searched M[Wa[l_Z[dY[ 7i_d]b[b[l[b??ijkZoehWfh[fedZ[h#
in an attempt to identify other articles that might have contrib- WdY[e\b[l[b???WdZ?LijkZ_[i_dYbkZ_d]
C
uted to the outcome of these clinical practice guidelines. ijWj[c[djie\Yedi[dikiXoYedj[dj
[nf[hjiikffehjj^[h[Yecc[dZWj_ed
Mabl`nb]êbg^pZlblln^]bg+))1[Zl^]nihgin[eb\Zmbhglbg 9edÔ_Yj_d][l_Z[dY[ >_]^[h#gkWb_joijkZ_[iYedZkYj[Zed
ma^l\b^gmbÖ\ebm^kZmnkîkbhkmhCng^+))0'Mabl`nb]êbg^pbee j^_ijef_YZ_iW]h[[m_j^h[if[Yjjej^[_h
be considered for review in 2012, or sooner if substantive new D
YedYbki_edi$J^[h[Yecc[dZWj_ed_i
evidence becomes available. Any updates to the guideline in the XWi[Zedj^[i[YedÔ_Yj_d]ijkZ_[i
interim period will be noted on the Orthopaedic Section of the
APTA website: www.orthopt.org J^[eh[j_YWb% 7fh[fedZ[hWdY[e\[l_Z[dY[\hec
\ekdZWj_edWb[l_Z[dY[ Wd_cWbehYWZWl[hijkZ_[i"\hec
B;L;BIE<;L?:;D9; E YedY[fjkWbceZ[bi%fh_dY_fb[i"eh\hec
Once the content experts of each subcategory had identified all XWi_YiY_[dY[i%X[dY^h[i[WhYîkffehj
relevant articles, they independently graded each article accord- j^_iYedYbki_ed
bg`mh\kbm^kbZ]^l\kb[^][rma^<^gm^k_hk>ob]^g\^&;Zl^]F^]b-
\bg^%Hq_hk]%Ngbm^]Dbg`]hf!MZ[e^*[êhp"'B_ma^+\hgm^gm ;nf[hjef_d_ed 8[ijfhWYj_Y[XWi[Zedj^[Yb_d_YWb
experts did not agree on a grade of evidence for a particular F [nf[h_[dY[e\j^[]k_Z[b_d[iZ[l[bef#
article, a third content expert was used to resolve the issue. c[djj[Wc
Methods (continued) these clinical guidelines that provides a summary of symptoms,

impairment findings, and matched interventions for each di-
agnostic category. This recommendation led the authors to add
Table 4 to these clinical guidelines.
H;L?;MFHE9;II
The Orthopaedic Section, APTA also selected consultants from 9B7II?<?97J?ED
the following areas to serve as reviewers of the early drafts of The primary ICD-10 codes and conditions associated with neck
this clinical practice guideline: iZbgZk^3F.-'+<^kob\Ze`bZ%F.-'/IZbgbgmahkZ\b\libg^%K.*
<eZbflkôb^p
A^Z]Z\a^%F.,')<^kob\h\kZgbZelrg]khf^%L*,'-LikZbgZg]
<h]bg`
lmkZbgh_\^kob\Zelibg^%F-0'+Lihg]rehlblpbmakZ]b\nehiZmar%
>ib]^fbheh`r
Zg]F.)'*<^kob\Ze]bl\]blhk]^kpbmakZ]b\nehiZmar'10 The
F^]b\ZeikZ\mb\^`nb]êbg^l
\hkk^lihg]bg`B<=&2<F\h]^lZg]\hg]bmbhgl%pab\aZk^nl^]
HkmahiZ^]b\iarlb\Zema^kZirk^lb]^g\r^]n\Zmbhg
bgma^NL:%Zk^0+,'*<^kob\Ze`bZ%0+-'*IZbgbgmahkZ\b\libg^%
Iarlb\Zema^kZirZ\Z]^fb\^]n\Zmbhg
01-')A^Z]Z\a^%0+,'+<^kob\h\kZgbZelrg]khf^%1-0')LikZbgl
Lihkmliarlb\Zema^kZirk^lb]^g\r^]n\Zmbhg
Zg]lmkZbglh_ma^g^\d%Zg]0+,'-;kZ\abZeg^nkbmblhkkZ]b\n-
Comments from these reviewers were utilized by the authors litis, not otherwise specified (Cervical radiculitis/Radicular
to edit this clinical practice guideline prior to submitting it for syndrome of upper limbs).
in[eb\Zmbhgmhma^ChnkgZeh_HkmahiZ^]b\LihkmlIarlb\Ze
Therapy The primary ICF body function codes associated with the above
noted ICD-10 conditions are the sensory functions related to
In addition, several physical therapists practicing in orthopae- pain and the movement functions related to joint motion and
dic and sports physical therapy settings were sent initial drafts control of voluntary movements. These body function codes are
of this clinical practice guideline along with feedback forms X-'&'CeX_b_joe\i[l[hWbè_dji"X(.&'&FW_d_d^[WZWdZd[Ya"X-,&'
to determine its usefulness, validity, and impact. All returned 9edjhebe\Yecfb[nlebkdjWhocel[c[dji"WdZX(.&)HWZ_Wj_d]fW_d_d

feedback forms from these practicing clinicians described this WZ[hcWjec[$
clinical practice guideline as:
ÊFh]^kZmêrnl^_neËhkÊ^qmk^fêrnl^_neË The primary ICF body structure codes associated with neck
:
gÊZ\\nkZm^kîk^l^gmZmbhgh_maî^^k&kôb^p^] pain are i-'&)@e_djie\^[WZWdZd[Yah[]_ed"i-'&*CkiYb[ie\^[WZ
ebm^kZmnk^Ë WdZd[Yah[]_ed"i-'&+B_]Wc[djiWdZ\WiY_W[e\^[WZWdZd[Yah[]_ed"
:`nb]êbg^maZmpbeeaZo^ZÊln[lmZgmbZeihlbmbo^bfiZ\mhg i-,&&&9[hl_YWbl[hj[XhWbYebkcd"WdZi'(&'If_dWbd[hl[i$
hkmahiZ^]b\iarlb\Zema^kZiriZmb^gm\Zk^Ë
The primary ICF activities and participation codes associated
with neck pain are Z*'&.9^Wd]_d]WXWi_YXeZofei_j_ed"Z*'+.
However, several reviewers noted that preliminary drafts of

this clinical guideline did not clearly link data gathered during CW_djW_d_d]WXeZofei_j_ed"WdZZ**+(H[WY^_d]$
the patient’s subjective and physical examinations to diagnos-
tic classification and intervention. To assist in clarifying these The ICD-10 and primary and secondary ICF codes associated
links, it was recommended that the authors add a table to with neck pain are provided in Table 3 (below).
ICD-10 and ICF Codes Associated With Neck Pain
INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS

D[YaFW_dM_j^CeX_b_jo:[ÓY_ji
Primary ICD-10 C+*$( 9[hl_YWb]_W
C+*$, FW_d_djêhWY_Yif_d[
D[YaFW_dM_j^>[WZWY^[i
Primary ICD-10 H+' >[WZWY^[
C+)$& 9[hl_YeYhWd_WbiodZhec[
D[YaFW_dM_j^Cel[c[dj9eehZ_dWj_ed?cfW_hc[dji
Primary ICD-10 I')$* IfhW_dWdZijhW_de\Y[hl_YWbif_d[
D[YaFW_dM_j^HWZ_Wj_d]FW_d
Primary ICD-10 C*-$( IfedZobei_im_j^hWZ_YkbefWjô
C+&$' 9[hl_YWbZ_iYZ_iehZ[hm_j^hWZ_YkbefWjô
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH

PRIMARY ICF CODES
Body functions X-'&' CeX_b_joe\i[l[hWbè_dji
Body structure i-,&&& 9[hl_YWbl[hj[XhWbYebkcd
Activities and participation Z*'&. 9^Wd]_d]WXWi_YXeZofei_j_ed"if[Y_Ó[ZWicel_d]j^[^[WZWdZd[Yam^_b[beea#
_d]jej^[b[\jehjej^[h_]^j
Body functions X(.&'& FW_d_d^[WZWdZd[Ya
Body structure i-'&) @e_djie\^[WZWdZd[Yah[]_ed
i-'&* CkiYb[ie\^[WZWdZd[Yah[]_ed
Activities and participation Z*'+. CW_djW_d_d]WXeZofei_j_ed"if[Y_Ó[ZWicW_djW_d_d]j^[^[WZ_dWÔ[n[Zfei_j_ed"
ikY^Wim^[dh[WZ_d]WXeea1eh"cW_djW_d_d]j^[^[WZ_dWd[nj[dZ[Zfei_j_ed"ikY^
Wim^[dbeea_d]kfWjWl_Z[eced_jeh
Body functions X-,&' 9edjhebe\Yecfb[nlebkdjWhocel[c[dji
Body structure i-'&+ B_]Wc[djiWdZ\WiY_W[e\^[WZWdZd[Yah[]_ed

Activities and participation Z*'+. CW_djW_d_d]WXeZofei_j_ed"if[Y_Ó[ZWicW_djW_d_d]Wb_]dc[dje\j^[^[WZ"d[Ya"WdZjê#
hWnikY^j^Wjj^[Y[hl_YWbl[hj[XhWbi[]c[dji\kdYj_ed_dWd[kjhWb"ehc_Z#hWd]["fei_j_ed
Body functions X(.&* HWZ_Wj_d]fW_d_dWi[]c[djehh[]_ed
Body structure i'(&' If_dWbd[hl[i
Activities and participation Z**+( H[WY^_d]
SECONDARY ICF CODES
X(.&') FW_d_dXWYa
X(.&'* FW_d_dkff[hb_cX
X-'&' CeX_b_joe\i[l[hWbè_dji
X-'+' IjWX_b_joe\i[l[hWbè_dji
X-)&+ Fem[he\ckiYb[ie\j^[jhkda
X-)+& Jed[e\_iebWj[ZckiYb[iWdZckiYb[]hekfi
X-*&& ;dZkhWdY[e\_iebWj[ZckiYb[i
X-,&' 9edjhebe\Yecfb[nlebkdjWhocel[c[dji
Body structure i'(&&' TêhWY_Yif_dWbYehZ
i')& IjhkYjkh[e\c[d_d][i
i-'&) @e_djie\^[WZWdZd[Yah[]_ed
i-'&+ B_]Wc[djiWdZ\WiY_W[e\^[WZWdZd[Yah[]_ed
i-,&&& 9[hl_YWbl[hj[XhWbYebkcd
i-,&&' JêhWY_Yl[hj[XhWbYebkcd
i-,&' CkiYb[ie\jhkda
i-,&( B_]Wc[djiWdZ\WiY_W[e\jhkda
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED)

Activities and participation Z()&( 9ecfb[j_d]j^[ZW_bohekj_d[
Z(*&& >WdZb_d]h[ifedi_X_b_j_[i
Z*'&& Bo_d]Zemd
Z*'&+ 8[dZ_d]
Z*'+& CW_djW_d_d]Wbo_d]fei_j_ed
Z*-+& :h_l_d]^kcWd#fem[h[ZjhWdifehjWj_ed
Z*-+' :h_l_d]cejeh_p[Zl[^_Yb[i
Z*-+( :h_l_d]Wd_cWb#fem[h[ZjhWdifehjWj_ed
Z*++* Im_cc_d]
Z,*&/ :e_d]êki[meha"kdif[Y_Ó[Z
Z/'&/ 9ecckd_job_\["kdif[Y_Ó[Z
Z/(&/ H[Yh[Wj_edWdZb[_ikh["kdif[Y_Ó[Z
Body functions X(.&) HWZ_Wj_d]fW_d_dWZ[hcWjec[
X(.&* HWZ_Wj_d]fW_d_dWi[]c[djehh[]_ed
X()+/ L[ij_XkbWh\kdYj_edi"kdif[Y_Ó[Z
X(*&/ I[diWj_ediWiieY_Wj[Zm_j^^[Wh_d]WdZl[ij_XkbWh\kdYj_ed"kdif[Y_Ó[Z
Body structure i'(&&& 9[hl_YWbif_dWbYehZ
i'(&&' JêhWY_Yif_dWbYehZ
i'(&' If_dWbd[hl[i
Activities and participation Z',) J^_da_d]
Z',, H[WZ_d]
Z()&( 9ecfb[j_d]j^[ZW_bohekj_d[
Z*'+) CW_djW_d_d]Wi_jj_d]fei_j_ed
Z*'+* CW_djW_d_d]WijWdZ_d]fei_j_ed
X(.&') FW_d_dXWYa
X-,&( 9eehZ_dWj_ede\lebkdjWhocel[c[dji
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED)

Body structure i-'&) @e_djie\^[WZWdZd[Yah[]_ed
Activities and participation Z()&( 9ecfb[j_d]j^[ZW_bohekj_d[
Z*'&+ 8[dZ_d]
Body functions X(.&') FW_d_dXWYa
X(.&) HWZ_Wj_d]fW_d_dWZ[hcWjec[
Body structure i'(&&& 9[hl_YWbif_dWbYehZ
i'(&&' JêhWY_Yif_dWbYehZ
i'(&' If_dWbd[hl[i
Activities and participation Z()&( 9ecfb[j_d]j^[ZW_bohektine
Z*)&& B_\j_d]
Z*)&' 9Whho_d]_dj^[^WdZi
Z*)&( 9Whho_d]_dj^[Whci
Z*)&) 9Whho_d]ediêkbZ[hi"^_f"WdZXWYa
Z*)&* 9Whho_d]edj^[^[WZ
Z*)&+ Fkjj_d]ZemdeX`[Yji
CLINICAL GUIDELINES
Impairment/Function-based
Diagnosis
FH;L7B;D9; in the majority of patients who present with complaints of
Pain and impairment of the neck is common. It is esti- neck pain and neck related symptoms of the upper quarter.*.
fZm^]maZm++mh0)h_maîhineZmbhgpbeeaZo^g^\diZbg Therefore, once serious medical pathology (such as cervical
some time in their lives.*2%+)%-+%-,%..%**.%*+2 In addition, it has been fracture or myelopathy) has been ruled out, patients with
suggested that the incidence of neck pain is increasing.*+/%*1* neck pain are often classified as having either a nerve root
At any given time, 10% to 20% of the population reports neck \hfikhfbl^hkZÊf^\aZgb\Zeg^\d]blhk]^k'Ë
problems,*2%--%01%*/0pbma.-h_bg]bob]nZelaZobg`^qi^kb^g\^]
g^\diZbgpbmabgmaêZlm/fhgmal'42 Prevalence of neck pain In some conditions, particularly those that are de-
increases with age and is most common in women around the

fifth decade of life.-%*2%-/%**/%*/,
II generative in nature or involve abnormalities of the
vertebral motion segment, abnormal findings are
not always associated with symimhfl' ?hnkm^^g mh *1 h_
Although the natural history of neck pain appears to be fa- people without neck pain demonstrate a wide range of ab-
vorable,.*%2+ rates of recurrence and chronicity are high.*.%1* normalities with imaging studies, including disc protrusion
One study reported that 30% of patients with neck pain or extrusion and impingement of the thecal sac on the nerve
will develop chronic symptoms, with neck pain of greater root and spinal cord.12 However, degenerative changes are
maZg/fhgmal]nkZmbhgZü^\mbg`*-h_Zeebg]bob]nZelpah still suggested to be a possible cause of mechanical neck pain
experience an episode of neck pain.19 Additionally, a recent in some cases,109,130,131 despite the fact that these changes are
lnko^r ]^fhglmkZm^] maZm ,0 h_ bg]bob]nZel pah ^qi^kb- present in asymptomatic individuals, are non-specific, and
ence neck pain will report persistent problems for at least are highly prevalent in the elderly.*/1 Disorders such as cervi-
12 months.44 Five percent of the adult population with neck cal radiculopathy and cervical compressive myelopathy are
pain will be disabled by the pain, representing a serious reported to be caused by space-occupying lesions (osteophy-
health concern.*2%11 In a survey of workers with injuries to tosis or herniated cervical disc). These may be secondary to
the neck and upper extremity, Pransky et al*,. reported that degenerative processes and can give rise to neck and/or up-
-+fbll^]fhk^maZg*p^^dh_phkdZg]+/^qi^kb^g\^] per quarter pain as well as neurologic signs and symptoms.*,/
recurrence within 1 year. The economic burden due to dis- While cervical disc herniation and spondylosis are most com-
orders of the neck is high, and includes costs of treatment, monly linked to cervical radiculopathy and myelopathy,*)%*,/
lost wages, and compensation expenditures.*/%*,1 Neck pain is the bony and ligamentous tissues affected by these conditions
second only to low back pain in annual workers’ compensa- are themselves pain generators and are capable of giving rise
mbhg\hlmlbgma^Ngbm^]LmZm^l'*1* In Sweden, neck and shoul- to some of the referred symptoms observed in patients with
]^kikh[e^flZ\\hngm_hk*1h_Zee]blZ[bebmriZrf^gml'*+/ these disorders.13,40
C^mm^^mZe91 reported that patients with neck pain make up
ZiikhqbfZmêr+.h_iZmb^gmlk^\^bobg`hnmiZmb^gmiarlb- Because most patients with neck pain usually lack
cal therapy. Additionally, patients with neck pain frequently
are treated without surgery by primary care and physical
II an identifiable pathoanatomic cause for their prob-
lem, the majority are classified as having mechani-
therapy providers.*0%.*%2+ cal neck disorders.1+
Although the cause of neck pain may be associ-

