Neck Pain:

Transcription

Neck Pain:

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
Functioning, Disability, and Health From
the Orthopaedic Section of the American
Physical Therapy Association
J Orthop Sports Phys Ther 2008;38(9):A1-A34. doi:10.2519/jospt.2008.0303
RECOMMENDATIONS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7(
INTRODUCTION$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7)
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
may be associated with degenerative processes or pathology
identified during diagnostic imaging, the tissue that is causing
a patient’s neck pain is most often unknown. Thus, clinicians
should assess for impaired function of muscle, connective, and
nerve tissues associated with the identified pathological tissues
when a patient presents with neck pain. (Recommendation
based on theoretical/foundational evidence.)
H?IA<79JEHI0 Clinicians should consider age greater than 40,
coexisting low back pain, a long history of neck pain, cycling as
a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors
for the development of chronic neck pain. (Recommendation
based on moderate evidence.)
:?7=DEI?I%9B7II?<?97J?ED0 Neck pain, without symptoms or
signs of serious medical or psychological conditions, associated
with (1) motion limitations in the cervical and upper thoracic
regions, (2) headaches, and (3) referred or radiating pain into
an upper extremity are useful clinical findings for classifying a
patient with neck pain into one of the following International
Statistical Classification of Diseases and Related Health Problems (ICD) categories: cervicalgia, pain in thoracic spine, headaches, cervicocranial syndrome, sprain and strain of cervical
spine, spondylosis with radiculopathy, and cervical disc disorder
with radiculopathy; and the associated International Classification of Functioning, Disability, and Health (ICF) impairmentbased category of neck pain with the following impairments of
body function:
G^\diZbgpbmafh[bebmr]^Ö\bml![0*)*Fh[bebmrh_
several joints)
G^\diZbgpbmaa^Z]Z\a^l!+1)*)IZbgbga^Z]Zg]g^\d"
G^\diZbgpbmafho^f^gm\hhk]bgZmbhgbfiZbkf^gml
![0/)*<hgmkheh_\hfie^qohengmZkrfho^f^gml"
G^\diZbgpbmakZ]bZmbgìZbg![+1)-KZ]bZmbgìZbgbgZ
segment or region)
The following physical examination measures may be useful in
classifying a patient in the ICF impairment-based category of
neck pain with mobility deficits and the associated ICD categories of cervicalgia or pain in thoracic spine. (Recommendation
<^kob\ZeZ\mbo^kZg`^h_fhmbhg
<^kob\ZeZg]mahkZ\b\l^`f^gmZefh[bebmr
neck pain with headaches and the associated ICD categories
of headaches or cervicocranial syndrome. (Recommendation
<^kob\Zel^`f^gmZefh[bebmr
<kZgbZe\^kob\Ze×^qbhgm^lm
a2
|
neck pain with movement coordination impairments and the
associated ICD category of sprain and strain of cervical spine.
(Recommendation based on moderate evidence.)
=^îg^\d×^qhk^g]nkZg\^m^lm
neck pain with radiating pain and the associated ICD categories
of spondylosis with radiculopathy or cervical disc disorder with
radiculopathy. (Recommendation based on moderate evidence.)
Nii^kebf[m^glbhgm^lm
Linkebg`Ílm^lm
=blmkZ\mbhgm^lm
:?<<;H;DJ?7B:?7=DEI?I0 Clinicians should consider diagnostic
classifications associated with serious pathological conditions
or psychosocial factors when the patient’s reported activity
limitations or impairments of body function and structure are
not consistent with those presented in the diagnosis/classification section of this guideline, or, when the patient’s symptoms
are not resolving with interventions aimed at normalization of
the patient’s impairments of body function. (Recommendation
;N7C?D7J?EDÅEKJ9EC;C;7IKH;I0 Clinicians should use
validated self-report questionnaires, such as the Neck Disability
Index and the Patient-Specific Functional Scale for patients
with neck pain. These tools are useful for identifying a patient’s
baseline status relative to pain, function, and disability and for
monitoring a change in a patient’s status throughout the course
of treatment. (Recommendation based on strong evidence.)
;N7C?D7J?EDÅ79J?L?JOB?C?J7J?ED7D:F7HJ?9?F7J?EDH;IJH?9J?EDC;7IKH;I0 Clinicians should utilize easily reproducible
activity limitation and participation restriction measures associated with their patient’s neck pain to assess the changes in the
patient’s level of function over the episode of care. (Recommendation based on expert opinion.)
?DJ;HL;DJ?EDIÅ9;HL?97BCE8?B?P7J?ED%C7D?FKB7J?ED0
Clinicians should consider utilizing cervical manipulation and
mobilization procedures, thrust and non-thrust, to reduce neck
pain and headache. Combining cervical manipulation and mobilization with exercise is more effective for reducing neck pain,
headache, and disability than manipulation and mobilization
alone. (Recommendation based on strong evidence.)
?DJ;HL;DJ?EDIÅJ>EH79?9CE8?B?P7J?ED%C7D?FKB7J?ED0
Thoracic spine thrust manipulation can be used for patients
with primary complaints of neck pain. Thoracic spine thrust
manipulation can also be used for reducing pain and disability
in patients with neck and neck-related arm pain. (Recommendation based on weak evidence.)
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
can be used for patients with neck symptoms. Examination
Zg]mZk`^m^]×^qb[bebmr^q^k\bl^l_hkma^_heehpbg`fnl\e^lZk^
suggested: anterior/medial/posterior scalenes, upper trapezius,
levator scapulae, pectoralis minor, and pectoralis major. (Recommendation based on weak evidence.)
?DJ;HL;DJ?EDIÅ9EEH:?D7J?ED"IJH;D=J>;D?D="7D:;D:KH7D9;;N;H9?I;I0 Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce
neck pain and headache. (Recommendation based on strong
evidence.)
and nerve mobilization procedures to reduce pain and disability
in patients with neck and arm pain. (Recommendation based
on moderate evidence.)
?DJ;HL;DJ?EDIÅJH79J?ED0 Clinicians should consider the use
of mechanical intermittent cervical traction, combined with
other interventions such as manual therapy and strengthening
exercises, for reducing pain and disability in patients with neck
and neck-related arm pain. (Recommendation based on moderate evidence.)
?DJ;HL;DJ?EDIÅ9;DJH7B?P7J?EDFHE9;:KH;I7D:;N;H9?I;I0
Specific repeated movements or procedures to promote centralization are not more beneficial in reducing disability when
compared to other forms of interventions. (Recommendation
based on weak evidence.)
?DJ;HL;DJ?EDIÅF7J?;DJ;:K97J?ED7D:9EKDI;B?D=0 To
improve recovery in patients with whiplash-associated disorder,
clinicians should (1) educate the patient that early return to
normal, non-provocative pre-accident activities is important,
and (2) provide reassurance to the patient that good prognosis
and full recovery commonly occurs. (Recommendation based
on strong evidence.)