F7J>E7D7JEC?97B<;7JKH;I
A variety of causes of neck pain have been described
E ated with degenerative processes or pathology
identified during diagnostic imaging, the tissue
and include osteoarthritis, discogenic disorders, trauma, tu- that is causing a patient’s neck pain is most often un-
mors, infection, myofascial pain syndrome, torticollis, and known. Thus, clinicians should assess for impaired func-
whiplash.121Ng_hkmngZmêr%\e^Zker]^Ög^]]bZ`ghlmb\\kbm^kbZ tion of muscle, connective, and nerve tissues associated
have not been established for many of these entities. Similar with the identified pathological tissues when a patient
to low back pain, a pathoanatomical cause is not identifiable presents with neck pain.
H?IA<79JEHI calculated. The changes in pain scores over the varying trial
Bot and colleagues18 investigated the clini- periods in these untreated subjects with chronic mechanical
II cal course and predictors of recovery for patients
with neck and shoulder pain. Four hundred forty
neck pain were consistently small and not significant.*0*
three patients who consulted their primary care physician Conversely, there is substantial evidence that favorable out-
with neck or shoulder symptoms were followed for 12 months. comes are attained following treatment of patients with cer-
At 12 months, 32% of patients reported that they had recov- vical radiculopathy.02%*,/ For example, Radhakrishnan and
ered. Predictors of poor pain-related outcome at 12 months colleagues*,/ reported that nearly 90% of patients with cer-
included less intense pain at baseline, a history of neck and vical radiculopathy presented with only mild symptoms at a
shoulder symptoms, more worrying, worse perceived health, median follow-up of 4.9 years. Honet and Puri02 found that
and a moderate or bad quality of life. The predictors for a 0)h_iZmb^gmlpbma\^kob\ZekZ]b\nehiZmar^qab[bm^]`hh]hk
poor disability-related response at 12 months included older excellent outcomes after a 2-year follow-up. Outcomes for the
age, less disability at baseline, longer duration of symptoms, patients in the aforementioned studies02%*,/ appeared favor-
loss of strength in hands, having multiple symptoms, more Z[e^Zg]ln``^lmmaZm0)&2)h_mablihineZmbhg\Zg^qi^kb-
worrying, moderate or bad quality of life, and less vitality. ence improvement without surgical intervention. In contrast,
the clinical prognosis of patients with whiplash-associated
Hill and colleagues0/ investigated the course of ]blhk]^kble^ll_ZohkZ[e^':lnko^rh_*)1iZmb^gmlpbmaZabl-
II neck pain in an adult population over a 12 month

period. Significant baseline characteristics, which
tory of whiplash requiring care at an emergency department
_hng]maZm..aZ]k^lb]nZeiZbg(]blZ[bebmrk^_^kZ[e^mhma^
ik^]b\m^]i^klblm^gmg^\diZbgp^k^Z`^!-.&.2r^Zkl"%[^bg` hkb`bgZeZ\\b]^gmZmZf^Zg_heehp&nih_*0r^ZkleZm^k'G^\d
off work at the time of the baseline survey (odds ratio [OR] pain, radiating pain, and headache were the most common
6*'/"%\hfhk[b]ehp[Z\diZbg!HK6*'/"%Zg][b\r\ebg`ZlZ symptoms. Thirty-three percent of the respondents with re-

regular activity (OR = 2.4). sidual symptoms suffered from work disability, compared to
/bgma^`khnih_iZmb^gmlpbmahnmk^lb]nZe]blhk]^kl'+.
In a prospective cohort study, Hoving et al1) ex-
II amined the predictors of outcome in a patient
ihineZmbhgpbmag^\diZbg':mhmZeh_*1,iZmb^gml :?7=DEI?I%9B7II?<?97J?ED
iZkmb\biZm^]bgma^lmn]rh_pab\a/,aZ]bfikho^]ZmZ Strategies for the classification of patients
12-month follow-up. In the short term, older age (l40),
concomitant low back pain, and headache were associated
III with neck pain have been recently proposed by
Wang et al,*00 Childs et al,+0 and Fritz and Bren-
/+
with poor outcome. In the long-term, in addition to age and nan. The underlying premise is that classifying patients
concomitant low back pain, previous trauma, a long dura- into groups based on clinical characteristics and matching
tion of neck pain, stable neck pain during the 2 weeks prior these patient subgroups to management strategies likely to
to baseline measurement, and previous neck pain predicted benefit them will improve the outcome of physical therapy
poor prognosis. interventions.+0 The classification system described by Wang
et al*00 categorized patients into 1 of 4 subgroups based on
Clinicians should consider age greater than 40, co- the area of symptoms and the presumed source of the symp-
B existing low back pain, a long history of neck pain,
bicycling as a regular activity, loss of strength in the
toms. The labels of these 4 categories were neck pain only,
headaches, referred arm pain and neck pain, and radicular
hands, worrisome attitude, poor quality of life, and less vital- arm pain and neck pain. Distinct treatment approaches were
ity as predisposing factors for the development of chronic linked to each of the 4 categories. Wang et al*00 reported the
neck pain. results of 30 patients treated using this classification strat-
^`rZlpêeZl+0iZmb^gmlpahp^k^ghmmk^Zm^]'LmZmblmb\Zeer
and clinically significant reductions in pain and disability
9B?D?97B9EKHI; were reported for the classification group only.*00 It is diffi-
Approximately 44% of patients experiencing neck pain cult to draw conclusions regarding the potential usefulness
will go on to develop chronic symptoms,*. and many will con- of the Wang et al*00 classification system because patients in
tinue to exhibit moderate disability at long-term follow-up.// ma^\hgmkhe`khnip^k^ghmmk^Zm^]%pab\ablghmk^×^\mbo^h_
A recent systematic review examined the outcomes of non- physical therapy practice. The classification system described
treatment control groups in clinical trials for the conserva- by Childs et al+0 and Fritz and Brennan/+ uses information
tive management of chronic mechanical neck pain - not due from the history and physical examination to place patients
to whiplash.*0* The outcomes of patients receiving a control bgmh*h_.lîZkZm^mk^Zmf^gmln[`khnil'MaêZ[êlh_ma^l^
or placebo intervention were analyzed and effect sizes were .ln[`khnil%pab\aZk^fh[bebmr%\^gmkZebsZmbhg%^q^k\bl^Zg]
conditioning, pain control, and headache, intend to capture Ehg`lmZg]bg`g^\diZbg!]nkZmbhg7*+p^^dl"

the primary focus or goal of treatment. Fritz and Brennan,/+ :[ghkfZe(ln[lmZg]Zk]i^k_hkfZg\^hgma^\kZgbZe\^kob-
nmbebsbg`Zikhli^\mbo^%h[l^koZmbhgZelmn]rh_+0-iZmb^gml% \Ze×^qbhgm^lm
reported that patients who received interventions matched :[ghkfZe(ln[lmZg]Zk] i^k_hkfZg\^ hg ma^ ]^î ×^qhk
with their treatment subgroup had better outcomes than pa- endurance test
tients who received interventions that were not matched with <hhk]bgZmbhg% lmk^g`ma% Zg] ^g]nkZg\^ ]^Ö\bml h_ g^\d
their subgroup. The classification system described in this and upper quarter muscles (longus colli, middle trapezius,
practice guideline linked to the ICF, parallels the Childs et al+0 lower trapezius, serratus anterior)
and Fritz and Brennan/+ classification with 2 noteworthy dif- ?e^qb[bebmr]^Ö\bmlh_nii^kjnZkm^kfnl\e^l!Zgm^kbhk(fb]-
ferences. The first difference is that the labels in this clinical dle/posterior scalenes, upper trapezius, levator scapulae,
practice guideline incorporate the following ICF impairments pectoralis minor, pectoralis major)
of body functions terminology: Neck pain with mobility defi- >k`hghfb\ bg^ú\b^g\b^l pbma i^k_hkfbg` kî^mbmbo^
cits, neck pain with headaches, neck pain with movement co- activities
ordination impairments, and neck pain with radiating pain.
The second difference is that Fritz and Brennan’s/+ÊiZbg\hg- The ICD diagnosis of spondylosis with radiculopa-
mkheË\Zm^`hkr%pab\apZlebgd^]mhfh[bebsZmbhgZg]kZg`^
of motion exercises following an acute cervical sprain, was
II thy or cervical disc disorder with radiculopathy and
the associated ICF diagnosis of neck pain with radi-
]bob]^]bgmhma^Êg^\diZbgpbmafho^f^gm\hhk]bgZmbhgbf- ating pain is made with a reasonable level of certainty when

iZbkf^gml%ËZg]Êg^\diZbgpbmafh[bebmr]^Ö\bmlË\Zm^`hkb^l% the patient presents with the following clinical findings*0.:
where the patient would receive interventions linked to the Nii^k^qmk^fbmrlrfimhfl%nlnZeerkZ]b\neZkhkk^_^kk^]
most relevant impairment(s) exhibited at a given period dur- pain, that are produced or aggravated with Spurling’s ma-
ing the patient’s episode of care. neuver and upper limb tension tests, and reduced with the
neck distraction test
The ICD diagnosis of cervicalgia, or pain in thoracic =^\k^Zl^] \^kob\Ze khmZmbhg !5/)" mhpZk] ma^ bgoheo^]
I spine and the associated ICF diagnosis of neck pain
with mobility deficits is made with a reasonable lev-
side
Lb`glh_g^ko^khhm\hfik^llbhg
el of certainty when the patient presents with the following Ln\\^llpbmak^]n\bg`nii^k^qmk^fbmrlrfimhflpbmabgb-
clinical findings,,%/+%1+%*//: tial examination and intervention procedures
Rhng`^kbg]bob]nZe!Z`^5.)r^Zkl"
:\nm^g^\diZbg!]nkZmbhg5*+p^^dl" Neck pain, without symptoms or signs of serious
B
LrfimhflblheZm^]mhma^g^\d medical or psychological conditions, associated

K^lmkb\m^]\^kob\ZekZg`^h_fhmbhg with (1) motion limitations in the cervical and up-
per thoracic regions, (2) headaches, and (3) referred or radi-
The ICD diagnosis of headaches, or cervicocranial ating pain into an upper extremity are useful clinical findings
II syndrome and the associated ICF diagnosis of neck
pain with headaches is made with a reasonable lev-
for classifying a patient with neck pain into the following In-
ternational Statistical Classification of Diseases and Related
el of certainty when the patient presents with the following Health Problems (ICD) categories: cervicalgia, pain in tho-
clinical findings/%/+%22%*1.: racic spine, headaches, cervicocranial syndrome, sprain and
NgbeZm^kZe a^Z]Z\a^ Zllh\bZm^] pbma g^\d(ln[h\\bibmZe strain of cervical spine, spondylosis with radiculopathy, and
area symptoms that are aggravated by neck movements or cervical disc disorder with radiculopathy; and the associated
positions International Classification of Functioning, Disability, and
A^Z]Z\aîkh]n\^]hkZ``kZoZm^]pbmaikhoh\Zmbhgh_ma^ Health (ICF) impairment-based category of neck pain with
ipsilateral posterior cervical myofascia and joints the following impairments of body function:
K^lmkb\m^]\^kob\ZekZg`^h_fhmbhg G^\diZbgpbmafh[bebmr]^Ö\bml([0*)*Fh[bebmrh_lô^kZe
K^lmkb\m^]\^kob\Zel^`f^gmZefh[bebmr joints)
:[ghkfZe(ln[lmZg]Zk]i^k_hkfZg\^hgma^\kZgbZe\^kob- G^\diZbgpbmaa^Z]Z\a^l(+1)*)IZbgbga^Z]Zg]g^\d"
\Ze×^qbhgm^lm G^\d iZbg pbma fho^f^gm \hhk]bgZmbhg bfiZbkf^gml
([0/)*<hgmkheh_\hfie^qohengmZkrfho^f^gml"
The ICD diagnosis of sprain and strain of cervical G^\diZbgpbmakZ]bZmbgìZbg![+1)-KZ]bZmbgìZbgbgZ
I spine and the associated ICF diagnosis of neck pain
with movement coordination impairments is made
segment or region)
with a reasonable level of certainty when the patient presents The following physical examination measures may be useful
with the following clinical findings++%+2%*-.%*/+%*1+%*1-: in classifying a patient in the ICF impairment-based category
of neck pain with mobility deficits and the associated ICD assist clinicians in determining when to order radiographs in
categories of cervicalgia or pain in thoracic spine: individuals who have experienced trauma.*.2
<^kob\ZeZ\mbo^kZg`^h_fhmbhg
<^kob\ZeZg]mahkZ\b\l^`f^gmZefh[bebmr In addition to medical conditions, clinicians should
The following physical examination measures may be useful

II be aware of psychosocial factors that may be con-
tributing to a patient’s persistent pain and dis-
in classifying a patient in the ICF impairment-based category ability, or that may contribute to the transition of an acute
of neck pain with headaches and the associated ICD catego- condition to a chronic, disabling condition. Researchers have
ries of headaches or cervicocranial syndrome: recently shown that psychosocial factors are an important
<^kob\ZeZ\mbo^kZg`^h_fhmbhg prognostic indicator of prolonged disability./,%/-%**-%*.) When
<^kob\Zel^`f^gmZefh[bebmr relevant psychosocial factors are identified, the rehabilitation
<kZgbZe\^kob\Ze×^qbhgm^lm approach may need to be modified to emphasize active reha-
bilitation, graded exercise programs, positive reinforcement
The following physical examination measures may be useful of functional accomplishments, and/or graduated exposure
in classifying a patient in the ICF impairment-based category to specific activities that a patient fears as potentially painful
of neck pain with movement coordination impairments and or difficult to perform./.
the associated ICD category of sprain and strain of cervical
spine: Clinicians should consider diagnostic classifications

<kZgbZe\^kob\Ze×^qbhgm^lm
=^îg^\d×^qhk^g]nkZg\^
B associated with serious pathological conditions or
psychosocial factors when the patient’s reported ac-
tivity limitations or impairments of body function and struc-
The following physical examination measures may be useful ture are not consistent with those presented in the diagnosis/
in classifying a patient in the ICF impairment-based catego- classification section of this guideline, or, when the patient’s
ry of neck pain with radiating pain and the associated ICD symptoms are not resolving with interventions aimed at nor-
categories of spondylosis with radiculopathy or cervical disc malization of the patient’s impairments of body function.
disorder with radiculopathy:
Nii^kebf[m^glbhgm^lm
Linkebg`Ílm^lm ?C7=?D=IJK:?;I
=blmkZ\mbhgm^lm Adults with cervical pain precipitated by trauma
should be classified as low risk or high risk based on the Ca-
nadian Cervical Spine Rule (CCR) for radiography in alert