?DJ;HL;DJ?EDIÅKFF;HGK7HJ;H7D:D;HL;CE8?B?P7J?EDFHE9;:KH;I0 Clinicians should consider the use of upper quarter
J^[i[h[Yecc[dZWj_ediWdZYb_d_YWbfhWYj_Y[]k_Z[b_d[iWh[XWi[Zedj^[
iY_[dj_ÓYb_j[hWjkh[fkXb_i^[Zfh_ehje@kd[(&&-$
Introduction
7?CE<J>;=K?:;B?D;
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based
practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described
in the World Health Organization’s International Classification
of Functioning, Disability, and Health (ICF).1/
The purposes of these clinical guidelines are to:
=^l\kb[^ôb]^g\^&[Zl^]iarlb\Zema^kZirikZ\mb\^bg\en]ing diagnosis, prognosis, intervention, and assessment of
outcome for musculoskeletal disorders commonly managed
by orthopaedic physical therapists
<eZllb_rZg]]^Ög^\hffhgfnl\nehldê^mZe\hg]bmbhgl
using the World Health Organization’s terminology related
to impairments of body function and body structure, activity
limitations, and participation restrictions
B]^gmb_rbgm^ko^gmbhgllniihkm^][r\nkk^gm[^lmôb]^g\^mh
address impairments of body function and structure, activity limitations, and participation restrictions associated with
common musculoskeletal conditions
B]^gmb_rZiikhikbZm^hnm\hf^f^Zlnk^lmhZll^ll\aZg`^l
resulting from physical therapy interventions in body function and structure as well as in activity and participation of
the individual
Ikhob]^Z]^l\kbimbhgmhiheb\rfZd^kl%nlbg`bgm^kgZmbhgZeer
accepted terminology, of the practice of orthopaedic physical therapists
Ikhob]^bg_hkfZmbhg_hkiZr^klZg]\eZbflkôb^p^klk^`Zk]ing the practice of orthopaedic physical therapy for common
musculoskeletal conditions
<k^Zm^Zk^_^k^g\în[eb\Zmbhg_hkhkmahiZ^]b\iarlb\Ze
therapy clinicians, academic instructors, clinical instructors,
students, interns, residents, and fellows regarding the best
current practice of orthopaedic physical therapy
IJ7J;C;DJE<?DJ;DJ
This guideline is not intended to be construed or to serve as a
standard of medical care. Standards of care are determined on
the basis of all clinical data available for an individual patient
and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of
practice should be considered guidelines only. Adherence to
them will not ensure a successful outcome in every patient, nor
should they be construed as including all proper methods of care
or excluding other acceptable methods of care aimed at the same
results. The ultimate judgment regarding a particular clinical
procedure or treatment plan must be made in light of the clinical
data presented by the patient, the diagnostic and treatment options available, and the patient’s values, expectations, and preferences. However, we suggest that significant departures from accepted guidelines should be documented in the patient’s medical
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,
APTA as developers and authors of clinical practice guidelines
for musculoskeletal conditions of the cervical region that are
commonly treated by physical therapists. These content experts
were given the task to identify impairments of body function
and structure, activity limitations, and participation restrictions, described using ICF terminology, that could (1) categorize
patients into mutually exclusive impairment patterns upon
which to base intervention strategies, and (2) serve as measures
of changes in function over the course of an episode of care. The
second task given to the content experts was to describe interventions 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 experts that a systematic search and review of the evidence solely
related to diagnostic categories based on International Statistical Classification of Diseases and Health Related Problems
(ICD)10 terminology would not be useful for these ICF-based
clinical practice guidelines as most of the evidence associated
with changes in levels of impairment or function in homogeneous populations is not readily searchable using the ICD terminology. Thus, the authors of this clinical practice guideline sysm^fZmb\Zeerl^Zk\a^]F>=EBG>%<BG:AE%Zg]ma^<h\akZg^
=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 content expert was assigned a specific subcategory (classification,
outcome measures, and intervention strategies for musculoskeletal conditions of the neck region) to search by the lead author
!C=<"[Zl^]nihgma^bkli^\bÖ\Zk^Zh_^qi^kmbl^'Mph\hgm^gm
experts were assigned to each subcategory and both individuals
performed a separate search, including but not limited to the
3 databases listed above, to identify articles to assure that no
studies of relevance were omitted. Additionally, when relevant
articles were identified, their reference lists were hand-searched
in an attempt to identify other articles that might have contributed to the outcome of these clinical practice guidelines.
Mabl`nb]êbg^pZlblln^]bg+))1[Zl^]nihgin[eb\Zmbhglbg
ma^l\b^gmbÖ\ebm^kZmnkîkbhkmhCng^+))0'Mabl`nb]êbg^pbee
be considered for review in 2012, or sooner if substantive new
evidence becomes available. Any updates to the guideline in the
interim period will be noted on the Orthopaedic Section of the
APTA website: www.orthopt.org
B;L;BIE<;L?:;D9;
Once the content experts of each subcategory had identified all
relevant articles, they independently graded each article accordbg`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
experts did not agree on a grade of evidence for a particular
article, a third content expert was used to resolve the issue.
a4
|
I
;l_Z[dY[eXjW_d[Z\hec^_]^#gkWb_johWdZec_p[ZYedjhebb[Z
jh_Wbi"fheif[Yj_l[ijkZ_[i"ehZ_W]deij_YijkZ_[i
II
;l_Z[dY[eXjW_d[Z\hecb[ii[h#gkWb_johWdZec_p[Z
Yedjhebb[Zjh_Wbi"fheif[Yj_l[ijkZ_[i"ehZ_W]deij_Y
ijkZ_[i[]"_cfhef[hhWdZec_pWj_ed"deXb_dZ_d]"2.&
\ebbem#kf
III
9Wi[Yedjhebb[ZijkZ_[iehh[jheif[Yj_l[ijkZ_[i
IV
9Wi[i[h_[i
V
;nf[hjef_d_ed
=H7:;IE<;L?:;D9;
The overall strength of the evidence supporting recommendations made in this guideline will be graded according to guidelines described by Guyatt et al,0* as modified by
FZ\=^kfb]Zg]Z]him^][rma^\hhk]bgZmhkZg]kôb^p^klh_
this project. In this modified system, the typical A, B, C, and
D grades of evidence have been modified to include the role
of consensus expert opinion and basic science research to
demonstrate biological or biomechanical plausibility (Table
2 below).
GRADES OF RECOMMENDATION
STRENGTH OF EVIDENCE
Ijhed][l_Z[dY[
7fh[fedZ[hWdY[e\b[l[b?WdZ%ehb[l[b
??ijkZ_[iikffehjj^[h[Yecc[dZWj_ed$
J^_ickij_dYbkZ[Wjb[Wij'b[l[b?ijkZo
CeZ[hWj[[l_Z[dY[
7i_d]b[^_]^#gkWb_johWdZec_p[ZYed#
jhebb[Zjh_WbehWfh[fedZ[hWdY[e\b[l[b
??ijkZ_[iikffehjj^[h[Yecc[dZWj_ed
M[Wa[l_Z[dY[
7i_d]b[b[l[b??ijkZoehWfh[fedZ[h#
WdY[e\b[l[b???WdZ?LijkZ_[i_dYbkZ_d]
ijWj[c[djie\Yedi[dikiXoYedj[dj
[nf[hjiikffehjj^[h[Yecc[dZWj_ed
9edÔ_Yj_d][l_Z[dY[
D
>_]^[h#gkWb_joijkZ_[iYedZkYj[Zed
j^_ijef_YZ_iW]h[[m_j^h[if[Yjjej^[_h
YedYbki_edi$J^[h[Yecc[dZWj_ed_i
XWi[Zedj^[i[YedÔ_Yj_d]ijkZ_[i
E
J^[eh[j_YWb%
7fh[fedZ[hWdY[e\[l_Z[dY[\hec
\ekdZWj_edWb[l_Z[dY[ Wd_cWbehYWZWl[hijkZ_[i"\hec
YedY[fjkWbceZ[bi%fh_dY_fb[i"eh\hec
XWi_YiY_[dY[i%X[dY^h[i[WhYîkffehj
j^_iYedYbki_ed
A
B
C
F
;nf[hjef_d_ed
8[ijfhWYj_Y[XWi[Zedj^[Yb_d_YWb
[nf[h_[dY[e\j^[]k_Z[b_d[iZ[l[bef#
c[djj[Wc
Methods (continued)
H;L?;MFHE9;II
The Orthopaedic Section, APTA also selected consultants from
the following areas to serve as reviewers of the early drafts of
this clinical practice guideline:
<eZbflkôb^p
<h]bg`
>ib]^fbheh`r
F^]b\ZeikZ\mb\^`nb]êbg^l
HkmahiZ^]b\iarlb\Zema^kZirk^lb]^g\r^]n\Zmbhg
Iarlb\Zema^kZirZ\Z]^fb\^]n\Zmbhg
Lihkmliarlb\Zema^kZirk^lb]^g\r^]n\Zmbhg
Comments from these reviewers were utilized by the authors
to edit this clinical practice guideline prior to submitting it for
in[eb\Zmbhgmhma^ChnkgZeh_HkmahiZ^]b\LihkmlIarlb\Ze
Therapy
In addition, several physical therapists practicing in orthopaedic and sports physical therapy settings were sent initial drafts
of this clinical practice guideline along with feedback forms
to determine its usefulness, validity, and impact. All returned
feedback forms from these practicing clinicians described this
clinical practice guideline as:
ÊFh]^kZmêrnl^_neËhkÊ^qmk^fêrnl^_neË
:gÊZ\\nkZm^kîk^l^gmZmbhgh_maî^^k&kôb^p^]
ebm^kZmnk^Ë
:`nb]êbg^maZmpbeeaZo^ZÊln[lmZgmbZeihlbmbo^bfiZ\mhg
hkmahiZ^]b\iarlb\Zema^kZiriZmb^gm\Zk^Ë
However, several reviewers noted that preliminary drafts of
this clinical guideline did not clearly link data gathered during
the patient’s subjective and physical examinations to diagnostic classification and intervention. To assist in clarifying these
links, it was recommended that the authors add a table to
these clinical guidelines that provides a summary of symptoms,
impairment findings, and matched interventions for each diagnostic category. This recommendation led the authors to add
Table 4 to these clinical guidelines.
9B7II?<?97J?ED
The primary ICD-10 codes and conditions associated with neck
iZbgZk^3F.-'+<^kob\Ze`bZ%F.-'/IZbgbgmahkZ\b\libg^%K.*
A^Z]Z\a^%F.,')<^kob\h\kZgbZelrg]khf^%L*,'-LikZbgZg]
lmkZbgh_\^kob\Zelibg^%F-0'+Lihg]rehlblpbmakZ]b\nehiZmar%
Zg]F.)'*<^kob\Ze]bl\]blhk]^kpbmakZ]b\nehiZmar'10 The
\hkk^lihg]bg`B<=&2<F\h]^lZg]\hg]bmbhgl%pab\aZk^nl^]
bgma^NL:%Zk^0+,'*<^kob\Ze`bZ%0+-'*IZbgbgmahkZ\b\libg^%
01-')A^Z]Z\a^%0+,'+<^kob\h\kZgbZelrg]khf^%1-0')LikZbgl
Zg]lmkZbglh_ma^g^\d%Zg]0+,'-;kZ\abZeg^nkbmblhkkZ]b\nlitis, not otherwise specified (Cervical radiculitis/Radicular
syndrome of upper limbs).
The primary ICF body function codes associated with the above
noted ICD-10 conditions are the sensory functions related to
pain and the movement functions related to joint motion and
control of voluntary movements. These body function codes are
X-'&'CeX_b_joe\i[l[hWbè_dji"X(.&'&FW_d_d^[WZWdZd[Ya"X-,&'
9edjhebe\Yecfb[nlebkdjWhocel[c[dji"WdZX(.&)HWZ_Wj_d]fW_d_d
WZ[hcWjec[$
The primary ICF body structure codes associated with neck
pain are i-'&)@e_djie\^[WZWdZd[Yah[]_ed"i-'&*CkiYb[ie\^[WZ
WdZd[Yah[]_ed"i-'&+B_]Wc[djiWdZ\WiY_W[e\^[WZWdZd[Yah[]_ed"
i-,&&&9[hl_YWbl[hj[XhWbYebkcd"WdZi'(&'If_dWbd[hl[i$
The primary ICF activities and participation codes associated
with neck pain are Z*'&.9^Wd]_d]WXWi_YXeZofei_j_ed"Z*'+.
CW_djW_d_d]WXeZofei_j_ed"WdZZ**+(H[WY^_d]$
The ICD-10 and primary and secondary ICF codes associated
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+*$(
C+*$,
9[hl_YWb]_W
FW_d_djêhWY_Yif_d[
H+'
C+)$&
>[WZWY^[
9[hl_YeYhWd_WbiodZhec[
D[YaFW_dM_j^>[WZWY^[i
Primary ICD-10
D[YaFW_dM_j^Cel[c[dj9eehZ_dWj_ed?cfW_hc[dji
Primary ICD-10
I')$*
IfhW_dWdZijhW_de\Y[hl_YWbif_d[
C*-$(
C+&$'
IfedZobei_im_j^hWZ_YkbefWjô
9[hl_YWbZ_iYZ_iehZ[hm_j^hWZ_YkbefWjô
D[YaFW_dM_j^HWZ_Wj_d]FW_d
Primary ICD-10
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
(.&'&
FW_d_d^[WZWdZd[Ya
Body structure
i-'&)
i-'&*
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hWnikY^j^Wjj^[Y[hl_YWbl[hj[XhWbi[]c[dji\kdYj_ed_dWd[kjhWb"ehc_Z#hWd]["fei_j_ed
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SECONDARY ICF CODES
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|
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED)
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a8
|
CLINICAL GUIDELINES
Impairment/Function-based
Diagnosis
FH;L7B;D9;
Pain and impairment of the neck is common. It is estifZm^]maZm++mh0)h_maîhineZmbhgpbeeaZo^g^\diZbg
some time in their lives.*2%+)%-+%-,%..%**.%*+2 In addition, it has been
suggested that the incidence of neck pain is increasing.*+/%*1*
At any given time, 10% to 20% of the population reports neck
problems,*2%--%01%*/0pbma.-h_bg]bob]nZelaZobg`^qi^kb^g\^]
g^\diZbgpbmabgmaêZlm/fhgmal'42 Prevalence of neck pain
increases with age and is most common in women around the
fifth decade of life.-%*2%-/%**/%*/,
Although the natural history of neck pain appears to be favorable,.*%2+ rates of recurrence and chronicity are high.*.%1*
One study reported that 30% of patients with neck pain
will develop chronic symptoms, with neck pain of greater
maZg/fhgmal]nkZmbhgZü^\mbg`*-h_Zeebg]bob]nZelpah
experience an episode of neck pain.19 Additionally, a recent
lnko^r ]^fhglmkZm^] maZm ,0 h_ bg]bob]nZel pah ^qi^kbence neck pain will report persistent problems for at least
12 months.44 Five percent of the adult population with neck
pain will be disabled by the pain, representing a serious
health concern.*2%11 In a survey of workers with injuries to
the neck and upper extremity, Pransky et al*,. reported that
-+fbll^]fhk^maZg*p^^dh_phkdZg]+/^qi^kb^g\^]
recurrence within 1 year. The economic burden due to disorders of the neck is high, and includes costs of treatment,
lost wages, and compensation expenditures.*/%*,1 Neck pain is
second only to low back pain in annual workers’ compensambhg\hlmlbgma^Ngbm^]LmZm^l'*1* In Sweden, neck and shoul]^kikh[e^flZ\\hngm_hk*1h_Zee]blZ[bebmriZrf^gml'*+/
C^mm^^mZe91 reported that patients with neck pain make up
ZiikhqbfZmêr+.h_iZmb^gmlk^\^bobg`hnmiZmb^gmiarlbcal therapy. Additionally, patients with neck pain frequently
are treated without surgery by primary care and physical
therapy providers.*0%.*%2+
F7J>E7D7JEC?97B<;7JKH;I
A variety of causes of neck pain have been described
and include osteoarthritis, discogenic disorders, trauma, tumors, infection, myofascial pain syndrome, torticollis, and
whiplash.121Ng_hkmngZmêr%\e^Zker]^Ög^]]bZ`ghlmb\\kbm^kbZ
have not been established for many of these entities. Similar
to low back pain, a pathoanatomical cause is not identifiable
in the majority of patients who present with complaints of
neck pain and neck related symptoms of the upper quarter.*.