:?<<;H;DJ?7B:?7=DEI?I and stable trauma patients*.2 and the 2001 American College
A primary goal of diagnosis is to match the pa- of Radiology (ACR) suspected Spine Trauma Appropriate-
III tient’s clinical presentation with the most efficacious
treatment approach. A component of this decision
ness Criteria.3 According to the CCR, patients who (1) are
able to sit in the emergency department; or (2) have had a
is determining whether the patient is, in fact, appropriate for simple rear-end motor vehicle collision; or (3) are ambula-
physical therapy management. In the vast majority of patients tory at any time; or (4) have had a delayed onset of neck pain;
with neck pain, symptoms can be attributed to mechanical hk!."]hghmaZo^fb]ebg^\^kob\Zelibg^m^g]^kg^ll4Zg]!/"
factors. However, in a much smaller percentage of patients, Zk^Z[e^mhZ\mboêrkhmZm^ma^bka^Z]-.bg^Z\a]bk^\mbhg%Zk^
the cause of neck pain may be something more serious, such as classified as low risk. Those who are classified as low risk do
cervical myelopathy, cervical instability,49 fracture,00 neoplastic not require imaging for acute conditions. Patients who are
conditions,2)%*-)%*.+%*.- vascular compromise,*.* or systemic dis- !*"`k^Zm^kmaZg/.r^Zklh_Z`^4hk!+"aZoâZ]Z]Zg`^khnl
ease.1%+- Clinicians must be aware of the key signs and symp- mechanism of injury; or (3) have paresthesias in the extremi-
toms associated with serious pathological neck conditions, ties, are classified as high risk.*.2 Those classified as high risk
continually screen for the presence of these conditions, and should undergo cervical radiography.2%-0
initiate referral to the appropriate medical practitioner when
a potentially serious medical condition is suspected. There is a paucity of available literature regarding the pediat-
ric population to help guide decision making on the need for
When a patient with neck pain reports a history of imaging. Adult risk classification features should be applied
I trauma, the therapist needs to be particularly alert
for the presence of cervical instability, spinal frac-
in children greater than age 14. Due to the added radiation
exposure of computed tomography the ACR recommends
ture, and the presence of or potential for spinal cord or brain ieZbg kZ]bh`kZiar !, ob^pl" bg mahl^ ng]^k */ r^Zkl h_ Z`^
stem injury. A clinical prediction rule has been developed to regardless of mental status.3
There is no consensus for routine investigation of patients with head position (turned) at time of impact, and disability levels
chronic neck pain with imaging beyond plain radiographs. ,%-1 (as measured with the Neck Disability Index).*)*%*)+%*)0
Routine use of ultrasonography, CT, and magnetic resonance
bfZ`bg`!FKB"bgiZmb^gmlpbmahnmg^nkheh`b\bglnemhkhma^k Elliott et al.,aZo^]^fhglmkZm^]maZm_^fZeîZmb^gml!*1&-.
disease has not been justified in view of the infrequency of r^Zklhe]"pbmai^klblm^gmP:=!`kZ]^BB"lahpFKB\aZg`^l
abnormalities detected, the lack of prognostic value, inacces- in the fat content of the cervical extensor musculature that
sibility, and the high cost of the procedures.*-%0,%**2%*,,%*-*%*-/%*0- A were not present in subjects with chronic insidious onset neck
major limitation is the lack of specific findings in patients pain or healthy controls. It is currently unclear whether the
with neck disorder and no definite correlation between the patterns of fatty infiltration are the result of local structural
patient’s subjective symptoms and abnormal findings seen on mkZnfZ\Znlbg`Z`^g^kZebg×ZffZmhkrk^lihgl^%Zli^\bÖ\
imaging studies. As a result, debate continues as to whether nerve injury or insult, or a generalized disuse phenomenon.
persistent pain is attributable to structural pathology or to Further, as the muscular changes were observed in the chron-
other underlying causes. ic state, it is not yet known whether they occur uniformly in
all people who have sustained whiplash injury irrespective
K^\^gmer%DkblmcZgllhg111 compared sagittal plane, rotational, of recovery or are unique to only those who develop chronic
and translational cervical segmental motion in women with symptoms.
(1) persistent whiplash-associated disorder (WAD) (grades I
and II), (2) persistent non-traumatic, insidious onset of neck In addition to fatty infiltration, Elliott et al.- have identified
pain, and (3) normal values of rotational and translational changes in the relative cross-sectional area (rCSA) of the cer-
fhmbhg'EZm^kZekZ]bh`kZiab\ZgZerlblkô^Ze^]lb`gbÖ\Zgmer vical paraspinal musculature in patients with chronic WAD
bg\k^Zl^]khmZmbhgZefhmbhgZm<,&-Zg]<-&._hkbg]bob]n- relative to control subjects with no history of neck pain. Spe-
als in the WAD and insidious groups, significantly excessive cifically, the WAD group demonstrated a consistent pattern
translational motion at C3-4 for individuals in the WAD and of larger rCSA in the multifidii muscles at each segment (C3-
insidious groups, and significantly excessive translational <0"'Bg_^k^g\^\Zg[^]kZpgmaZmma^larger rCSAs recorded
fhmbhgZm<.&/_hkbg]bob]nZelbgma^P:=`khnipa^g\hf- in the multifidii muscles of those with chronic WAD are the
pared to normal subjects. result of larger amounts of fatty infiltrate.
NemkZlhgh`kZiar aZl [^^g nl^] mh Z\\nkZmêr f^Zlnk^ ma^ In summary, imaging studies often fail to identify any
size of the cervical multifidus muscle at the C4 level in as- structural pathology related to symptoms in patients with
ymptomatic female subjects. For those with chronic WAD, neck disorder and in particular, whiplash injury. How-
ultrasonography did not accurately measure the cervical ever, emerging evidence into upper cervical ligamentous
multifidus because the fascial borders of the multifidus were disruption, altered segmental motion, and muscular de-
largely indistinguishable, indicating possible pathological generation has been demonstrated with radiographs, ul-
conditions.110 mkZlhgh`kZiar% Zg] FKB lmn]b^l' Bm k^fZbgl ngdghpg b_
(1) these findings are unique to chronic WAD; (2) whether
Abàk^lhenmbhgikhmhg]^glbmr&p^bàm^]FKBaZlk^\^gmer they relate to patients’ physical signs and symptoms, and
demonstrated abnormal signal intensity (indicative of tissue (3) whether specific physical therapy intervention can alter
damage) in both the alar and transverse ligaments in some such degeneration. Such knowledge may offer prognostic
subjects with chronic WAD.*)1EZm^k_heehp&nilmn]b^lbg]b- information and provide the foundation for interventional
cated a strong relationship between alar ligament damage, based studies.
CLINICAL GUIDELINES
Examination
EKJ9EC;C;7IKH;I tients to list 3 activities that are difficult as a result of their
The Neck Disability Index (NDI) is a commonly symptoms, injury, or disorder. The patient rates each activity
I utilized outcome measure to capture perceived dis-
ability in patients with neck pain.134 The NDI con-
on a 0-10 scale, with 0 representing the inability to perform
the activity, and 10 representing the ability to perform the ac-
mZbgl*)bm^fl%0kêZm^]mhZ\mbobmb^lh_]Zberebobg`%+kêZm^] tivity as well as they could prior to the onset of symptoms.*/)
to pain, and 1 related to concentration.*0+ Each item is scored The final PSFS score is the average of the 3 activity scores.
_khf)&.Zg]ma^mhmZel\hk^bl^qik^ll^]ZlZi^k\^gmZ`^%pbma The PSFS was developed by Stratford et al*/) in an attempt
higher scores corresponding to greater disability. Riddle and to present a standardized measure for recording a patient’s
Stratford139 identified a significant association between the perceived level of disability across a variety of conditions.
NDI and both the physical and mental health components The PSFS has been evaluated for reliability and validity in
h_ma^L?&,/'Ma^ZnmahklZelhb]^gmbÖ^]maZmma^G=Bihl- patients with neck pain.*02 The ICC value for test retest reli-
sesses adequate sensitivity as compared to the magnitude of Z[bebmrbgiZmb^gmlpbma\^kob\ZekZ]b\nehiZmarpZl)'1+',0 The
change that occurred for patients reaching their functional minimal detectable change in that population was identified
goals, work status, and if the patient was currently in litiga- to be 2.1 points with a minimum clinically important differ-
tion.139C^mm^Zg]C^mm^92 further substantiated the sensitivity ence of 2.0.,0
to change by calculating the effect sizes for change scores of
[hmama^G=BZg]L?&,/' Clinicians should use validated self-report ques-
Two studies*/*%*02 with small sample sizes have identified the

A tionnaires, such as the Neck Disability Index and
the Patient-Specific Functional Scale for patients
minimal detectable change, or the amount of change that with neck pain. These tools are useful for identifying a pa-
must be observed before the change can be considered to tient’s baseline status relative to pain, function, and disability
exceed the measurement error, for the NDI. Westaway*02 and for monitoring a change in patient’s status throughout
b]^gmbÖ^]ma^fbgbfZe]^m^\mZ[e^\aZg`^Zl.!*)i^k\^gmZ`^ the course of treatment.

points) in a group of 31 patients with neck pain. Stratford
and colleagues*/* identified the minimal detectable change
Zelhmh[^.!*)i^k\^gmZ`îhbgml"bgZ`khnih_-1iZmb^gml 79J?L?JOB?C?J7J?ED7D:F7HJ?9?F7J?EDH;IJH?9-
with neck pain. However, the minimum clinically important J?EDC;7IKH;I
difference, the smallest difference which patients perceive as There are no activity limitation and partici-
beneficial, may be more useful to clinicians.12 Stratford and
colleagues*/* identified the minimal clinically important dif-
V pation restriction measures specifically reported in
the literature associated with neck pain - other than
_^k^g\^ Zl . ihbgml !*) i^k\^gmZ`^ ihbgml"' Fhk^ k^\^gmer% those that are part of the self-report questionnaire noted in
Cleland and colleagues,,. described the minimum clinically mabl`nb]êbg^Íll^\mbhghgHnm\hf^F^Zlnk^l'Ahpô^k%ma^
bfihkmZgm ]bü^k^g\^ _hk ma^ G=B mh [^ 2'. !*2 i^k\^gmZ`^ following measures are options that a clinician may use to
points) for patients with mechanical neck disorders. assess changes in a patient’s level of function over an episode
of care.
The NDI has demonstrated moderate test re-test reliability IZbgeôêZm^g]kZg`^lh_ehhdbg`ho^klahne]^k
and has been shown to be a valid health outcome measure IZbgeôêZm^g]kZg`^lh_ehhdbg`]hpg
in a patient population with cervical radiculopathy. ,0 In this IZbgeôêZm^g]kZg`^lh_ehhdbg`ni
group, the intraclass correlation coefficient (ICC) for test re- IZbgeôêZ_m^klbmmbg`_hk+ahnkl
m^lmkêbZ[bebmrpZl)'/1_hkma^G=BZg]ma^fbgbfnf\ebgb- Gnf[^kh_mbf^li^kgbàmmaZmiZbg]blknimlle^î
\ZeerbfihkmZgm]bü^k^g\^pZl0!*-i^k\^gmZ`îhbgml"' ,0 =^ldphkdmhe^kZg\^!bggnf[^kh_fbgnm^lhkahnkl"
I^k\^gmh_mbf^^qi^kb^g\bg`g^\diZbgho^kmaîkôbhnl
The Patient-Specific Functional Scale (PSFS) is a 24 hours
I practical alternative or supplement to generic and
condition-specific measures.*02 The PSFS asks pa-
I^k\^gmh_mbf^^qi^kb^g\bgà^Z]Z\a^!l"ho^kmaîkôb-
ous month
In addition, the Patient-Specific Functional Scale is a ability Index. *02

questionnaire that can be used to quantify changes in
activity limitations and participation restrictions for pa- Clinicians should utilize easily reproducible activ-
tients with neck pain.*/) This scale enables the clinician to
collect measures related to function that may be different
F ity limitation and participation restriction mea-
sures associated with their patient’s neck pain to
then the measures that are components of the region- assess the changes in the patient’s level of function over the
specific outcome measures section such as the Neck Dis- episode of care.
F>OI?97B?CF7?HC;DJC;7IKH;I
Cervical Active Range of Motion
ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅceX_b_joe\i[l[hWbè_dji
Description J^[Wcekdje\WYj_l[d[YaÔ[n_ed"[nj[di_ed"hejWj_ed"WdZi_Z[X[dZ_d]cej_edc[Wikh[Zki_d]Wd_dYb_dec[j[h
Measurement method 7bbY[hl_YWbhWd][e\cej_edHECc[Wikh[iWh[f[h\ehc[Z_dj^[kfh_]^ji_jj_d]fei_j_ed$9Wh[iêkbZX[jWa[dje[dikh[j^[

fWj_[djcW_djW_diWdkfh_]^ji_jj_d]fei_j_edj^hek]êkjj^[[nWc_dWj_edWdZZkh_d]ikXi[gk[dj\ebbem#kf[nWc_dWj_edi$J^[
\ebbem_d]fheY[Zkh[iWh[ki[Zjec[Wikh[j^[HEC\ehj^[Y[hl_YWbif_d[$
D[Ya<b[n_ed%;nj[di_ed0<ehd[YaÔ[n_ed"j^[_dYb_dec[j[h_ifbWY[Zedj^[jefe\j^[fWj_[djÊi^[WZWb_]d[Zm_j^j^[[nj[hdWb
WkZ_jehoc[WjkiWdZj^[dp[he[Z$J^[fWj_[dj_iWia[ZjeÔ[nj^[^[WZ\ehmWhZWi\WhWifeii_Xb["Xh_d]_d]j^[Y^_djej^[Y^[ij$
J^[Wcekdje\d[YaÔ[n_ed_ih[YehZ[Z\hecj^[_dYb_dec[j[h$<eh[nj[di_edHEC"j^[_dYb_dec[j[h_ifei_j_ed[Z_dj^[iWc[
cWdd[h"WdZj^[fWj_[dj_iWia[Zje[nj[dZj^[d[YaXWYamWhZiWi\WhWifeii_Xb[$J^[Wcekdje\d[Ya[nj[di_ed_ih[YehZ[Zm_j^
j^[_dYb_dec[j[h$
D[YaI_Z[X[dZ_d]0J^[_dYb_dec[j[h_ifei_j_ed[Z_dj^[\hedjWbfbWd[edj^[jefe\j^[fWj_[djÊi^[WZ_dWb_]dc[djm_j^j^[[nj[hdWb
WkZ_jehoc[Wjki$Jec[Wikh[h_]^ji_Z[X[dZ_d]"j^[fWj_[dj_iWia[Zjecel[j^[h_]^j[Whjej^[h_]^jiêkbZ[h$J^[Wcekdje\
i_Z[X[dZ_d]_ih[YehZ[Zm_j^j^[_dYb_dec[j[h$J^[effei_j[_if[h\ehc[Zjec[Wikh[b[\ji_Z[X[dZ_d]$9Wh[iêkbZX[jWa[dje
Wle_ZYedYec_jWdjhejWj_edehÔ[n_edm_j^j^[i_Z[X[dZ_d]cel[c[dj$
D[YaHejWj_ed0HejWj_edYWdX[c[Wikh[Zm_j^Wkd_l[hiWb%ijWdZWhZ]ed_ec[j[h$J^[fWj_[dj_ii[Wj[Z"beea_d]Z_h[Yjbo\ehmWhZ
m_j^j^[d[Ya_dd[kjhWbfei_j_ed$J^[\kbYhkce\j^[]ed_ec[j[h_ifbWY[Zel[hj^[jefe\j^[^[WZm_j^j^[ijWj_edWhoWhcWb_]d[Z
m_j^j^[WYhec_edfheY[iie\j^[iêkbZ[h"WdZj^[cel[WXb[WhcX_i[Yj_d]j^[fWj_[djÊidei[$J^[fWj_[dj_iWia[ZjehejWj[_d[WY^
Z_h[Yj_edWi\WhWifeii_Xb[$
Nature of variable 9edj_dkeki

Units of measurement :[]h[[i
Measurement properties 9[hl_YWb HEC c[Wikh[c[dji \eh Ô[n_ed" [nj[di_ed" WdZ i_Z[X[dZ_d] ki_d] W XkXXb[ _dYb_dec[j[h ^Wl[ [n^_X_j[Z h[b_WX_b_jo
Ye[øY_[djihWd]_d]\hec&$,,je&$.*?99("'$)("'-+
Instrument variations ?dWZZ_j_edjeki_d]Wd_dYb_dec[j[h"+".)"'(."'.&Y[hl_YWbHECYWdWbieX[c[Wikh[Z\ehYb_d_YWbfkhfei[iki_d]WY[hl_YWbhWd][e\cej_ed

9HECZ[l_Y['')"',+ehWjWf[c[Wikh[$7bbc[jêZiWh[ceZ[hWj[boYehh[bWj[Zm_j^ceh[Z[Ód_j_l[hWZ_e]hWf^_YWdZ):a_d[cWj_Y
c[Wikh[c[dj$*"+
Cervical And Thoracic Segmental Mobility
ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅceX_b_joe\i_d]b[è_dji
Description M_j^j^[fWj_[djfhed["Y[hl_YWbWdZjêhWY_Yif_d[i[]c[djWbcel[c[djWdZfW_dh[ifedi[Wh[Wii[ii[Z
Measurement method J^[fWj_[dj_ifhed[$J^[[nWc_d[hYedjWYji[WY^Y[hl_YWbif_dekifheY[iim_j^j^[j^kcXi$J^[bWj[hWbd[YackiYkbWjkh[_i][djbo

fkbb[Zib_]^jbofeij[h_ehm_j^j^[Ód][hi$J^[[nWc_d[hiêkbZX[Z_h[Yjboel[hj^[YedjWYjWh[Wa[[f_d][bXemi[nj[dZ[Z"j^[d^[%
i^[ki[ij^[kff[hjhkdaje_cfWhjWfeij[h_ehjeWdj[h_eh\ehY[_dWfhe]h[ii_l[eiY_bbWjeho\Wi^_edel[hj^[if_dekifheY[ii$J^_i
_ih[f[Wj[Z\eh[WY^Y[hl_YWbi[]c[dj$J^[[nWc_d[hj^[dY^Wd][i^_i%^[hYedjWYjfei_j_edWdZfbWY[ij^[ôfej^[dWh[c_d[dY[
`kijZ_ijWbjej^[f_i_\ehce\ed[^WdZel[hj^[if_dekifheY[iie\[WY^jêhWY_Yif_dekifheY[iiWdZh[f[Wjij^[iWc[feij[h_eh
jeWdj[h_eh\ehY[i_dWfhe]h[ii_l[eiY_bbWjeho\Wi^_ed$J^[j[ijh[ikbj_iYedi_Z[h[ZjeX[fei_j_l[_\j^[fWj_[djh[fehjih[fheZkYj_ed
e\fW_d$J^[ceX_b_joe\j^[i[]c[dj_i`kZ][ZjeX[dehcWb"ôf[hceX_b["ehôfeceX_b[$?dj[hfh[jWj_ede\ceX_b_jo_iXWi[Zedj^[
[nWc_d[hÊif[hY[fj_ede\j^[ceX_b_joWj[WYîf_dWbi[]c[djh[bWj_l[jejêi[WXel[WdZX[bemj^[j[ij[Zi[]c[dj"WdZXWi[Zed
j^[[nWc_d[hÊi[nf[h_[dY[WdZf[hY[fj_ede\dehcWbceX_b_jo$
Nature of variable Dec_dWbfW_dh[ifedi[WdZehZ_dWbceX_b_jo`kZ]c[dj
Cervical And Thoracic Segmental Mobility (continued)
Units of measurement None
Diagnostic accuracy and :_W]deij_Y7YYkhWYo'**0

measurement properties FW_dZkh_d]i[]c[djWbj[ij_d]WiieY_Wj[Zm_j^h[fehjie\d[YafW_d$
I[di_j_l_jo3&$.(1d[]Wj_l[b_a[b_êeZhWj_e#BH3&$()
If[Y_ÓY_jo3&$-/1fei_j_l[b_a[b_êeZhWj_e!BH3)$/
H[b_WX_b_jo\ehY[hl_YWbif_d[Wii[iic[dj0
AWffW3&$'*je&$)-fW_d',/
?993&$*(je&$-/fW_d''
?993&$-.je'$&fh[i[dY[e\è_djZoi\kdYj_ed_dkff[h)Y[hl_YWbif_d[i[]c[dji'&&
M[_]^j[ZaWffW0#&$(,je&$-*ceX_b_jo"#&$+(je&$/&fW_d)(
H[b_WX_b_jo\ehjêhWY_Yif_d[Wii[iic[dj0
M[_]^j[ZaWffW0&$')je&$.(ceX_b_jo"#&$''je&$/&fW_d)(
Cranial Cervical Flexion Test
ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅYedjhebe\i_cfb[lebkdjWhocel[c[djiWdZ[dZkhWdY[e\_iebWj[ZckiYb[i
Description ?dikf_d["j^[WX_b_joje_d_j_Wj[WdZcW_djW_d_iebWj[ZYhWd_WbWdZY[hl_YWbÔ[n_ed
Measurement method FWj_[dj_ifei_j_ed[Zikf_d[_dêeabo_d]WdZj^[^[WZWdZd[Ya_dc_Z#hWd][d[kjhWb_cW]_dWhob_d[X[jm[[d\eh[^[WZWdZY^_dWdZ

_cW]_dWhob_d[X[jm[[dj^[jhW]kie\j^[[WhWdZj^[d[Yabed]_jkZ_dWbboiêkbZX[fWhWbb[bje[WYêj^[hWdZj^[ikh\WY[e\j^[
jh[Wjc[djjWXb[$Jem[bicWoX[d[[Z[ZkdZ[hj^[eYY_fkjjeWY^_[l[j^_id[kjhWbfei_j_ed$7fd[kcWj_Yfh[iikh[Z[l_Y["ikY^WiW
fh[iikh[X_e\[[ZXWYakd_j"_i_dÔWj[Zje(&cc>]jeÓbbj^[ifWY[X[jm[[dj^[Y[hl_YWbbehZej_YYkhl[WdZj^[ikh\WY[e\j^[jWXb[
X[^_dZj^[ikXeYY_f_jWbh[]_ed"dejX[bemj^[bem[hY[hl_YWbWh[W$
M^_b[a[[f_d]j^[feij[h_eh^[WZ%eYY_fkjijWj_edWhoZedejb_\j"Zedejfki^Zemd"j^[fWj_[djf[h\ehciYhWd_WbY[hl_YWbÔ[n_ed
99<_dW]hWZ[Z\Wi^_ed_d+_dYh[c[dji(("(*"(,"(."WdZ)&cc>]WdZW_cijeêbZ[WY^fei_j_ed\eh'&i[YedZi$J[di[YedZi
h[ij_ifhel_Z[ZX[jm[[dijW][i$Jef[h\ehc99<"j^[fWj_[dj_i_dijhkYj[Zje][djbodeZj^[^[WZWijêk]^j^[om[h[iWo_d]Ço[iÈ
m_j^j^[kff[hd[Ya$J^_icej_edm_bbÔWjj[dj^[Y[hl_YWbbehZei_i"j^kiY^Wd]_d]j^[fh[iikh[_dj^[fd[kcWj_Yfh[iikh[Z[l_Y[$M^_b[
j^[fWj_[dj_if[h\ehc_d]j^[j[ijcel[c[dj"j^[j^[hWf_ijfWbfWj[ij^[d[Yajeced_jeh\ehkdmWdj[ZWYj_lWj_ede\j^[ikf[hÓY_Wb
Y[hl_YWbckiYb[i"ikY^Wij^[ij[hdeYb[_ZecWije_Z$J^[fWj_[djYWdfbWY[^_i%^[hjed]k[edj^[hee\e\j^[cekj^"m_j^b_fije][j^[h
Xkjj^[j[[jîb_]^jboi[fWhWj[Z"je^[bfZ[Yh[Wi[fbWjoicWWdZ%ehôe_ZWYj_lWj_ed$J^[j[ij_i]hWZ[ZWYYehZ_d]jej^[fh[iikh[b[l[b
j^[fWj_[djYWdWY^_[l[m_j^YedY[djh_YYedjhWYj_ediWdZWYYkhWj[boikijW_d_iec[jh_YWbbo$J^[j[ij_ij[hc_dWj[Zm^[dj^[fh[iikh[
_iZ[Yh[Wi[ZXoceh[j^Wd(&ehm^[dj^[fWj_[djYWddejf[h\ehcj^[fhef[h99<cel[c[djm_jêkjikXij_jkj_edijhWj[]_[i$
7dehcWbh[ifedi[_i\ehj^[fh[iikh[je_dYh[Wi[jeX[jm[[d(,#)&cc>]WdZX[cW_djW_d[Z\eh'&i[YedZim_jêkjkj_b_p_d]
ikf[hÓY_WbY[hl_YWbckiYb[ikXij_jkj_edijhWj[]_[i$
7dWXdehcWbh[ifedi[_im^[h[j^[fWj_[dj0
'$?ikdWXb[je][d[hWj[Wd_dYh[Wi[_dfh[iikh[e\Wjb[Wij,cc>]"
($?ikdWXb[jeêbZj^[][d[hWj[Zfh[iikh[\eh'&i[YedZi"
)$Ki[iikf[hÓY_Wbd[YackiYb[ijeWYYecfb_i^j^[Y[hl_YWbÔ[n_edcej_ed"eh
*$Ki[iWikZZ[dcel[c[dje\j^[Y^_dehfki^_d][nj[dZ_d]j^[d[Ya\ehY[\kbboW]W_dijj^[fh[iikh[Z[l_Y[
IYeh_d]0
7Yj_lWj_edIYeh[0Fh[iikh[WY^_[l[ZWdZ^[bZ\eh'&i[YedZ
F[h\ehcWdY[?dZ[n0?dYh[Wi[_dFh[iikh[dkcX[he\h[f[j_j_edi
Units of measurement cc>]\ehj^[WYj_lWj_ediYeh[
Measurement properties H[b_WX_b_joWii[iic[dj\eh+&WiocfjecWj_YikX`[Yji"j[ij[Zjm_Y['m[[aWfWhj07Yj_lWj_ediYeh[0?993&$.'1F[h\ehcWdY[?dZ[n0?993$/)/,
Neck Flexor Muscle Endurance Test
ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅ[dZkhWdY[e\_iebWj[ZckiYb[i
Description ?dikf_d["j^[WX_b_jojeb_\jj^[^[WZWdZd[YaW]W_dij]hWl_jo\ehWd[nj[dZ[Zf[h_eZ
Neck Flexor Muscle Endurance Test (continued)
Measurement method J^[j[ij_if[h\ehc[Z_dWikf_d["êea#bo_d]fei_j_ed$M_j^j^[Y^_dcWn_cWbboh[jhWYj[ZWdZcW_djW_d[Z_iec[jh_YWbbo"j^[fWj_[dj

b_\jij^[^[WZWdZd[Yakdj_bj^[^[WZ_iWffhen_cWj[bo($+Yc'_dWXel[j^[fb_dj^m^_b[a[[f_d]j^[Y^_dh[jhWYj[Zjej^[Y^[ij$
J^[Yb_d_Y_Wd\eYki[iedj^[ia_d\ebZiWbed]j^[fWj_[djÊid[YaWdZfbWY[iW^WdZedj^[jWXb[`kijX[bemj^[eYY_f_jWbXed[e\j^[
fWj_[djÊi^[WZ$L[hXWbYeccWdZi_["ÇJkYaoekhY^_dÈehÇ>ebZoekh^[WZkfÈWh[]_l[dm^[d[_j^[hj^[ia_d\ebZiX[]_dije
i[fWhWj[ehj^[fWj_[djÊieYY_fkjjekY^[ij^[Yb_d_Y_WdÊi^WdZ$J^[j[ij_ij[hc_dWj[Z_\j^[ia_d\ebZi_ii[fWhWj[ZZk[jebeiie\
Y^_djkYaehj^[fWj_[djÊi^[WZjekY^[ij^[Yb_d_Y_WdÊi^WdZ\ehceh[j^Wd'i[YedZ$-+
Units of measurement I[YedZi
Measurement properties ?dWijkZoXo>Whh_i[jWb"-+*'ikX`[Yjim_j^WdZm_jêkjd[YafW_df[h\ehc[Zj^_ij[ij$JmehWj[hij[ij[ZWbbikX`[YjiWjXWi[b_d["WdZ

ikX`[Yjim_jêkjd[YafW_dm[h[j[ij[ZW]W_d'm[[abWj[h$
H[b_WX_b_jo0
IkX`[Yjim_jêkjd[YafW_d0
?99)"'3&$.(je&$/'"I;C.$&#''$&i[YedZi
?99("'3&$,-je&$-."I;C'($,#'+$)i[YedZi
IkX`[Yjim_j^d[YafW_d0
?99("'3&$,-"I;C''$+i[YedZi
J[ijh[ikbji0
IkX`[Yjim_jêkjd[YafW_d0C[Wd).$/+i[YedZiI:3(,$*
IkX`[Yjim_j^d[YafW_d0C[Wd(*$'i[YedZiI:3'($.
Upper Limb Tension Test
ICF category C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z
Description ?dded#m[_]^jX[Wh_d]"j^[Wcekdje\ceX_b_joe\j^[d[khWb[b[c[djie\j^[kff[hb_cXWh[Wii[ii[Zm^_b[Z[j[hc_d_d]m^[j^[hj^[
fWj_[djÊikff[hgkWhj[hiocfjeciWh[[b_Y_j[ZZkh_d]f[h\ehcWdY[e\j^[j[ij
Measurement method Kff[hb_cXj[di_edj[ijiWh[f[h\ehc[Zm_j^j^[fWj_[djikf_d[$:kh_d]f[h\ehcWdY[e\j^[kff[hb_cXj[di_edj[ijj^WjfbWY[iW

X_Wi jemWhZ j[ij_d] j^[ fWj_[djÊi h[ifedi[ je j[di_ed fbWY[Z ed j^[ c[Z_Wd d[hl[" j^[ [nWc_d[h i[gk[dj_Wbbo _djheZkY[i j^[
\ebbem_d]cel[c[djijej^[iocfjecWj_Ykff[h[njh[c_jo0
IYWfkbWhZ[fh[ii_ed
IêkbZ[hWXZkYj_edjeWXekj/&m_j^j^[[bXemÔ[n[Z
<eh[Whcikf_dWj_ed"mh_ijWdZÓd][h[nj[di_ed
IêkbZ[hbWj[hWbhejWj_ed
;bXem[nj[di_ed
9edjhWbWj[hWbj^[d_fi_bWj[hWbY[hl_YWbi_Z[#X[dZ_d]
7fei_j_l[j[ijeYYkhim^[dWdoe\j^[\ebbem_d]ÓdZ_d]iWh[fh[i[dj0
'$h[fheZkYj_ede\WbbehfWhje\j^[fWj_[djÊiiocfjeci
($i_Z[#je#i_Z[Z_÷[h[dY[ie\]h[Wj[hj^Wd'&e\[bXem[nj[di_edehmh_ij[nj[di_ed
)$edj^[iocfjecWj_Yi_Z["YedjhWbWj[hWbY[hl_YWbi_Z[#X[dZ_d]_dYh[Wi[ij^[fWj_[djÊiiocfjeci"eh_fi_bWj[hWbi_Z[#X[dZ_d]
Z[Yh[Wi[ij^[fWj_[djÊiiocfjeci
Nature of variable Dec_dWb
Diagnostic accuracy indices for /+9edÓZ[dY[?dj[hlWb

the upper limb tension test, based AWffW &$-, &$+'#'$&
on the study by Wainner et al175 I[di_j_l_jo &$/- &$/&#'$&
If[Y_ÓY_jo &$(( &$'(#&$))
Fei_j_l[b_a[b_êeZhWj_e '$)& '$'&#'$+
D[]Wj_l[b_a[b_êeZhWj_e &$'( &$&'#'$/
Spurling’s Test
Spurling’s Test (continued)
Description 9ecX_dWj_ede\i_Z[X[dZ_d]jej^[iocfjecWj_Yi_Z[Yekfb[Zm_j^Yecfh[ii_edjeh[ZkY[j^[Z_Wc[j[he\j^[d[khWb\ehWc[dWdZ
[b_Y_jj^[fWj_[djÊiiocfjeci
Measurement method J^[fWj_[dj_ii[Wj[ZWdZ_iWia[Zjei_Z[X[dZWdZib_]^jbohejWj[j^[^[WZjej^[fW_d\kbi_Z[$J^[[nWc_d[hfbWY[iWYecfh[ii_ed\ehY[

e\Wffhen_cWj[bo-a]j^hek]^j^[jefe\j^[^[WZ_dWd[÷ehjje\khj^[hdWhhemj^[_dj[hl[hj[XhWb\ehWc[d$J^[j[ij_iYedi_Z[h[Zfei_j_l[
m^[d_jh[fheZkY[ij^[fWj_[djÊiiocfjeci$J^[j[ij_idej_dZ_YWj[Z_\j^[fWj_[dj^Widekff[h[njh[c_joehiYWfkbWhh[]_ediocfjeci$
Nature of variable Dec_dWb%Z_Yêjeceki