Therefore, once serious medical pathology (such as cervical
fracture or myelopathy) has been ruled out, patients with
neck pain are often classified as having either a nerve root
\hfikhfbl^hkZÊf^\aZgb\Zeg^\d]blhk]^k'Ë
In some conditions, particularly those that are degenerative in nature or involve abnormalities of the
vertebral motion segment, abnormal findings are
not always associated with symimhfl' ?hnkm^^g mh *1 h_
people without neck pain demonstrate a wide range of abnormalities with imaging studies, including disc protrusion
or extrusion and impingement of the thecal sac on the nerve
root and spinal cord.12 However, degenerative changes are
still suggested to be a possible cause of mechanical neck pain
in some cases,109,130,131 despite the fact that these changes are
present in asymptomatic individuals, are non-specific, and
are highly prevalent in the elderly.*/1 Disorders such as cervical radiculopathy and cervical compressive myelopathy are
reported to be caused by space-occupying lesions (osteophytosis or herniated cervical disc). These may be secondary to
degenerative processes and can give rise to neck and/or upper quarter pain as well as neurologic signs and symptoms.*,/
While cervical disc herniation and spondylosis are most commonly linked to cervical radiculopathy and myelopathy,*)%*,/
the bony and ligamentous tissues affected by these conditions
are themselves pain generators and are capable of giving rise
to some of the referred symptoms observed in patients with
these disorders.13,40
II
Because most patients with neck pain usually lack
an identifiable pathoanatomic cause for their problem, the majority are classified as having mechanical neck disorders.1+
II
Although the cause of neck pain may be associated with degenerative processes or pathology
identified during diagnostic imaging, the tissue
that is causing a patient’s neck pain is most often unknown. Thus, clinicians should assess for impaired function of muscle, connective, and nerve tissues associated
with the identified pathological tissues when a patient
presents with neck pain.
E
H?IA<79JEHI
Bot and colleagues18 investigated the clinical course and predictors of recovery for patients
with neck and shoulder pain. Four hundred forty
three patients who consulted their primary care physician
with neck or shoulder symptoms were followed for 12 months.
At 12 months, 32% of patients reported that they had recovered. Predictors of poor pain-related outcome at 12 months
included less intense pain at baseline, a history of neck and
shoulder symptoms, more worrying, worse perceived health,
and a moderate or bad quality of life. The predictors for a
poor disability-related response at 12 months included older
age, less disability at baseline, longer duration of symptoms,
loss of strength in hands, having multiple symptoms, more
worrying, moderate or bad quality of life, and less vitality.
II
Hill and colleagues0/ investigated the course of
neck pain in an adult population over a 12 month
period. Significant baseline characteristics, which
ik^]b\m^]i^klblm^gmg^\diZbgp^k^Z`^!-.&.2r^Zkl"%[^bg`
off work at the time of the baseline survey (odds ratio [OR]
6*'/"%\hfhk[b]ehp[Z\diZbg!HK6*'/"%Zg][b\r\ebg`ZlZ
regular activity (OR = 2.4).
II
In a prospective cohort study, Hoving et al1) examined the predictors of outcome in a patient
ihineZmbhgpbmag^\diZbg':mhmZeh_*1,iZmb^gml
iZkmb\biZm^]bgma^lmn]rh_pab\a/,aZ]bfikho^]ZmZ
12-month follow-up. In the short term, older age (l40),
concomitant low back pain, and headache were associated
with poor outcome. In the long-term, in addition to age and
concomitant low back pain, previous trauma, a long duration of neck pain, stable neck pain during the 2 weeks prior
to baseline measurement, and previous neck pain predicted
poor prognosis.
II
Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain,
bicycling as a regular activity, loss of strength in the
hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic
neck pain.
B
9B?D?97B9EKHI;
Approximately 44% of patients experiencing neck pain
will go on to develop chronic symptoms,*. and many will continue to exhibit moderate disability at long-term follow-up.//
A recent systematic review examined the outcomes of nontreatment control groups in clinical trials for the conservative management of chronic mechanical neck pain - not due
to whiplash.*0* The outcomes of patients receiving a control
or placebo intervention were analyzed and effect sizes were
a10
|
calculated. The changes in pain scores over the varying trial
periods in these untreated subjects with chronic mechanical
neck pain were consistently small and not significant.*0*
Conversely, there is substantial evidence that favorable outcomes are attained following treatment of patients with cervical radiculopathy.02%*,/ For example, Radhakrishnan and
colleagues*,/ reported that nearly 90% of patients with cervical radiculopathy presented with only mild symptoms at a
median follow-up of 4.9 years. Honet and Puri02 found that
0)h_iZmb^gmlpbma\^kob\ZekZ]b\nehiZmar^qab[bm^]`hh]hk
excellent outcomes after a 2-year follow-up. Outcomes for the
patients in the aforementioned studies02%*,/ appeared favorZ[e^Zg]ln``^lmmaZm0)&2)h_mablihineZmbhg\Zg^qi^kbence improvement without surgical intervention. In contrast,
the clinical prognosis of patients with whiplash-associated
]blhk]^kble^ll_ZohkZ[e^':lnko^rh_*)1iZmb^gmlpbmaZabltory of whiplash requiring care at an emergency department
_hng]maZm..aZ]k^lb]nZeiZbg(]blZ[bebmrk^_^kZ[e^mhma^
hkb`bgZeZ\\b]^gmZmZf^Zg_heehp&nih_*0r^ZkleZm^k'G^\d
pain, radiating pain, and headache were the most common
symptoms. Thirty-three percent of the respondents with residual symptoms suffered from work disability, compared to
/bgma^`khnih_iZmb^gmlpbmahnmk^lb]nZe]blhk]^kl'+.
:?7=DEI?I%9B7II?<?97J?ED
Strategies for the classification of patients
with neck pain have been recently proposed by
Wang et al,*00 Childs et al,+0 and Fritz and Bren/+
nan. The underlying premise is that classifying patients
into groups based on clinical characteristics and matching
these patient subgroups to management strategies likely to
benefit them will improve the outcome of physical therapy
interventions.+0 The classification system described by Wang
et al*00 categorized patients into 1 of 4 subgroups based on
the area of symptoms and the presumed source of the symptoms. The labels of these 4 categories were neck pain only,
headaches, referred arm pain and neck pain, and radicular
arm pain and neck pain. Distinct treatment approaches were
linked to each of the 4 categories. Wang et al*00 reported the
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
were reported for the classification group only.*00 It is difficult to draw conclusions regarding the potential usefulness
of the Wang et al*00 classification system because patients in
ma^\hgmkhe`khnip^k^ghmmk^Zm^]%pab\ablghmk^×^\mbo^h_
physical therapy practice. The classification system described
by Childs et al+0 and Fritz and Brennan/+ uses information
from the history and physical examination to place patients
bgmh*h_.lîZkZm^mk^Zmf^gmln[`khnil'MaêZ[êlh_ma^l^
.ln[`khnil%pab\aZk^fh[bebmr%\^gmkZebsZmbhg%^q^k\bl^Zg]
III
conditioning, pain control, and headache, intend to capture
the primary focus or goal of treatment. Fritz and Brennan,/+
nmbebsbg`Zikhli^\mbo^%h[l^koZmbhgZelmn]rh_+0-iZmb^gml%
reported that patients who received interventions matched
with their treatment subgroup had better outcomes than patients who received interventions that were not matched with
their subgroup. The classification system described in this
practice guideline linked to the ICF, parallels the Childs et al+0
and Fritz and Brennan/+ classification with 2 noteworthy differences. The first difference is that the labels in this clinical
practice guideline incorporate the following ICF impairments
of body functions terminology: Neck pain with mobility deficits, neck pain with headaches, neck pain with movement coordination impairments, and neck pain with radiating pain.