Spurling’s test, based on the AWffW &$,& &$)(#&$.-
study by Wainner et al175 I[di_j_l_jo &$+& &$(-#&$-)
If[Y_ÓY_jo &$., &$--#&$/*
Fei_j_l[b_a[b_êeZhWj_e )$+& '$,&#-$+&
D[]Wj_l[b_a[b_êeZhWj_e &$+. &$),#&$/*
D istraction Test

Description :_ijhWYj_ede\j^[Y[hl_YWbif_d[jecWn_c_p[j^[Z_Wc[j[he\j^[d[khWb\ehWc[dWdZh[ZkY[eh[b_c_dWj[j^[fWj_[djÊiiocfjeci
Measurement method J^[Z_ijhWYj_edj[ij_iki[Zje_Z[dj_\oY[hl_YWbhWZ_YkbefWjôWdZ_if[h\ehc[Zm_j^j^[fWj_[djikf_d[$J^[[nWc_d[h]hWifikdZ[h

j^[ Y^_d WdZ eYY_fkj" Ô[n[i j^[ fWj_[djÊi d[Ya je W fei_j_ed e\ Yec\ehj" WdZ ]hWZkWbbo Wffb_[i W Z_ijhWYj_ed \ehY[ e\ kf je
Wffhen_cWj[bo'*a]$7fei_j_l[j[ijeYYkhim_j^j^[h[ZkYj_edeh[b_c_dWj_ede\j^[fWj_[djÊikff[h[njh[c_joehiYWfkbWhiocfjeci$
J^_ij[ij_idej_dZ_YWj[Z_\j^[fWj_[dj^Widekff[h[njh[c_joehiYWfkbWhh[]_ediocfjeci$
Nature of variable Dec_dWb


the upper limb tension test, based AWffW &$.. &$,*#'$&
on the study by Wainner et al175 I[di_j_l_jo &$** &$('#&$,-
If[Y_ÓY_jo &$/& &$.(#&$/.
Fei_j_l[b_a[b_êeZhWj_e *$*& '$.&#''$'
D[]Wj_l[b_a[b_êeZhWj_e &$,( &$*&#&$/&
Valsalva Test
Description CWd[kl[h_dm^_Y^j^[fWj_[djX[WhiZemdm_jêkj[n^Wb_d]je_dYh[Wi[_djhWj^[YWbfh[iikh[WdZ[b_Y_jkff[hgkWhj[hiocfjeci
Measurement method J^[fWj_[dj_ii[Wj[ZWdZ_dijhkYj[ZjejWa[WZ[[fXh[Wj^WdZêbZ_jm^_b[Wjj[cfj_d]je[n^Wb[\eh(#)i[YedZi$7fei_j_l[

h[ifedi[eYYkhim_j^h[fheZkYj_ede\iocfjeci$
Nature of variable Dec_dWb%Z_Yêjeceki

the valsalva test, based on the AWffW &$,/ &$),#'$&
study by Wainner et al175 I[di_j_l_jo &$(( &$&)#&$*'
If[Y_ÓY_jo &$/* &$..#'$&
Fei_j_l[b_a[b_êeZhWj_e )$+& &$/-#'($,
D[]Wj_l[b_a[b_êeZhWj_e &$.) &$,*#'$'
CLINICAL GUIDELINES
Interventions
A variety of interventions have been described for the treat- rendered by a general practitioner and non-manual physical
ment of neck pain and there is good evidence from high- therapy interventions, the combination of manipulation and
quality randomized, controlled trials and systematic reviews ^q^k\bl^k^lnem^]bglb`gbÖ\Zgm\hlm&lZobg`lh_nimh/1'*)/
to support the benefits of physical therapy intervention in
these patients. Although many patients experience a significant
II benefit when treated with thrust manipulation, it
is still unclear which patients benefit most. Tseng
9;HL?97BCE8?B?P7J?ED%C7D?FKB7J?ED et al*//kîhkm^]/ik^]b\mhkl_hkiZmb^gmlpah^qi^kb^g\^]Zg
The most recent Cochrane Collaboration immediate improvement in either pain, satisfaction, or per-
I Review/2 of mobilization and manipulation for

mechanical neck disorders included 33 randomized
ception of condition following manipulation of the cervical
spine. These predictors included*//:
controlled trials of which 42% were considered high qual- BgbmbZel\hk^lhgG^\d=blZ[bebmrBg]^qe^llmaZg**'.
ity. They concluded that the most beneficial manipulative AZobg`[beZm^kZebgoheo^f^gmiZmm^kg
interventions for patients with mechanical neck pain with Ghm i^k_hkfbg` l^]^gmZkr phkd fhk^ maZg . ahnkl i^k
or without headaches should be combined with exercise to day
k^]n\îZbgZg]bfikhoîZmb^gmlZmbl_Z\mbhg'FZgbineZmbhg ?^êbg`[^mm^kpabe^fhobg`ma^g^\d
(thrust) and mobilization (non-thrust manipulation) inter- =b]ghm_^êphkl^pabe^^qm^g]bg`ma^g^\d
vention alone were determined to be less effective than when Ma^]bZ`ghlblh_lihg]rehlblpbmahnmkZ]b\nehiZmar
combined with exercise (combined intervention)./2 A recently
published clinical practice guideline concluded that the evi- The presence of 4 or more of these predictors increased the
dence for combined intervention was relatively strong, while ikh[Z[bebmrh_ln\\^llpbmafZgbineZmbhg_khf/)mh12'*//
the evidence for the effectiveness of thrust or non-thrust ma- Predictors of which patients respond best to combined inter-
nipulation in isolation was weaker./1 vention have not been reported.
The recommendations of the Cochrane Review/2 and the re- Nilsson et al*+. conducted a randomized, clinical tri-
cently published clinical practice guideline/1 were based on
key findings that warrant further discussion. Studies cited
I Ze!g6.,"bgbg]bob]nZelpbma\^kob\h`^gb\a^Z]Z\a^'
Subjects were randomized to receive high velocity
included patients with both acute1+and chronic neck pain22 low amplitude spinal manipulation or low level laser and
and interventions consisted of soft-tissue mobilization and deep friction massage. The use of analgesics were reduced
manual stretching procedures, as well as thrust,*0%1, and non- [r,/bgma^fZgbineZmbhg`khni[nmp^k^ng\aZg`^]bg
thrust manipulative procedures1+ directed at spinal motion the laser/massage group. The number of headache hours per
l^`f^gml' Gnf[^k h_ oblbml kZg`^] _khf / ho^k Z , p^^d ]Zr]^\k^Zl^][r/2_hkma^bg]bob]nZelbgma^fZgbineZmbhg
period1+ to 20 over an 11 week period22 and the duration of `khniZg],0bgmaêZl^k(fZllZ`^`khni'A^Z]Z\a^bgm^g-
sessions ranged from 30 minutes99 mh /) fbgnm^l'22 Com- lbmri^kîblh]^]^\k^Zl^][r,/_hkmahl^bgma^fZgbineZ-
bined intervention was compared with various competing mbhg`khniZg]*0bgmaêZl^k(fZllZ`^`khni'
interventions that included manipulation alone,22,99 various
non-manual physical therapy interventions,1+ high-tech and A systematic review by Vernon et al,*0* which includ-
low-tech exercises,++%1+%22 general practitioner care (medica-
tion, advice, education),1+ and no treatment.99 The majority
II ^]lmn]b^lin[ebla^]makhnà+)).%\hg\en]^]maZm
there is moderate- to high-quality evidence that sub-
of studies report either clinically or statistically important jects with chronic neck pain and headaches show clinically im-
differences in pain in favor of combined intervention when portant improvements from a course of spinal mobilization or
compared to competing single interventions./2 Differences in fZgbineZmbhgZm/%*+%Zg]nimh*)-p^^dlihlm&mk^Zmf^gm'
muscle performance22,99 as well as patient satisfaction have
also been reported for both short-term++%1+%22 as well as long- Despite good evidence to support the benefits of cervical
term outcomes 122 and 2 years later..1 When compared to care mobilization/manipulation, it is important that physical
therapists be aware of the potential risks in using these tech- Recommendation: Clinicians should consider utiliz-
niques./1%/2 However, it is impossible to determine the pre-
cise risk because (1) it is extremely difficult to quantify the
A ing cervical manipulation and mobilization proce-
dures, thrust and non-thrust, to reduce neck pain and
number of cervical spine mobilization/manipulative inter- headache. Combining cervical manipulation and mobilization
ventions performed each year, and (2) not all adverse events with exercise is more effective for reducing neck pain, headache,
occurring after mobilization/manipulation interventions are and disability than manipulation and mobilization alone.
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 T>EH79?9CE8?B?P7J?ED%C7D?FKB7J?ED
use, and smoking.0+ However, the prevalence of these factors A survey among clinicians that practice manual physi-
in the study by Haldeman et al0+ is largely the same or lower cal therapy reported that the thoracic spine is the region of
than that which occurs in the general population. the spine most often manipulated, despite the fact that more
patients complain of neck pain.1 While several randomized
Although the true risk for complications remains unknown, clinical trials have examined the effectiveness of thoracic
ma^kbld_hkl^kbhnl\hfieb\Zmbhglbl^lmbfZm^]mh[^/bg*) libg^ maknlm fZgbineZmbhg !MLF" _hk iZmb^gml pbma g^\d
fbeebhg!)'))))/"fZgbineZmbhgl%pbmama^kbldh_]^Zma[^- pain, patients in these studies also received cervical manipu-
ing 3 in 10 million (0.000003%). Importantly, these rates are lation.+%++%.0 The rationale to include thoracic spine mobiliza-
adjusted assuming that only 1 in 10 complications is actually tion/manipulation in the treatment of patients with neck
reported in the literature.1- Gross et al0) recently reported, pain stems from the theory that disturbances in joint mobil-
in a clinical practice guideline on the use of mobilization/ ity in the thoracic spine may be an underlying contributor to
manipulation in patients with mechanical neck pain, that musculoskeletal disorders in the neck. 2-%*).
estimates for serious complication for manipulation ranged

_khf*bg+)%)))!)')*"mh.bg*)fbeebhg!)')))."'0) Cleland et al34\hfiZk^]ma^^ü^\mbo^g^llh_MLFbg
The risk estimate for patients experiencing non-serious

I a trial in which patients were randomized to either a
lbgè^l^llbhgh_MLFhklaZffZgbineZmbhg'IZmb^gml
side effects such as increased symptoms, ranges from 1% to pahk^\^bo^]MLF^qi^kb^g\^]Z\ebgb\Zeerf^Zgbg`_neZg]lmZ-
2%.149 The most common side effects included local discom- tistically significant reduction in pain on the visual analogue
_hkm!.,"%eh\Zea^Z]Z\a^!*+"%_Zmb`n^!**"%hkkZ]bZmbg` scale (VAS) compared to patients who received the sham inter-
]bl\hf_hkm!*)"'IZmb^gml\aZkZ\m^kbs^]1.h_ma^l^\hf- vention (P.001).34 A similar finding (reduction of pain) was
ieZbgmlZlfbe]hkfh]^kZm^%pbma/-h_lb]^^ü^\mlZii^Zk- Zelhkîhkm^]bgZkZg]hfbs^]mkbZemaZm\hfiZk^]MLFbgm^k-
ing within 4 hours after manipulation. Within 24 hours after vention to an active exercise program.*-0 A subsequent random-
fZgbineZmbhg%0-h_ma^\hfieZbgmlaZ]k^lheo^]'E^llmaZg ized trial by Cleland et al,1pab\a\hfiZk^]MLFmhghg&maknlm
.h_lb]^^ü^\mlp^k^\aZkZ\m^kbs^]Zl]bssbg^ll%gZnl^Z%ahm manipulation (mobilization) found significant differences in fa-
skin, or other complaints. Side effects were rarely still noted ohkh_ma^MLF`khnibgiZbg%]blZ[bebmr%Zg]iZmb^gmi^k\^bo^]
on the day after manipulation, and very few patients reported bfikho^f^gmnihgk^&ôZenZmbhg-1ahnkleZm^k'
the side effects as being severe.
While preliminary reports indicate that patients
Due the potential risk of serious adverse effects associated
with cervical manipulation, such as vertebrobasilar artery
II with complaints of primary neck pain experience a
lb`gbÖ\Zgm[^g^Ömpa^gmk^Zm^]pbmaMLF%bmbllmbee
stroke,./ it has been recommended that non-thrust cervi- unclear which patients benefit most. Cleland et al33 reported a
cal mobilization/manipulation be utilized in favor of thrust preliminary clinical prediction rule for patients with primary
manipulation..)%1. However, information regarding the risk/ neck pain who experience short-term improvement (1-week)
benefit ratio of providing cervical thrust manipulation to pbmaMLF'>Z\aln[c^\mk^\^bo^]ZmhmZeh_,mahkZ\b\fZgbin-
patients with impairments of body function purported to lations directed at the upper and middle thoracic spine for up
benefit from cervical mobilization/manipulation, such as cer- mh+l^llbhgl'Nlbg`Zèh[ZekZmbg`h_\aZg`^l\hk^l.ZlZ
vical segmental mobility deficits, has not been reported. In k^_^k^g\^\kbm^kbhg%/oZkbZ[e^lp^k^kîhkm^]Zlik^]b\mhklh_
addition, the case reports in the literature describing serious improvement and included33:
adverse effects associated with cervical thrust manipulation Lrfimhf]nkZmbhgh_e^llmaZg,)]Zrl
do not provide information regarding either the presence of Ghlrfimhfl]blmZemhma^lahne]^k
bfiZbkf^gmlh_[h]r_ng\mbhgl%hkmaîk^l^g\^h_k^]×Z`l Ln[c^\m kîhkml maZm ehhdbg` ni ]h^l ghm Z``kZoZm^
for vertebrobasilar insufficiency,0 prior to the application of symptoms
the manipulative procedure suspected to be linked with the ?^Zk&Zohb]Zg\^ ;êb^_l Jn^lmbhggZbk^&Iarlb\Ze :\mbobmr
reported harmful effects. Scale score less than 12
=bfbgbla^]nii^kmahkZ\b\libg^driahlbl!M,ÈM." nipulation can also be used for reducing pain and disability
<^kob\Ze^qm^glbhgh_e^llmaZg,) in patients with neck and neck-related arm pain.
Interestingly, the lack of symptom aggravation with looking

up was also one of the predictors reported by Tseng et al*// in IJH;J9>?D=;N;H9?I;I
the cervical manipulation clinical prediction rule. Validation In a randomized controlled trial, Ylinen et
h_[hmama^\^kob\ZeZg]MLF\ebgb\Zekne^lblk^jnbk^][^_hk^
they can be recommended for widespread clinical use.
I al*1, assessed the effectiveness of manual therapy
procedures implemented twice a week compared
pbmaZlmk^m\abg`k^`bf^gi^k_hkf^].mbf^lZp^^dbgmahl^
In a randomized clinical trial Fernández de las Pe- with non-specific neck pain. At the 4 and 12 week follow-up
I ñas et al.2 demonstrated that patients with neck
pain related to a whiplash-associated disorder re-
both groups improved but there were no significant differenc-
es between the groups related to pain. Neck pain and disabil-
ceiobg` MLF ^qi^kb^g\^] Z lb`gbÖ\Zgmer `k^Zm^k !I5'))," ity outcome measures, shoulder pain and disability outcome
reduction in pain as measured by the visual analogue scale, measures, and neck stiffness were reduced significantly more
than those who did not receive the thoracic manipulation. in those receiving manual therapy, but the clinical difference
Ma^f^Zg\aZg`^bgiZbgeôêlbgma^`khnik^\^bobg`MLF was minimal. The authors concluded that the low-cost of
pZl.-'*ff!L=*1'1ff"\hfiZk^]mhZf^Zg\aZg`^h_ stretching exercises should be included in the initial treat-
*,'-ff!L=1'2ff"bgma^`khnighmk^\^bobg`mahkZ\b\fZ- ment plan for patients with neck pain.

nipulation. The length of follow-up was not clearly defined.
The authors of this clinical practice guideline have
Self-reported levels of pain and cervical active V observed that patients with neck pain often pres-
IV
KHFp^k^Zll^ll^][^_hk^Zg]bff^]bZmêrZ_m^k ^gmpbmabfiZbkf^gmlh_×^qb[bebmrh_d^rfnl\e^l
MLF bg +/ iZmb^gml pbma Z ikbfZkr \hfieZbgm h_ related to the lower cervical and upper thoracic spine, such
neck pain. The mean reduction in pain on an 11-point nu- as the anterior, medial, and posterior scalenes, upper trape-
meric pain rating scale was approximately 2 points (P.01), zius, levator scapulae, pectoralis minor, and pectoralis major,
which has been shown to indicate that a clinically meaningful that should be addressed with stretching exercises. One study
improvement has occurred. Significant increases in cervical kîhkm^]maZmnii^kjnZkm^kfnl\e^×^qb[bebmr]^Ö\bmlp^k^
Z\mbo^KHFp^k^Zelhh[l^ko^]bgZee]bk^\mbhgl^q\îm^qm^g- common in dental hygienists,2. an occupation that requires
lbhg!I5'))*"'Mabllmn]r]b]ghmbg\en]^Z\hgmkhe`khniZg] frequent repetitive activities involving the shoulders, arms,
only consisted of an immediate follow-up, but the immediate and hands. Although research generally does not support the
bfikho^f^gmlbgiZbgZg]\^kob\ZeZ\mbo^KHFln``^lmmaZm effectiveness of interventions that focus on stretching and

MLFfZraZo^lhf^f^kbmbgiZmb^gmlpbmag^\diZbg'/* ×^qb[bebmr%\ebgb\Ze^qi^kb^g\^ln``^lmlmaZmZ]]k^llbg`li^-
cific impairments of muscle length for an individual patient
There have been 4 case series that have incorpo- may be a beneficial addition to a comprehensive treatment
IV rated thoracic spine thrust manipulation in the
multi-modal management of patients with cervi-
program.
cal radiculopathy.+,%,2%*+)%*0/ In the first case series,39 10 of the Recommendation: Flexibility exercises can be used
11 patients (91%) demonstrated a clinically meaningful im-
ikho^f^gm bg iZbg Zg] _ng\mbhg Zm ma^ /&fhgma _heehp&ni
C for patients with neck symptoms. Examination and
mZk`^m^]×^qb[bebmr^q^k\bl^l_hkma^_heehpbg`fnl-
Z_m^kZf^Zgh_0'*iarlb\Zema^kZiroblbml'Bgma^l^\hg]\Zl^ cles are suggested: anterior/medial/posterior scalenes, upper
series*0/ all patients except for 1 exhibited a significant reduc- trapezius, levator scapulae, pectoralis minor, and pectoralis
tion in disability. In the third case series,120 full resolution of major.
iZbgpZlkîhkm^]bg1h_*.!.,"iZmb^gml%pa^k^Zee/h_ma^
patients receiving mobilization and manipulation achieved
full resolution of pain. In addition, there has been 1 case se- 9EEH:?D7J?ED"IJH;D=J>;D?D="7D:;D:KH7D9;
ries23 that included thoracic spine thrust manipulation in the ;N;H9?I;I
fZgZ`^f^gmh_0iZmb^gmlpbma`kZ]^B\^kob\Ze\hfik^llbo^ Jull et al99 conducted a multi-centered,
myelopathy. All patients exhibited a reduction in pain and
improvement in function at the time of discharge.
I randomized clinical trial (n=200) in participants
who met the diagnostic criteria for cervicogenic
headache. The inclusion criteria were unilateral or unilateral
Recommendation: Thoracic spine thrust ma- dominant side-consistent headache associated with neck pain
C nipulation can be used for patients with primary
complaints of neck pain. Thoracic spine thrust ma-
and aggravated by neck postures or movement, joint tender-
ness in at least 1 of the upper 3 cervical joints as detected by
manual palpation, and a headache frequency of at least 1 per HÍE^Zkr ^m Ze*+0 compared the effect of 2 specific
week over a period of 2 months to 10 years. Subjects were
randomized into 4 groups: mobilization/manipulation group,
III \^kob\Ze ×^qhk fnl\e^ ^q^k\bl^ ikhmh\hel hg bf-
mediate pain relief in the cervical spine of people
exercise therapy group, combined mobilization/manipulation with chronic neck pain. They found that those performing
and exercise group, and a control group. The primary out- ma^ li^\bÖ\ \kZgbh\^kob\Ze ×^qbhg ^q^k\bl^ ]^fhglmkZm^]
come was a change in headache frequency. At the 12-month greater improvements in pressure pain thresholds, me-
follow-up, the mobilization/manipulation, combined mobi- chanical hyperalgesia, and perceived pain relief during ac-
lization/manipulation and exercise, and the specific exercise tive movement.
groups had significantly reduced headache frequency and in-
tensity. Additionally 10% more patients experienced a com- In a cross-sectional comparative study, Chiu et al29
plete reduction in headache frequency when treated with
mobilization/manipulation and exercise than those treated
III compared the performance of the deep cervical
×^qhkfnl\e^lhgma^\kZgbh\^kob\Ze×^qbhgm^lmbg
with the alternative approaches. 99 individuals with (n = 20) and without (n = 20) chronic neck
pain. Those with chronic neck pain had significantly poorer
Ma^^q^k\blîkh`kZfbgmabl\ebgb\ZemkbZe[rCnee^mZe99 used i^k_hkfZg\^hgma^\kZgbh\^kob\Ze×^qbhgm^lm!f^]bZgik^l-
low load endurance exercises to train muscle control of the sure achieved, 24 mmHg when starting at 20 mmHg) when
cervicoscapular region. The first stage consisted of specific compared with those in the asymptomatic group (median
\kZgbh\^kob\Ze ×^qbhg ^q^k\bl^l% i^k_hkf^] bg lnibg^ erbg`% ik^llnk^Z\abô^]%+1ffA`pa^glmZkmbg`Zm+)ffA`"'

Zbf^]mhmZk`^mma^]^îg^\d×^qhkfnl\e^l%pab\aZk^ma^
longus capitis and longus colli. Subsequently, isometric exer- Cnee ^m Ze20 compared the effects of conventional
cises using a low level of rotatory resistance were used to train I ikhikbh\îmbo^mkZbgbg`Zg]\kZgbh\^kob\Ze×^qbhg
ma^\h&\hgmkZ\mbhgh_ma^g^\d×^qhklZg]^qm^glhkl'Ma^^q- training on cervical joint position error in people

ercise groups had significantly reduced headache frequency with persistent neck pain. The aim was to evaluate whether
and intensity when compared to the controls. proprioceptive training was superior in improving proprio-
ceptive acuity compared to a form of exercise that has been
Chiu et al+1 assessed the benefits of an exercise pro- shown to be effective in reducing neck pain. Sixty-four female
I gram that focused both on motor control training of
ma^]^îg^\d×^qhklZg]]rgZfb\lmk^g`ma^gbg`':
subjects with persistent neck pain and deficits in cervical
joint position error were randomized into 2 exercise groups:
mhmZeh_*-.iZmb^gmlpbma\akhgb\g^\diZbgp^k^kZg]hfbs^] ikhikbh\îmbo^ mkZbgbg` hk \kZgbh\^kob\Ze ×^qbhg mkZbgbg`'
to either an exercise or a non-exercise control group. At week >q^k\bl^ k^`bf^gl p^k^ \hg]n\m^] ho^k Z /&p^^d i^kbh]'
/%ma^^q^k\bl^`khniaZ]lb`gbÖ\Zgmer[^mm^kbfikho^f^gml The results demonstrated that both proprioceptive training

in disability scores, pain levels, and isometric neck muscle Zg]\kZgbh\^kob\Ze×^qbhgmkZbgbgàZo^Z]^fhglmkZ[e^[^g-
strength. However, significant differences between the 2 efit on impaired cervical joint position error in people with
groups were found only in pain and patient satisfaction at neck pain, with marginally more benefit gained from prop-
ma^/&fhgma_heehp&ni' rioceptive training. The results suggest that improved prop-
rioceptive acuity following intervention with either exercise
BgZkZg]hfbs^]%\ebgb\ZemkbZe%Rebg^g^mZe*1- dem- protocol may occur through an improved quality of cervical
I onstrated the effectiveness of both strengthening
exercises and endurance training of the deep neck
afferent input or by addressing input through direct training
of relocation sense.20
×^qhkfnl\e^lbgk^]n\bgìZbgZg]]blZ[bebmrZmma^*&r^Zk
_heehp&nibgphf^g!g6*1)"pbma\akhgb\%ghgli^\bÖ\g^\d In a randomized, clinical trial, Taimela et al*/+ com-
pain. The endurance training group performed dynamic neck
exercises, which included lifting the head up from the supine
I pared the efficacy of a multimodal treatment em-
phasizing proprioceptive training in patients with
and prone positions. The strength training group performed ghg&li^\bÖ\\akhgb\g^\diZbg!g60/"'Maîkhikbh\îmbo^
high-intensity isometric neck strengthening and stabiliza- treatment, which consisted of exercises, relaxation, and be-
tion exercises with an elastic band. Both training groups havioral support was more efficacious than comparison in-
performed dynamic exercises for the shoulders and upper terventions that consisted of (1) attending a lecture on the
extremities with dumbbells. Both groups were advised to neck and 2 sessions of practical training for a home exercise
also do aerobic and stretching exercises 3 times a week. In a program, and (2) a lecture regarding care of the neck with a
,&r^Zk_heehp&nilmn]r%Rebg^g^mZe*1+ found that women (n = recommendation to exercise. Specifically, the proprioceptive
**1"bg[hmama^lmk^g`ma^gbg`^q^k\bl^Zg]^g]nkZg\^mkZbg- treatment group had greater reductions in neck symptoms,
ing groups achieved long-term benefits from the 12-month improvements in general health, and improvements in the
programs. ability to work.
In a randomized clinical trial, Viljanen et al*0, as- BgZlrlm^fZmb\kôb^p%DZr^mZe103 concluded that

I sessed the effectiveness of dynamic muscle training
!g6*,."%kêZqZmbhgmkZbgbg`!g6*+1"%hkhk]bgZkr
I specific exercises may be effective for the treatment
of acute and chronic mechanical neck pain, with or
Z\mbobmr!g6*,."_hk_^fZe^hú\^phkd^klpbma\akhgb\g^\d without headache.
pain. Dynamic muscle training and relaxation training did
not lead to better improvements in neck pain compared with A recent Cochrane review/2 concluded that mo-
ordinary activity. I bilization and/or manipulation when used with
exercise are beneficial for patients with persistent
In a randomized clinical trial, Bronfort et al22 found mechanical neck disorders with or without headache. How-
I that a combined program of strengthening and en-
durance exercises combined with manual therapy
ever, manual therapy without exercise or exercise alone were
not superior to one another.
resulted in greater gains in strength, endurance, range of mo-
tion, and long-term patient pain ratings in those with chron- Although evidence is generally lacking, postural
ic neck pain than programs that only incorporated manual
therapy. Additionally, Evans et al.1 found that these results
V correction and body mechanics education and
training may also be indicated if clinicians identify
were maintained at a 2-year follow-up. ergonomic inefficiencies during either the examination or
treatment of patients with motor control, movement coordi-
In a prospective case series, Nelson et al124 followed nation, muscle power, or endurance impairments.
IV patients with cervical and lumbar pain and found
that an aggressive strengthening program was able Recommendation: Clinicians should consider the
mhikô^gmlnk`^krbg,.h_ma^/)iZmb^gml!-/h_ma^/)\hf- A use of coordination, strengthening, and endurance
ie^m^]maîkh`kZf%,1p^k^ZoZbeZ[e^_hk_heehp&ni%Zg]hger exercises to reduce neck pain and headache.

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 9;DJH7B?P7J?EDFHE9;:KH;I7D:;N;H9?I;I
in the short term following participation in an aggressive Kjellman and colleagues104 randomly assigned
strengthening exercise program. I 00iZmb^gmlpbmag^\diZbg!+2h_pab\aik^l^gm^]
with cervical radiculopathy) to general exercise,
In a systematic review of 9 randomized clinical tri- F\D^gsb^f^mah]h_^qZfbgZmbhgZg]mk^Zmf^gm%hkZ\hgmkhe
II ZelZg]0\hfiZkZmbo^mkbZelpbmafh]^kZm^f^mah]- `khni!ehpbgm^glbmrnemkZlhng]Zg]^]n\Zmbhg"'Ma^F\D^g-
ological quality for patients with mechanical neck zie method of treatment consists of patient positioning, spe-
disorders, Sarig-Bahat*-. reported relatively strong evidence cific repeated movements, manual procedures, and patient
supporting the effectiveness of proprioceptive exercises and education in self management in case of recurrence.*)-%**1 The
dynamic resisted strengthening exercises of the neck-shoul- kî^Zm^]li^\bÖ\fho^f^gmlpbmama^F\D^gsb^f^mah]bg-
der musculature for patients with chronic or frequent neck tend to centralize (promote the migration of symptoms from
disorders. The evidence identified could not support the ef- an area more distal to location more proximal) or reduce
fectiveness of group exercise, neck schools, or single sessions pain.**1 At the 12 month follow-up all groups showed signifi-
of extension-retraction exercises. cant reductions in pain intensity and disability but no signifi-
cant difference between groups existed. Seventy-nine percent
In a randomized clinical trial, Chiu et al30 found of patients reported that they were better or completely re-
I bgiZmb^gmlpbma\akhgb\g^\diZbg!g6+*1"%maZm
Z /&p^^d mk^Zmf^gm h_ mkZgl\nmZg^hnl ê^\mkb-
lmhk^]Z_m^kmk^Zmf^gm%Zemahnà.*kîhkm^]\hglmZgm(]Zber
pain. All 3 groups had similar recurrence rates.
cal nerve stimulation or exercise had a better and clinically
relevant improvement in disability, isometric neck muscle Fnkiar^mZe122bg\hkihkZm^]F\D^gsbîkh\^]nk^l
strength, and pain compared to a control group. All the im-
provements in the intervention groups were maintained at
III to promote centralization in the management of a
cohort of 31 patients with cervical radiculopathy.
ma^/&fhgma_heehp&ni' These patients also received cervical manipulation or muscle
energy techniques and neural mobilization. Seventy-seven
Hammill et al0- used a combination of postural percent of patients at the short-term follow-up and 93% of
IV education, stretching, and strengthening exercises
to reduce the frequency of headaches and improve
patients at the long-term follow-up exhibited a clinically im-
portant improvement in disability. However, specific details
disability in a series of 20 patients, with results being main- regarding the number of patients receiving procedures to
tained at a 12-month follow-up. promote centralization was not reported.
There has not been a clinical trial that recruited patients with Recommendation: Clinicians should consider the
only cervical radiculopathy. Therefore, it is not possible to
\hff^gmhgma^^ú\Z\rh_ma^F\D^gsb^f^mah]hkma^nl^
B use of upper quarter and nerve mobilization proce-
dures to reduce pain and disability in patients with
of centralization procedures and exercises for this particular neck and arm pain.
subgroup of patients.31
Recommendation: Specific repeated movements or JH79J?ED