The second difference is that Fritz and Brennan’s/+ÊiZbg\hgmkheË\Zm^`hkr%pab\apZlebgd^]mhfh[bebsZmbhgZg]kZg`^
of motion exercises following an acute cervical sprain, was
]bob]^]bgmhma^Êg^\diZbgpbmafho^f^gm\hhk]bgZmbhgbfiZbkf^gml%ËZg]Êg^\diZbgpbmafh[bebmr]^Ö\bmlË\Zm^`hkb^l%
where the patient would receive interventions linked to the
most relevant impairment(s) exhibited at a given period during the patient’s episode of care.
The ICD diagnosis of cervicalgia, or pain in thoracic
spine and the associated ICF diagnosis of neck pain
with mobility deficits is made with a reasonable level of certainty when the patient presents with the following
clinical findings,,%/+%1+%*//:
Rhng`^kbg]bob]nZe!Z`^5.)r^Zkl"
:\nm^g^\diZbg!]nkZmbhg5*+p^^dl"
LrfimhflblheZm^]mhma^g^\d
K^lmkb\m^]\^kob\ZekZg`^h_fhmbhg
I
The ICD diagnosis of headaches, or cervicocranial
syndrome and the associated ICF diagnosis of neck
pain with headaches is made with a reasonable level of certainty when the patient presents with the following
clinical findings/%/+%22%*1.:
NgbeZm^kZe a^Z]Z\a^ Zllh\bZm^] pbma g^\d(ln[h\\bibmZe
area symptoms that are aggravated by neck movements or
positions
A^Z]Z\aîkh]n\^]hkZ``kZoZm^]pbmaikhoh\Zmbhgh_ma^
ipsilateral posterior cervical myofascia and joints
K^lmkb\m^]\^kob\ZekZg`^h_fhmbhg
K^lmkb\m^]\^kob\Zel^`f^gmZefh[bebmr
:[ghkfZe(ln[lmZg]Zk]i^k_hkfZg\^hgma^\kZgbZe\^kob\Ze×^qbhgm^lm
II
The ICD diagnosis of sprain and strain of cervical
spine and the associated ICF diagnosis of neck pain
with movement coordination impairments is made
with a reasonable level of certainty when the patient presents
with the following clinical findings++%+2%*-.%*/+%*1+%*1-:
I
Ehg`lmZg]bg`g^\diZbg!]nkZmbhg7*+p^^dl"
:[ghkfZe(ln[lmZg]Zk]i^k_hkfZg\^hgma^\kZgbZe\^kob\Ze×^qbhgm^lm
:[ghkfZe(ln[lmZg]Zk] i^k_hkfZg\^ hg ma^ ]^î ×^qhk
endurance test
<hhk]bgZmbhg% lmk^g`ma% Zg] ^g]nkZg\^ ]^Ö\bml h_ g^\d
and upper quarter muscles (longus colli, middle trapezius,
lower trapezius, serratus anterior)
?e^qb[bebmr]^Ö\bmlh_nii^kjnZkm^kfnl\e^l!Zgm^kbhk(fb]dle/posterior scalenes, upper trapezius, levator scapulae,
pectoralis minor, pectoralis major)
>k`hghfb\ bg^ú\b^g\b^l pbma i^k_hkfbg` kî^mbmbo^
activities
The ICD diagnosis of spondylosis with radiculopathy or cervical disc disorder with radiculopathy and
the associated ICF diagnosis of neck pain with radiating pain is made with a reasonable level of certainty when
the patient presents with the following clinical findings*0.:
Nii^k^qmk^fbmrlrfimhfl%nlnZeerkZ]b\neZkhkk^_^kk^]
pain, that are produced or aggravated with Spurling’s maneuver and upper limb tension tests, and reduced with the
neck distraction test
=^\k^Zl^] \^kob\Ze khmZmbhg !5/)" mhpZk] ma^ bgoheo^]
side
Lb`glh_g^ko^khhm\hfik^llbhg
Ln\\^llpbmak^]n\bg`nii^k^qmk^fbmrlrfimhflpbmabgbtial examination and intervention procedures
II
Neck pain, without symptoms or signs of serious
medical or psychological conditions, associated
with (1) motion limitations in the cervical and upper thoracic regions, (2) headaches, and (3) referred or radiating pain into an upper extremity are useful clinical findings
for classifying a patient with neck pain into the following International Statistical Classification of Diseases and Related
Health Problems (ICD) categories: cervicalgia, pain in thoracic spine, headaches, cervicocranial syndrome, sprain and
strain of cervical spine, spondylosis with radiculopathy, and
cervical disc disorder with radiculopathy; and the associated
International Classification of Functioning, Disability, and
Health (ICF) impairment-based category of neck pain with
the following impairments of body function:
G^\diZbgpbmafh[bebmr]^Ö\bml([0*)*Fh[bebmrh_lô^kZe
joints)
G^\diZbgpbmaa^Z]Z\a^l(+1)*)IZbgbga^Z]Zg]g^\d"
G^\d iZbg pbma fho^f^gm \hhk]bgZmbhg bfiZbkf^gml
([0/)*<hgmkheh_\hfie^qohengmZkrfho^f^gml"
G^\diZbgpbmakZ]bZmbgìZbg![+1)-KZ]bZmbgìZbgbgZ
segment or region)
B
The following physical examination measures may be useful
in classifying a patient in the ICF impairment-based category
of neck pain with mobility deficits and the associated ICD
categories of cervicalgia or pain in thoracic spine:
<^kob\ZeZg]mahkZ\b\l^`f^gmZefh[bebmr
of neck pain with headaches and the associated ICD categories of headaches or cervicocranial syndrome:
<^kob\Zel^`f^gmZefh[bebmr
of neck pain with movement coordination impairments and
the associated ICD category of sprain and strain of cervical
spine:
=^îg^\d×^qhk^g]nkZg\^
in classifying a patient in the ICF impairment-based category of neck pain with radiating pain and the associated ICD
categories of spondylosis with radiculopathy or cervical disc
disorder with radiculopathy:
Nii^kebf[m^glbhgm^lm
Linkebg`Ílm^lm
=blmkZ\mbhgm^lm
:?<<;H;DJ?7B:?7=DEI?I
A primary goal of diagnosis is to match the patient’s clinical presentation with the most efficacious
treatment approach. A component of this decision
is determining whether the patient is, in fact, appropriate for
physical therapy management. In the vast majority of patients
with neck pain, symptoms can be attributed to mechanical
factors. However, in a much smaller percentage of patients,
the cause of neck pain may be something more serious, such as
cervical myelopathy, cervical instability,49 fracture,00 neoplastic
conditions,2)%*-)%*.+%*.- vascular compromise,*.* or systemic disease.1%+- Clinicians must be aware of the key signs and symptoms associated with serious pathological neck conditions,
continually screen for the presence of these conditions, and
initiate referral to the appropriate medical practitioner when
a potentially serious medical condition is suspected.
III
When a patient with neck pain reports a history of
trauma, the therapist needs to be particularly alert
for the presence of cervical instability, spinal fracture, and the presence of or potential for spinal cord or brain
stem injury. A clinical prediction rule has been developed to
I
a12
|
assist clinicians in determining when to order radiographs in
individuals who have experienced trauma.*.2
In addition to medical conditions, clinicians should
be aware of psychosocial factors that may be contributing to a patient’s persistent pain and disability, or that may contribute to the transition of an acute
condition to a chronic, disabling condition. Researchers have
recently shown that psychosocial factors are an important
prognostic indicator of prolonged disability./,%/-%**-%*.) When
relevant psychosocial factors are identified, the rehabilitation
approach may need to be modified to emphasize active rehabilitation, graded exercise programs, positive reinforcement
of functional accomplishments, and/or graduated exposure
to specific activities that a patient fears as potentially painful
or difficult to perform./.
II
Clinicians should consider diagnostic classifications
associated with serious pathological conditions or
psychosocial factors when the patient’s reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/
classification section of this guideline, or, when the patient’s
symptoms are not resolving with interventions aimed at normalization of the patient’s impairments of body function.