C procedures to promote centralization are not more A systematic review by Graham and col-
beneficial in reducing disability when compared to
other forms of interventions.
I leagues/0 reported that there is moderate evidence
to support the use of mechanical intermittent cervi-
cal traction.
KFF;HGK7HJ;H7D:D;HL;CE8?B?P7J?ED MZàb ChàZmZ^b ^m Ze93 randomly assigned 30 pa-

FHE9;:KH;I
Allison et al2 examined the effectiveness of
II tients to receive a treatment program consisting
of ultrasound and exercise with or without me-
II 2 different manual therapy techniques (neural
mobilization and cervical/upper quadrant mobi-
chanical intermittent cervical traction for 10 sessions. The
group receiving traction exhibited greater improvements
lization) in the management of cervico-brachial syndrome. bg`kbilmk^g`ma%maîkbfZkrhnm\hf^f^Zlnk^%Z_m^k.l^l-

:eeiZmb^gmlk^\^bo^]mk^Zmf^gm_hk1p^^dlbgZ]]bmbhgmh sions. However, no statistically significant difference be-
a home exercise program. The results demonstrated that tween groups existed at the time of discharge from physical
both manual therapy groups exhibited improvements in therapy.93
pain and function. At the final data collection there ex-

isted no difference between the manual therapy groups Saal et al143 bgo^lmb`Zm^] ma^ hnm\hf^l h_ +/ \hg-
for function but a significant difference between groups
for reduction in pain was identified in favor of the neural
III secutive patients who fit the diagnostic criteria for
herniated cervical disc with radiculopathy who re-
mobilization group. ceived a rehabilitation program consisting of cervical traction
and exercise. Twenty-four patients avoided surgical interven-
In a randomized clinical trial, Coppieters et al41 tion and 20 exhibited good or excellent outcomes.
II assigned 20 patients with cervico-brachial pain to
receive either cervical mobilization with the upper In a prospective cohort design Cleland et al,/ iden-
II
extremity in an upper limb neurodynamic position or thera- tified predictor variables of short-term success for
peutic ultrasound. The group receiving the mobilizations patients presenting to physical therapy with cervi-
exhibited significantly greater improvements in elbow range cal radiculopathy. One of the predictor variables for patients
of motion during neurodynamic testing as well as greater re- who exhibited a short-term success included a multimodal
ductions in pain compared to the ultrasound group. physical therapy approach consisting of manual or mechani-
cal traction, manual therapy (cervical or thoracic mobiliza-
Fnkiar^mZe122 incorporated neural mobilization in mbhg(fZgbineZmbhg"%Zg]]^îg^\d×^qhklmk^g`ma^gbg`'Ma^
III the management of a cohort of patients with cervi-
cal radiculopathy. Seventy seven percent of patients
pretest probability for the likelihood of short-term success
pZl.,'Ma^f^Zg]nkZmbhgh_f^\aZgb\ZemkZ\mbhgnl^]hg
at the short-term follow-up and 93% of patients at the long iZmb^gmlbgmabllmn]rpZl*0'1fbgnm^lpbmaZgZo^kZ`^_hk\^
term follow-up exhibited a clinically important decrease in of pull of 11 kg (24.3 pounds). The positive likelihood ratio
disability. However, no specifics were provided relative to for patients receiving the multimodal treatment approach
which patients received neural mobilization procedures. (excluding other predictor variables) was 2.2, resulting in a
ihlm&m^lmikh[Z[bebmrh_ln\\^llh_0*' ,/
Cleland et al39 described the outcomes of a con-
IV secutive series of patients presenting to physical Raney et al*,0 recently developed a clinical predic-
therapy who received cervical mobilization (cer-
vical lateral glides) with the upper extremity in a neuro-
II tion rule to identify patients with neck pain likely
to benefit from cervical mechanical traction. Sixty-
dynamic position as well as thoracic spine manipulation, ^bàmiZmb^gml!,1_^fZe^"p^k^bg\en]^]bg]ZmZZgZerlblh_
cervical traction, and strengthening exercises. Ten of the pab\a,)aZ]Zln\\^ll_nehnm\hf^':eeiZmb^gmlk^\^bo^]/
11 patients (91%) demonstrated a clinically meaningful sessions of mechanical intermittent cervical traction start-
bfikho^f^gmbgiZbgZg]_ng\mbhg_heehpbg`Zf^Zgh_0'* bg`pbmaZ_hk\^h_inee[^mp^^g-'.&.'-d`!*)&*+ihng]l"
physical therapy visits. _hkZ]nkZmbhgh_*.fbgnm^l'Ma^_hk\^h_ineeikh`k^llboêr
increased based on centralization of symptoms at each sub- bg?ng\mbhgZeKZmbg`Bg]^ql\hk^lpZl+/_khfZ[Zlêbg^

l^jn^gm l^llbhg' : \ebgb\Ze ik^]b\mbhg kne^ pbma . oZkbZ[e^l of 44%.
was identified:
IZmb^gmkîhkm^]i^kbia^kZebsZmbhgpbmaehp^k\^kob\Zelibg^ Recommendation: Clinicians should consider
!<-&0"fh[bebmrm^lmbg`
Ihlbmbo^lahne]^kZ[]n\mbhglb`g
B the use of mechanical intermittent cervical trac-
tion, combined with other interventions such as
:`^l..r^Zkl manual therapy and strengthening exercises, for reducing
Ihlbmbo^nii^kebf[m^glbhgm^lm!f^]bZgg^ko^[bZlnmbebs- pain and disability in patients with neck and neck-related
bg`lahne]^kZ[]n\mbhgmh2)" arm pain.
Kêb^_h_lrfimhflpbmafZgnZe]blmkZ\mbhgm^lm
AZobg` Zm e^Zlm , hnm h_ . oZkbZ[e^l ik^l^gm k^lnem^] bg Z F7J?;DJ;:K97J?ED7D:9EKDI;B?D=
ihlbmboêbdêbahh]kZmbh^jnZemh-'1*!2.<B6+'*0&**'-"% There is a paucity of high quality evidence
increasing the likelihood of success with cervical traction
_khf--mh02'+'B_Zme^Zlm-hnmh_.oZkbZ[e^lp^kîk^l-
I surrounding efficacy of treatments for whiplash-
associated disorder (WAD). However, existing re-
^gm%maîhlbmboêbdêbahh]kZmbhpZl^jnZemh**'0!2.<B search supports instructing patients in active interventions,
6+')2&/2'.1"%bg\k^Zlbg`maîhlm&m^lmikh[Z[bebmrh_aZobg` such as exercises, and early return to regular activities as a
improvement with cervical traction to 90.2%. means of pain control. Rosenfeld et al142 compared the long-
term efficacy of active intervention with that of standard in-
Three separate case series,2%*+)%*0/ describe the man- tervention and the effect of early versus delayed initiation
IV agement of patients with cervical radiculopathy, of intervention. Patients were randomized to an interven-
where the interventions included traction. In these tion using frequent active cervical rotation range of motion
case series, the patients were treated with a multimodal treat- exercises complemented by assessment and treatment ac-
ment approach and the vast majority of patients exhibited \hk]bg`mhF\D^gsb^Ílikbg\bie^lhkmhZgbgm^ko^gmbhgmaZm
improved outcomes. In the first report, Cleland et al39 de- promoted initial rest, soft collar utilization, and gradual self-
scribed the outcomes of a consecutive series of 11 patients mobilization. In patients with WAD, early active interven-
presenting to physical therapy with cervical radiculopathy tion was more effective in reducing pain intensity and sick
and managed with the use of manual physical therapy, cervi- leave, and in retaining/regaining total range of motion than
\ZemkZ\mbhg%Zg]lmk^g`ma^gbg`^q^k\bl^l':m/fhgma_heehp& intervention that promoted rest, collar usage, and gradual
up, 91% demonstrated a clinically meaningful improvement self-mobilization. Patient education promoting an active ap-
bgiZbgZg]_ng\mbhg_heehpbg`Zf^Zgh_0'*iarlb\Zema^kZir proach can be carried out as home exercises and progressive

visits. Similarly, Waldrop*0/mk^Zm^]/iZmb^gmlpbma\^kob\Ze return to activities initiated and supported by appropriately
radiculopathy with mechanical intermittent cervical traction, trained health professionals.
thoracic thrust joint manipulation, and range of motion and
lmk^g`ma^gbg`^q^k\bl^l_hkma^\^kob\Zelibg^'Nihg]bl\aZk`^ An often prescribed intervention for acute whiplash
!f^Zgmk^Zmf^gm*)oblbml%kZg`^.&*1oblbml4]nkZmbhg,,]Zrl%
kZg`^*2&./]Zrl"%ma^k^pZlZk^]n\mbhgbg]blZ[bebmr[^mp^^g
I injury is the use of a soft cervical collar. Crawford
et al-.ikhli^\mboêrbgo^lmb`Zm^]*)1\hgl^\nmbo^
*,Zg]11'Bgma^mabk]\Zl^l^kb^l%Fh^mbZg]FZk\a^mmb120 patients following a soft tissue injury of the neck that result-
investigated the outcomes associated with cervical traction, ed from motor vehicle accidents. Each patient was random-
neck retraction exercises, scapular muscle strengthening, ized to a group instructed to engage in early mobilization
and mobilization/manipulation techniques (used for some using an exercise regime or to a group that was instructed to
iZmb^gml"_hk*.iZmb^gmlpbma\^kob\ZekZ]b\nehiZmar'Ma^l^ utilize a soft cervical collar for 3 weeks followed by the same
Znmahklkîhkm^]_neek^lhenmbhgh_iZbgbg.,h_iZmb^gmlZm exercise regime. Patients were assessed clinically at 3, 12,
the time of discharge. Zg].+p^^dbgm^koZel_khfbgcnkr'Bgm^ko^gmbhgmaZmnmbebs^]
a soft collar was found to have no obvious benefit in terms
Browder and colleagues23 investigated the effec- of functional recovery after neck injury and was associated
IV tiveness of a multimodal treatment approach in
ma^fZgZ`^f^gmh_0_^fZeîZmb^gmlpbma`kZ]^B
with a prolonged time period off work. Other investigations
have reported similar results.*-1%*0) Interventions that instruct
cervical compressive myelopathy. Patients were treated with patients to perform exercises early in their recovery from
intermittent mechanical cervical traction and thoracic ma- whiplash type injuries have been reported to be more ef-
gbineZmbhg _hk Z f^]bZg h_ 2 l^llbhgl ho^k Z f^]bZg h_ ./ fective in reducing pain intensity and disability following
]Zrl'Ma^f^]bZg]^\k^Zl^bgiZbgl\hk^lpZl._khfZ[Zl^- whiplash injury than interventions that instruct patients to
ebg^h_/!nlbg`Z)&*)iZbgl\Ze^"%Zg]f^]bZgbfikho^f^gm use cervical collars.*-1%*0)
Existing research supports active interventions and between groups in severity of remaining symptoms, limita-
I early return to regular activities but it has largely
been unknown as to which type of active interven-
tions in daily activities, therapy use, medications used, lost
time from work, or litigation. This study concluded that an
tion would yield the most benefit. Brison et al21 assessed the evidence-based educational pamphlet provided to patients at
efficacy of an educational video in the prevention of persis- discharge from the emergency department is no more effec-
tent WAD symptoms following rear-end motor vehicle colli- tive than usual care for patients with grade I or II WAD./)
sions. The video provided reassurance, and education about
posture, return to regular activities, specific exercises, and Cnee ^m Ze99 conducted a preliminary randomized
pain management. Patients were randomized to receive ei-
ther an educational video plus usual care or usual care alone.
I \hgmkhee^]mkbZepbma0*iZkmb\biZgmlpbmai^klblm^gm
neck pain following a motor vehicle accident to ex-
The primary outcome was presence of persistent WAD symp- plore whether a multimodal program of physical therapies
toms at 24 weeks post injury, based on the frequency and was an appropriate management strategy compared to a self-
severity of neck, shoulder, or upper back pain. The group re- management approach. Participants were randomly allocated
ceiving the instructional video demonstrated a trend toward to receive either a multimodal physical therapy program or
less severe WAD symptoms suggesting that the ‘act as usual’ a self-management program (advice and exercise). Further-
recommendation that is often prescribed as a management more, participants were stratified according to the presence
strategy for patients with WAD is not sufficient and, in fact, or absence of widespread mechanical or cold hyperalgesia.
may exacerbate their symptoms if such activities are provoca- The intervention period was 10 weeks and outcomes were as-
tive of pain.21 sessed immediately following treatment. Even with the pres-
^g\^ h_ l^glhkr ari^kl^glbmbobmr bg 0+'. h_ ln[c^\ml% [hma
A reduction in pain alone is not sufficient to ad- groups reported some relief of neck pain and disability, mea-
III
dress the neuromuscular control deficits in patients sured using Neck Disability Index scores, and it was superior
with chronic symptoms,*.0 as these deficits require in the group receiving multimodal physical therapy (P=.04).
specific rehabilitation techniques.99 For example, persistent However, the overall effects of both programs were mitigated
sensory and motor deficits may render the patient at risk for in the group presenting with both widespread mechanical
symptom persistence.*..%*./ Support for specificity in reha- and cold hyperalgesia. Further research aimed at testing the
bilitation can be indirectly found from a recent population- validity of this sub-group observation is warranted. 21
based, incidence cohort study evaluating a government policy
of funding community and hospital-based fitness training and A comprehensive review**0 of the available scientific
multidisciplinary rehabilitation for whiplash.+/ No supportive II evidence produced a set of unambiguous patient
evidence was found for the effectiveness of this general reha- centered messages that challenge unhelpful beliefs
bilitation approach. Therefore, only addressing the lack of about whiplash, promoting an active approach to recovery.
fitness and conditioning in this patient population may not The use of this rigorously developed educational booklet
be the most efficacious approach to treatment. (The Whiplash Book) was capable of improving beliefs about
whiplash and its management for patients with whiplash-
Ferrari et al/) studied whether an educational in- associated disorders.**0
I tervention using a pamphlet provided to patients
in the acute stage of whiplash injury might im- BgZlfZee \Zl^l^kb^l% Lh]^keng] Zg]Ebg][^k`*.,
prove the recovery rate. One hundred twelve consecutive
subjects were randomized to 1 of 2 treatment groups: edu-
IV reported that physical therapy integrated with
cognitive behavioral components decreased pain
cational intervention or usual care. The education interven- intensity in problematic daily activities in 3 individuals with
tion group received an educational pamphlet based on the chronic WAD.
current evidence, whereas the control group only received
usual emergency department care and a standard non-di- Predictors of outcome following whiplash injury
rected discharge information sheet. Both groups underwent
follow-up by telephone interview at 2 weeks and 3 months.
II have been limited to socio-demographic and fac-
tors of symptom location and severity, which are
The primary outcome measure of recovery was the patient’s not readily amenable to intervention. However, evidence
k^lihgl^mhma^jn^lmbhg%ÊAhppêe]hrhn_^êrhnZk^k^\ho- exists to demonstrate that psychological factors are pres-
^kbg`_khfrhnkbgcnkb^l8Ë:m,fhgmalihlm\heeblbhg%+*'1 ent soon following injury and play a role in recovery from
in the education intervention group reported complete recov- whiplash injury.21%*..%*.1 These factors can be as diverse as
ery compared with 21.0% in the control group (absolute risk the physical presentation and can include affective distur-
]bü^k^g\^%)'142.<B6&*-'-mh*/')"':m,fhgmal% bances, anxiety, depression, and fear of movement.*+,%*,+%*01
there were no clinically or statistically significant differences Furthermore, post-traumatic stress disorder112 has also been
observed in both the acute.+ and chronic conditions and has Recommendation: To improve the recovery in pa-
been shown to be prognostic.*0* Identifying these factors in
patients may assist in the development of relevant subgroups
A tients with whiplash-associated disorder, clinicians
should (1) educate the patient that early return to
and appropriately matched education and counseling strate- normal, non-provocative pre-accident activities is important,
gies that practitioners should utilize in management of pa- and (2) provide reassurance to the patient that good progno-
tients with WAD. sis and full recovery commonly occurs.
Neck Pain Impairment/Function-based Diagnosis, Examination and