B
?C7=?D=IJK:?;I
Adults with cervical pain precipitated by trauma
should be classified as low risk or high risk based on the Canadian Cervical Spine Rule (CCR) for radiography in alert
and stable trauma patients*.2 and the 2001 American College
of Radiology (ACR) suspected Spine Trauma Appropriateness Criteria.3 According to the CCR, patients who (1) are
able to sit in the emergency department; or (2) have had a
simple rear-end motor vehicle collision; or (3) are ambulatory at any time; or (4) have had a delayed onset of neck pain;
hk!."]hghmaZo^fb]ebg^\^kob\Zelibg^m^g]^kg^ll4Zg]!/"
Zk^Z[e^mhZ\mboêrkhmZm^ma^bka^Z]-.bg^Z\a]bk^\mbhg%Zk^
classified as low risk. Those who are classified as low risk do
not require imaging for acute conditions. Patients who are
!*"`k^Zm^kmaZg/.r^Zklh_Z`^4hk!+"aZoâZ]Z]Zg`^khnl
mechanism of injury; or (3) have paresthesias in the extremities, are classified as high risk.*.2 Those classified as high risk
should undergo cervical radiography.2%-0
There is a paucity of available literature regarding the pediatric population to help guide decision making on the need for
imaging. Adult risk classification features should be applied
in children greater than age 14. Due to the added radiation
exposure of computed tomography the ACR recommends
ieZbg kZ]bh`kZiar !, ob^pl" bg mahl^ ng]^k */ r^Zkl h_ Z`^
regardless of mental status.3
There is no consensus for routine investigation of patients with
chronic neck pain with imaging beyond plain radiographs. ,%-1
Routine use of ultrasonography, CT, and magnetic resonance
bfZ`bg`!FKB"bgiZmb^gmlpbmahnmg^nkheh`b\bglnemhkhma^k
disease has not been justified in view of the infrequency of
abnormalities detected, the lack of prognostic value, inaccessibility, and the high cost of the procedures.*-%0,%**2%*,,%*-*%*-/%*0- A
major limitation is the lack of specific findings in patients
with neck disorder and no definite correlation between the
patient’s subjective symptoms and abnormal findings seen on
imaging studies. As a result, debate continues as to whether
persistent pain is attributable to structural pathology or to
other underlying causes.
K^\^gmer%DkblmcZgllhg111 compared sagittal plane, rotational,
and translational cervical segmental motion in women with
(1) persistent whiplash-associated disorder (WAD) (grades I
and II), (2) persistent non-traumatic, insidious onset of neck
pain, and (3) normal values of rotational and translational
fhmbhg'EZm^kZekZ]bh`kZiab\ZgZerlblkô^Ze^]lb`gbÖ\Zgmer
bg\k^Zl^]khmZmbhgZefhmbhgZm<,&-Zg]<-&._hkbg]bob]nals in the WAD and insidious groups, significantly excessive
translational motion at C3-4 for individuals in the WAD and
insidious groups, and significantly excessive translational
fhmbhgZm<.&/_hkbg]bob]nZelbgma^P:=`khnipa^g\hfpared to normal subjects.
NemkZlhgh`kZiar aZl [^^g nl^] mh Z\\nkZmêr f^Zlnk^ ma^
size of the cervical multifidus muscle at the C4 level in asymptomatic female subjects. For those with chronic WAD,
ultrasonography did not accurately measure the cervical
multifidus because the fascial borders of the multifidus were
largely indistinguishable, indicating possible pathological
conditions.110
Abàk^lhenmbhgikhmhg]^glbmr&p^bàm^]FKBaZlk^\^gmer
demonstrated abnormal signal intensity (indicative of tissue
damage) in both the alar and transverse ligaments in some
subjects with chronic WAD.*)1EZm^k_heehp&nilmn]b^lbg]bcated a strong relationship between alar ligament damage,
head position (turned) at time of impact, and disability levels
(as measured with the Neck Disability Index).*)*%*)+%*)0
Elliott et al.,aZo^]^fhglmkZm^]maZm_^fZeîZmb^gml!*1&-.
r^Zklhe]"pbmai^klblm^gmP:=!`kZ]^BB"lahpFKB\aZg`^l
in the fat content of the cervical extensor musculature that
were not present in subjects with chronic insidious onset neck
pain or healthy controls. It is currently unclear whether the
patterns of fatty infiltration are the result of local structural
mkZnfZ\Znlbg`Z`^g^kZebg×ZffZmhkrk^lihgl^%Zli^\bÖ\
nerve injury or insult, or a generalized disuse phenomenon.
Further, as the muscular changes were observed in the chronic state, it is not yet known whether they occur uniformly in
all people who have sustained whiplash injury irrespective
of recovery or are unique to only those who develop chronic
symptoms.
In addition to fatty infiltration, Elliott et al.- have identified
changes in the relative cross-sectional area (rCSA) of the cervical paraspinal musculature in patients with chronic WAD
relative to control subjects with no history of neck pain. Specifically, the WAD group demonstrated a consistent pattern
of larger rCSA in the multifidii muscles at each segment (C3<0"'Bg_^k^g\^\Zg[^]kZpgmaZmma^larger rCSAs recorded
in the multifidii muscles of those with chronic WAD are the
result of larger amounts of fatty infiltrate.
In summary, imaging studies often fail to identify any
structural pathology related to symptoms in patients with
neck disorder and in particular, whiplash injury. However, emerging evidence into upper cervical ligamentous
disruption, altered segmental motion, and muscular degeneration has been demonstrated with radiographs, ulmkZlhgh`kZiar% Zg] FKB lmn]b^l' Bm k^fZbgl ngdghpg b_
(1) these findings are unique to chronic WAD; (2) whether
they relate to patients’ physical signs and symptoms, and
(3) whether specific physical therapy intervention can alter
such degeneration. Such knowledge may offer prognostic
information and provide the foundation for interventional
based studies.
CLINICAL GUIDELINES
Examination
EKJ9EC;C;7IKH;I
The Neck Disability Index (NDI) is a commonly
utilized outcome measure to capture perceived disability in patients with neck pain.134 The NDI conmZbgl*)bm^fl%0kêZm^]mhZ\mbobmb^lh_]Zberebobg`%+kêZm^]
to pain, and 1 related to concentration.*0+ Each item is scored
_khf)&.Zg]ma^mhmZel\hk^bl^qik^ll^]ZlZi^k\^gmZ`^%pbma
higher scores corresponding to greater disability. Riddle and
Stratford139 identified a significant association between the
NDI and both the physical and mental health components
h_ma^L?&,/'Ma^ZnmahklZelhb]^gmbÖ^]maZmma^G=Bihlsesses adequate sensitivity as compared to the magnitude of
change that occurred for patients reaching their functional
goals, work status, and if the patient was currently in litigation.139C^mm^Zg]C^mm^92 further substantiated the sensitivity
to change by calculating the effect sizes for change scores of
[hmama^G=BZg]L?&,/'
I
Two studies*/*%*02 with small sample sizes have identified the
minimal detectable change, or the amount of change that
must be observed before the change can be considered to
exceed the measurement error, for the NDI. Westaway*02
b]^gmbÖ^]ma^fbgbfZe]^m^\mZ[e^\aZg`^Zl.!*)i^k\^gmZ`^
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
with neck pain. However, the minimum clinically important
difference, the smallest difference which patients perceive as
beneficial, may be more useful to clinicians.12 Stratford and
colleagues*/* identified the minimal clinically important dif_^k^g\^ Zl . ihbgml !*) i^k\^gmZ`^ ihbgml"' Fhk^ k^\^gmer%
Cleland and colleagues,,. described the minimum clinically
bfihkmZgm ]bü^k^g\^ _hk ma^ G=B mh [^ 2'. !*2 i^k\^gmZ`^
points) for patients with mechanical neck disorders.
The NDI has demonstrated moderate test re-test reliability
and has been shown to be a valid health outcome measure
in a patient population with cervical radiculopathy. ,0 In this
group, the intraclass correlation coefficient (ICC) for test rem^lmkêbZ[bebmrpZl)'/1_hkma^G=BZg]ma^fbgbfnf\ebgb\ZeerbfihkmZgm]bü^k^g\^pZl0!*-i^k\^gmZ`îhbgml"' ,0
I
a14
|
The Patient-Specific Functional Scale (PSFS) is a
practical alternative or supplement to generic and
condition-specific measures.*02 The PSFS asks pa-
tients to list 3 activities that are difficult as a result of their
symptoms, injury, or disorder. The patient rates each activity
on a 0-10 scale, with 0 representing the inability to perform
the activity, and 10 representing the ability to perform the activity as well as they could prior to the onset of symptoms.*/)
The final PSFS score is the average of the 3 activity scores.
The PSFS was developed by Stratford et al*/) in an attempt
to present a standardized measure for recording a patient’s
perceived level of disability across a variety of conditions.
The PSFS has been evaluated for reliability and validity in
patients with neck pain.*02 The ICC value for test retest reliZ[bebmrbgiZmb^gmlpbma\^kob\ZekZ]b\nehiZmarpZl)'1+',0 The
minimal detectable change in that population was identified
to be 2.1 points with a minimum clinically important difference of 2.0.,0
Clinicians should use validated self-report questionnaires, such as the Neck Disability Index and
the Patient-Specific Functional Scale for patients
with neck pain. These tools are useful for identifying a patient’s baseline status relative to pain, function, and disability
and for monitoring a change in patient’s status throughout
the course of treatment.
A
79J?L?JOB?C?J7J?ED7D:F7HJ?9?F7J?EDH;IJH?9J?EDC;7IKH;I
There are no activity limitation and participation restriction measures specifically reported in
the literature associated with neck pain - other than
those that are part of the self-report questionnaire noted in
mabl`nb]êbg^Íll^\mbhghgHnm\hf^F^Zlnk^l'Ahpô^k%ma^
following measures are options that a clinician may use to
assess changes in a patient’s level of function over an episode
of care.
IZbgeôêZm^g]kZg`^lh_ehhdbg`ho^klahne]^k
IZbgeôêZm^g]kZg`^lh_ehhdbg`]hpg
IZbgeôêZm^g]kZg`^lh_ehhdbg`ni
IZbgeôêZ_m^klbmmbg`_hk+ahnkl
Gnf[^kh_mbf^li^kgbàmmaZmiZbg]blknimlle^î
=^ldphkdmhe^kZg\^!bggnf[^kh_fbgnm^lhkahnkl"
I^k\^gmh_mbf^^qi^kb^g\bg`g^\diZbgho^kmaîkôbhnl
24 hours
I^k\^gmh_mbf^^qi^kb^g\bgà^Z]Z\a^!l"ho^kmaîkôbous month
V
In addition, the Patient-Specific Functional Scale is a
questionnaire that can be used to quantify changes in
activity limitations and participation restrictions for patients with neck pain.*/) This scale enables the clinician to
collect measures related to function that may be different
then the measures that are components of the regionspecific outcome measures section such as the Neck Dis-
ability Index. *02
Clinicians should utilize easily reproducible activity limitation and participation restriction measures associated with their patient’s neck pain to
assess the changes in the patient’s level of function over the
episode of care.
F
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)
None
Diagnostic accuracy and
measurement properties
:_W]deij_Y7YYkhWYo'**0
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
Nature of variable
9edj_dkeki
cc>]\ehj^[WYj_lWj_ediYeh[
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
a16
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$-+
Nature of variable
9edj_dkeki
I[YedZi
?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
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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
)$edj^[iocfjecWj_Yi_Z["YedjhWbWj[hWbY[hl_YWbi_Z[#X[dZ_d]_dYh[Wi[ij^[fWj_[djÊiiocfjeci"eh_fi_bWj[hWbi_Z[#X[dZ_d]
Z[Yh[Wi[ij^[fWj_[djÊiiocfjeci
Nature of variable
Dec_dWb
None
Diagnostic accuracy indices for
the upper limb tension test, based
on the study by Wainner et al175
AWffW
I[di_j_l_jo
If[Y_ÓY_jo
Fei_j_l[b_a[b_êeZhWj_e
D[]Wj_l[b_a[b_êeZhWj_e
&$-,
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&$&'#'$/
Spurling’s Test
ICF category
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
None
Spurling’s test, based on the
study by Wainner et al175
AWffW
I[di_j_l_jo
If[Y_ÓY_jo
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D istraction Test
ICF category
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
None
the upper limb tension test, based
on the study by Wainner et al175
AWffW
I[di_j_l_jo
If[Y_ÓY_jo
&$..
&$**
&$/&
*$*&
&$,(
&$,*#'$&
&$('#&$,&$.(#&$/.
'$.&#''$'
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Valsalva Test
ICF category
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
None
the valsalva test, based on the
study by Wainner et al175
a18
|
AWffW
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&$,*#'$'
CLINICAL GUIDELINES
Interventions
A variety of interventions have been described for the treatment of neck pain and there is good evidence from highquality randomized, controlled trials and systematic reviews
to support the benefits of physical therapy intervention in
these patients.
CERVICAL MOBILIZATION/MANIPULATION
The most recent Cochrane Collaboration
Review69 of mobilization and manipulation for
mechanical neck disorders included 33 randomized
controlled trials of which 42% were considered high quality. They concluded that the most beneficial manipulative
interventions for patients with mechanical neck pain with
or without headaches should be combined with exercise to
reduce pain and improve patient satisfaction. Manipulation
(thrust) and mobilization (non-thrust manipulation) intervention alone were determined to be less effective than when
combined with exercise (combined intervention).69 A recently
published clinical practice guideline concluded that the evidence for combined intervention was relatively strong, while
the evidence for the effectiveness of thrust or non-thrust manipulation in isolation was weaker.68
I
The recommendations of the Cochrane Review69 and the recently published clinical practice guideline68 were based on
key findings that warrant further discussion. Studies cited
included patients with both acute82and chronic neck pain22
and interventions consisted of soft-tissue mobilization and
manual stretching procedures, as well as thrust,17,83 and nonthrust manipulative procedures82 directed at spinal motion
segments. Number of visits ranged from 6 over a 3 week
period82 to 20 over an 11 week period22 and the duration of
sessions ranged from 30 minutes99 to 60 minutes.22 Combined intervention was compared with various competing
interventions that included manipulation alone,22,99 various
non-manual physical therapy interventions,82 high-tech and
low-tech exercises,22,82,99 general practitioner care (medication, advice, education),82 and no treatment.99 The majority
of studies report either clinically or statistically important
differences in pain in favor of combined intervention when
compared to competing single interventions.69 Differences in
muscle performance22,99 as well as patient satisfaction have
also been reported for both short-term22,82,99 as well as longterm outcomes 122 and 2 years later.58 When compared to care
rendered by a general practitioner and non-manual physical
therapy interventions, the combination of manipulation and
exercise resulted in significant cost-savings of up to 68%.106
Although many patients experience a significant
benefit when treated with thrust manipulation, it
is still unclear which patients benefit most. Tseng
et al166 reported 6 predictors for patients who experienced an
immediate improvement in either pain, satisfaction, or perception of condition following manipulation of the cervical
spine. These predictors included166:
BgbmbZel\hk^lhgG^\d=blZ[bebmrBg]^qe^llmaZg**'.
AZobg`[beZm^kZebgoheo^f^gmiZmm^kg
Ghm i^k_hkfbg` l^]^gmZkr phkd fhk^ maZg . ahnkl i^k
day
?^êbg`[^mm^kpabe^fhobg`ma^g^\d
=b]ghm_^êphkl^pabe^^qm^g]bg`ma^g^\d
Ma^]bZ`ghlblh_lihg]rehlblpbmahnmkZ]b\nehiZmar
II
The presence of 4 or more of these predictors increased the
probability of success with manipulation from 60% to 89%.166
Predictors of which patients respond best to combined intervention have not been reported.