J78B;*
Intervention Recommended Classification Criteria*
?cfW_hc[dj#8Wi[Z9Wj[]eho
M_j^?9:#'&7iieY_Wj_edi Iocfjeci ?cfW_hc[djie\8eZo<kdYj_ed ?dj[hl[dj_edi
D[YafW_dm_j^ceX_b_joZ[ÓY_j Kd_bWj[hWbd[YafW_d B_c_j[ZY[hl_YWbhWd][e\cej_ed 9[hl_YWbceX_b_pWj_ed%
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* Recommendation based on expert opinion.
CLINICAL GUIDELINES
Summary of Recommendations
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journal of orthopaedic & sports physical therapy | volume 39 | number 4 | april 2009 | 297
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vertebral artery blood flow in healthy individuals. Manual Therapy 16:1, 87-93. [Crossref]
389. Manuel A. Domenech, Phil S. Sizer, Gregory S. Dedrick, Michael K. McGalliard, Jean-Michel Brismee. 2011. The Deep Neck
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390. Robert C. Manske. Spinal Disorders 451-562. [Crossref]
391. Bryan S. Dennison, Michael H. Leal. Mechanical neck pain 94-111. [Crossref]
392. Hilla Sarig Bahat, Patrice L. Weiss, Yocheved Laufer. 2010. The Effect of Neck Pain on Cervical Kinematics, as Assessed in a
Virtual Environment. Archives of Physical Medicine and Rehabilitation 91:12, 1884-1890. [Crossref]
393. Rob Sillevis, Joshua Cleland, Madeleine Hellman, Kristina Beekhuizen. 2010. Immediate effects of a thoracic spine thrust
manipulation on the autonomic nervous system: a randomized clinical trial. Journal of Manual & Manipulative Therapy 18:4,
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394. Gert Bronfort, Mitch Haas, Roni Evans, Brent Leininger, Jay Triano. 2010. Effectiveness of manual therapies: the UK evidence
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396. Joshua A. Cleland, Paul E. Mintken, Kristin Carpenter, Julie M. Fritz, Paul Glynn, Julie Whitman, John D. Childs. 2010.
Examination of a Clinical Prediction Rule to Identify Patients With Neck Pain Likely to Benefit From Thoracic Spine Thrust
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Clinical Guidelines

JOHN D. CHILDS, PT, PhD@EI>K77$9B;B7D:"PT, PhD@7C;IC$;BB?EJJ"PT, PhD:;O:H;I$J;O>;D"PT, PhD

Functioning, Disability, and Health From

Physical Therapy Association

AUTHOR/REVIEWER AFFILIATIONS & CONTACTS$ $ $ $ $ $ $ $ $ $ 7(/

based category of neck pain with the following impairments of

9;:KH;I0 Clinicians should consider the use of upper quarter iY_[dj_ÓYb_j[hWjkh[fkXb_i^[Zfh_ehje@kd[(&&-$

practice guidelines for orthopaedic physical therapy manage-

Content experts were appointed by the Orthopaedic Section,

related to diagnostic categories based on International Statis-

neous populations is not readily searchable using the ICD termi-

Methods (continued) these clinical guidelines that provides a summary of symptoms,

to determine its usefulness, validity, and impact. All returned 9edjhebe\Yecfb[nlebkdjWhocel[c[dji"WdZX(.&)HWZ_Wj_d]fW_d_d

However, several reviewers noted that preliminary drafts of

ICD-10 and ICF Codes Associated With Neck Pain

INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH

Body structure i-'&+ B_]Wc[djiWdZ\WiY_W[e\^[WZWdZd[Yah[]_ed

Activities and participation Z**+( H[WY^_d]

SECONDARY ICF CODES

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED)

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED)

increases with age and is most common in women around the

Although the cause of neck pain may be associ-

II neck pain in an adult population over a 12 month

6*'/"%\hfhk[b]ehp[Z\diZbg!HK6*'/"%Zg][b\r\ebg`ZlZ symptoms. Thirty-three percent of the respondents with re-

conditioning, pain control, and headache, intend to capture Ehg`lmZg]bg`g^\diZbg!]nkZmbhg7*+p^^dl"

]bob]^]bgmhma^Êg^\diZbgpbmafho^f^gm\hhk]bgZmbhgbf- ating pain is made with a reasonable level of certainty when

LrfimhflblheZm^]mhma^g^\d medical or psychological conditions, associated

The following physical examination measures may be useful

spine: Clinicians should consider diagnostic classiﬁcations

nadian Cervical Spine Rule (CCR) for radiography in alert

Two studies*/*%*02 with small sample sizes have identiﬁed the

b]^gmbÖ^]ma^fbgbfZe]^m^\mZ[e^\aZg`^Zl.!*)i^k\^gmZ`^ the course of treatment.

In addition, the Patient-Specific Functional Scale is a ability Index. *02

Cervical Active Range of Motion

ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅceX_b_joe\i[l[hWb`e_dji

Measurement method 7bbY[hl_YWbhWd][e\cej_edHECc[Wikh[iWh[f[h\ehc[Z_dj^[kfh_]^ji_jj_d]fei_j_ed$9Wh[i^ekbZX[jWa[dje[dikh[j^[

Nature of variable 9edj_dkeki

Units of measurement :[]h[[i

Instrument variations ?dWZZ_j_edjeki_d]Wd_dYb_dec[j[h"+".)"'(."'.&Y[hl_YWbHECYWdWbieX[c[Wikh[Z\ehYb_d_YWbfkhfei[iki_d]WY[hl_YWbhWd][e\cej_ed

Cervical And Thoracic Segmental Mobility

ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅceX_b_joe\i_d]b[`e_dji

Measurement method J^[fWj_[dj_ifhed[$J^[[nWc_d[hYedjWYji[WY^Y[hl_YWbif_dekifheY[iim_j^j^[j^kcXi$J^[bWj[hWbd[YackiYkbWjkh[_i][djbo

Nature of variable Dec_dWbfW_dh[ifedi[WdZehZ_dWbceX_b_jo`kZ]c[dj

Cervical And Thoracic Segmental Mobility (continued)

Units of measurement None

Diagnostic accuracy and :_W]deij_Y7YYkhWYo'**0

Cranial Cervical Flexion Test

ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅYedjhebe\i_cfb[lebkdjWhocel[c[djiWdZ[dZkhWdY[e\_iebWj[ZckiYb[i

Measurement method FWj_[dj_ifei_j_ed[Zikf_d[_d^eeabo_d]WdZj^[^[WZWdZd[Ya_dc_Z#hWd][d[kjhWb_cW]_dWhob_d[X[jm[[d\eh[^[WZWdZY^_dWdZ

Nature of variable 9edj_dkeki

Units of measurement cc>]\ehj^[WYj_lWj_ediYeh[

Measurement properties H[b_WX_b_joWii[iic[dj\eh+&WiocfjecWj_YikX`[Yji"j[ij[Zjm_Y['m[[aWfWhj07Yj_lWj_ediYeh[0?993&$.'1F[h\ehcWdY[?dZ[n0?993$/)/,

Neck Flexor Muscle Endurance Test

ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅ[dZkhWdY[e\_iebWj[ZckiYb[i

Neck Flexor Muscle Endurance Test (continued)

Measurement method J^[j[ij_if[h\ehc[Z_dWikf_d["^eea#bo_d]fei_j_ed$M_j^j^[Y^_dcWn_cWbboh[jhWYj[ZWdZcW_djW_d[Z_iec[jh_YWbbo"j^[fWj_[dj

Nature of variable 9edj_dkeki

Units of measurement I[YedZi

Measurement properties ?dWijkZoXo>Whh_i[jWb"-+*'ikX`[Yjim_j^WdZm_j^ekjd[YafW_df[h\ehc[Zj^_ij[ij$JmehWj[hij[ij[ZWbbikX`[YjiWjXWi[b_d["WdZ

Upper Limb Tension Test

ICF category C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z

JOHN D. CHILDS, PT, PhD@EI>K77$9B;B7D:"PT, PhD@7C;IC$;BB?EJJ"PT, PhD:;O:H;I$J;O>;D"PT, PhD

AUTHOR/REVIEWER AFFILIATIONS & CONTACTS$ $ $ $ $ $ $ $ $ $ 7(/

9;:KH;I0 Clinicians should consider the use of upper quarter iY_[dj_ÓYb_j[hWjkh[fkXb_i^[Zfh_ehje@kd[(&&-$

to determine its usefulness, validity, and impact. All returned 9edjhebe\Yecfb[nlebkdjWhocel[c[dji"WdZX(.&)HWZ_Wj_d]fW_d_d

Body structure i-'&+ B_]Wc[djiWdZ\WiY_W[e\^[WZWdZd[Yah[]_ed

6'/"%\hfhk[b]ehp[Z\diZbg!HK6'/"%Zg][b\r\ebg`ZlZ symptoms. Thirty-three percent of the respondents with re-

conditioning, pain control, and headache, intend to capture Ehg`lmZg]bg`g^\diZbg!]nkZmbhg7*+p^^dl"

]bob]^]bgmhma^Êg^\diZbgpbmafho^f^gm\hhk]bgZmbhgbf- ating pain is made with a reasonable level of certainty when

LrfimhflblheZm^]mhma^g^\d medical or psychological conditions, associated

Two studies/%*02 with small sample sizes have identiﬁed the

b]^gmbÖ^]ma^fbgbfZe]^m^\mZ[e^\aZg`^Zl.!*)i^k\^gmZ`^ the course of treatment.

ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅceX_b_joe\i[l[hWb`e_dji

Measurement method 7bbY[hl_YWbhWd][e\cej_edHECc[Wikh[iWh[f[h\ehc[Z_dj^[kfh_]^ji_jj_d]fei_j_ed$9Wh[i^ekbZX[jWa[dje[dikh[j^[

Instrument variations ?dWZZ_j_edjeki_d]Wd_dYb_dec[j[h"+".)"'(."'.&Y[hl_YWbHECYWdWbieX[c[Wikh[Z\ehYb_d_YWbfkhfei[iki_d]WY[hl_YWbhWd][e\cej_ed

ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅceX_b_joe\i_d]b[`e_dji

Measurement method J^[fWj_[dj_ifhed[$J^[[nWc_d[hYedjWYji[WY^Y[hl_YWbif_dekifheY[iim_j^j^[j^kcXi$J^[bWj[hWbd[YackiYkbWjkh[_i][djbo

Nature of variable Dec_dWbfW_dh[ifedi[WdZehZ_dWbceX_b_jo`kZ]c[dj

Diagnostic accuracy and :_W]deij_Y7YYkhWYo'**0

ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅYedjhebe\i_cfb[lebkdjWhocel[c[djiWdZ[dZkhWdY[e\_iebWj[ZckiYb[i

Measurement method FWj_[dj_ifei_j_ed[Zikf_d[_d^eeabo_d]WdZj^[^[WZWdZd[Ya_dc_Z#hWd][d[kjhWb_cW]_dWhob_d[X[jm[[d\eh[^[WZWdZY^_dWdZ

Units of measurement cc>]\ehj^[WYj_lWj_ediYeh[

Measurement properties H[b_WX_b_joWii[iic[dj\eh+&WiocfjecWj_YikX`[Yji"j[ij[Zjm_Y['m[[aWfWhj07Yj_lWj_ediYeh[0?993&$.'1F[h\ehcWdY[?dZ[n0?993$/)/,

ICF category C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅ[dZkhWdY[e\_iebWj[ZckiYb[i

Measurement method J^[j[ij_if[h\ehc[Z_dWikf_d["^eea#bo_d]fei_j_ed$M_j^j^[Y^_dcWn_cWbboh[jhWYj[ZWdZcW_djW_d[Z_iec[jh_YWbbo"j^[fWj_[dj

Measurement properties ?dWijkZoXo>Whh_i[jWb"-+*'ikX`[Yjim_j^WdZm_j^ekjd[YafW_df[h\ehc[Zj^_ij[ij$JmehWj[hij[ij[ZWbbikX`[YjiWjXWi[b_d["WdZ

ICF category C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z

Measurement method Kff[hb_cXj[di_edj[ijiWh[f[h\ehc[Zm_j^j^[fWj_[djikf_d[$:kh_d]f[h\ehcWdY[e\j^[kff[hb_cXj[di_edj[ijj^WjfbWY[iW

Diagnostic accuracy indices for /+9edÓZ[dY[?dj[hlWb

ICF category C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z

Measurement method J^[fWj_[dj_ii[Wj[ZWdZ_iWia[Zjei_Z[X[dZWdZib_]^jbohejWj[j^[^[WZjej^[fW_d\kbi_Z[$J^[[nWc_d[hfbWY[iWYecfh[ii_ed\ehY[

Diagnostic accuracy indices for /+9edÓZ[dY[?dj[hlWb

ICF category C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z

Measurement method J^[Z_ijhWYj_edj[ij_iki[Zje_Z[dj_\oY[hl_YWbhWZ_YkbefWj^oWdZ_if[h\ehc[Zm_j^j^[fWj_[djikf_d[$J^[[nWc_d[h]hWifikdZ[h

Diagnostic accuracy indices for /+9edÓZ[dY[?dj[hlWb

ICF category C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z

Measurement method J^[fWj_[dj_ii[Wj[ZWdZ_dijhkYj[ZjejWa[WZ[[fXh[Wj^WdZ^ebZ_jm^_b[Wjj[cfj_d]je[n^Wb[\eh(#)i[YedZi$7fei_j_l[

Diagnostic accuracy indices for /+9edÓZ[dY[?dj[hlWb

*,'-ff!L=1'2ff"bgma^`khnighmk^\^bobg`mahkZ\b\fZ- ment plan for patients with neck pain.

bfikho^f^gmlbgiZbgZg]\^kob\ZeZ\mbo^KHFln``^lmmaZm effectiveness of interventions that focus on stretching and

\kZgbh\^kob\Ze ×^qbhg ^q^k\bl^l% i^k_hkf^] bg lnibg^ erbg`% ik^llnk^Z\ab^o^]%+1ffA`pa^glmZkmbg`Zm+)ffA`"'

ma^\h&\hgmkZ\mbhgh_ma^g^\d×^qhklZg]^qm^glhkl'Ma^^q- training on cervical joint position error in people

/%ma^^q^k\bl^`khniaZ]lb`gbÖ\Zgmer[^mm^kbfikho^f^gml The results demonstrated that both proprioceptive training

In a randomized clinical trial, Viljanen et al*0, as- BgZlrlm^fZmb\k^ob^p%DZr^mZe103 concluded that

ie^m^]ma^ikh`kZf%,1p^k^ZoZbeZ[e^_hk_heehp&ni%Zg]hger exercises to reduce neck pain and headache.

KFF;HGK7HJ;H7D:D;HL;CE8?B?P7J?ED MZ`ab Ch`aZmZ^b ^m Ze93 randomly assigned 30 pa-

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increased based on centralization of symptoms at each sub- bg?ng\mbhgZeKZmbg`Bg]^ql\hk^lpZl+/_khfZ[Zl^ebg^

bgiZbgZg]_ng\mbhg_heehpbg`Zf^Zgh_0'*iarlb\Zema^kZir proach can be carried out as home exercises and progressive

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CORRECTIONS Ng]^k L^\hg]Zkr B<? <h]^l hg Ng]^kL^\hg]ZkrB<?\h]^lhgiZ`^l