Nilsson et al125 conducted a randomized, clinical trial (n=53) in individuals with cervicogenic headache.
Subjects were randomized to receive high velocity
low amplitude spinal manipulation or low level laser and
deep friction massage. The use of analgesics were reduced
by 36% in the manipulation group but were unchanged in
the laser/massage group. The number of headache hours per
day decreased by 69% for the individuals in the manipulation
`khniZg],0bgmaêZl^k(fZllZ`^`khni'A^Z]Z\a^bgm^gsity per episode decreased by 36% for those in the manipulation group and 17% in the laser/massage group.
I
A systematic review by Vernon et al,171 which included studies published through 2005, concluded that
there is moderate- to high-quality evidence that subjects with chronic neck pain and headaches show clinically important improvements from a course of spinal mobilization or
manipulation at 6, 12, and up to 104 weeks post-treatment.
II
Despite good evidence to support the benefits of cervical
mobilization/manipulation, it is important that physical
therapists be aware of the potential risks in using these techniques./1%/2 However, it is impossible to determine the precise risk because (1) it is extremely difficult to quantify the
number of cervical spine mobilization/manipulative interventions performed each year, and (2) not all adverse events
occurring after mobilization/manipulation interventions are
published in the peer-reviewed literature, and there is no accepted standard for reporting these injuries. Reported risk
factors include hypertension, migraines, oral contraceptive
use, and smoking.0+ However, the prevalence of these factors
in the study by Haldeman et al0+ is largely the same or lower
than that which occurs in the general population.
Although the true risk for complications remains unknown,
ma^kbld_hkl^kbhnl\hfieb\Zmbhglbl^lmbfZm^]mh[^/bg*)
fbeebhg!)'))))/"fZgbineZmbhgl%pbmama^kbldh_]^Zma[îng 3 in 10 million (0.000003%). Importantly, these rates are
adjusted assuming that only 1 in 10 complications is actually
reported in the literature.1- Gross et al0) recently reported,
in a clinical practice guideline on the use of mobilization/
manipulation in patients with mechanical neck pain, that
estimates for serious complication for manipulation ranged
_khf*bg+)%)))!)')*"mh.bg*)fbeebhg!)')))."'0)
The risk estimate for patients experiencing non-serious
side effects such as increased symptoms, ranges from 1% to
2%.149 The most common side effects included local discom_hkm!.,"%eh\Zea^Z]Z\a^!*+"%_Zmb`n^!**"%hkkZ]bZmbg`
]bl\hf_hkm!*)"'IZmb^gml\aZkZ\m^kbs^]1.h_ma^l^\hfieZbgmlZlfbe]hkfh]^kZm^%pbma/-h_lb]^^ü^\mlZii^Zking within 4 hours after manipulation. Within 24 hours after
fZgbineZmbhg%0-h_ma^\hfieZbgmlaZ]k^lheo^]'E^llmaZg
.h_lb]^^ü^\mlp^k^\aZkZ\m^kbs^]Zl]bssbg^ll%gZnl^Z%ahm
skin, or other complaints. Side effects were rarely still noted
on the day after manipulation, and very few patients reported
the side effects as being severe.
Due the potential risk of serious adverse effects associated
with cervical manipulation, such as vertebrobasilar artery
stroke,./ it has been recommended that non-thrust cervical mobilization/manipulation be utilized in favor of thrust
manipulation..)%1. However, information regarding the risk/
benefit ratio of providing cervical thrust manipulation to
patients with impairments of body function purported to
benefit from cervical mobilization/manipulation, such as cervical segmental mobility deficits, has not been reported. In
addition, the case reports in the literature describing serious
adverse effects associated with cervical thrust manipulation
do not provide information regarding either the presence of
bfiZbkf^gmlh_[h]r_ng\mbhgl%hkmaîk^l^g\^h_k^]×Z`l
for vertebrobasilar insufficiency,0 prior to the application of
the manipulative procedure suspected to be linked with the
reported harmful effects.
a20
|
Recommendation: Clinicians should consider utilizing cervical manipulation and mobilization procedures, thrust and non-thrust, to reduce neck pain and
headache. Combining cervical manipulation and mobilization
with exercise is more effective for reducing neck pain, headache,
and disability than manipulation and mobilization alone.
A
T>EH79?9CE8?B?P7J?ED%C7D?FKB7J?ED
A survey among clinicians that practice manual physical therapy reported that the thoracic spine is the region of
the spine most often manipulated, despite the fact that more
patients complain of neck pain.1 While several randomized
clinical trials have examined the effectiveness of thoracic
libg^ maknlm fZgbineZmbhg !MLF" _hk iZmb^gml pbma g^\d
pain, patients in these studies also received cervical manipulation.+%++%.0 The rationale to include thoracic spine mobilization/manipulation in the treatment of patients with neck
pain stems from the theory that disturbances in joint mobility in the thoracic spine may be an underlying contributor to
musculoskeletal disorders in the neck. 2-%*).
Cleland et al34\hfiZk^]ma^^ü^\mbo^g^llh_MLFbg
a trial in which patients were randomized to either a
lbgè^l^llbhgh_MLFhklaZffZgbineZmbhg'IZmb^gml
pahk^\^bo^]MLF^qi^kb^g\^]Z\ebgb\Zeerf^Zgbg`_neZg]lmZtistically significant reduction in pain on the visual analogue
scale (VAS) compared to patients who received the sham intervention (P.001).34 A similar finding (reduction of pain) was
Zelhkîhkm^]bgZkZg]hfbs^]mkbZemaZm\hfiZk^]MLFbgm^kvention to an active exercise program.*-0 A subsequent randomized trial by Cleland et al,1pab\a\hfiZk^]MLFmhghg&maknlm
manipulation (mobilization) found significant differences in faohkh_ma^MLF`khnibgiZbg%]blZ[bebmr%Zg]iZmb^gmi^k\^bo^]
bfikho^f^gmnihgk^&ôZenZmbhg-1ahnkleZm^k'
I
While preliminary reports indicate that patients
with complaints of primary neck pain experience a
lb`gbÖ\Zgm[^g^Ömpa^gmk^Zm^]pbmaMLF%bmbllmbee
unclear which patients benefit most. Cleland et al33 reported a
preliminary clinical prediction rule for patients with primary
neck pain who experience short-term improvement (1-week)
pbmaMLF'>Z\aln[c^\mk^\^bo^]ZmhmZeh_,mahkZ\b\fZgbinlations directed at the upper and middle thoracic spine for up
mh+l^llbhgl'Nlbg`Zèh[ZekZmbg`h_\aZg`^l\hk^l.ZlZ
k^_^k^g\^\kbm^kbhg%/oZkbZ[e^lp^k^kîhkm^]Zlik^]b\mhklh_
improvement and included33:
Lrfimhf]nkZmbhgh_e^llmaZg,)]Zrl
Ghlrfimhfl]blmZemhma^lahne]^k
Ln[c^\m kîhkml maZm ehhdbg` ni ]h^l ghm Z``kZoZm^
symptoms
?^Zk&Zohb]Zg\^ ;êb^_l Jn^lmbhggZbk^&Iarlb\Ze :\mbobmr
Scale score less than 12
II
=bfbgbla^]nii^kmahkZ\b\libg^driahlbl!M,ÈM."
<^kob\Ze^qm^glbhgh_e^llmaZg,)
Interestingly, the lack of symptom aggravation with looking
up was also one of the predictors reported by Tseng et al*// in
the cervical manipulation clinical prediction rule. Validation
h_[hmama^\^kob\ZeZg]MLF\ebgb\Zekne^lblk^jnbk^][^_hk^
they can be recommended for widespread clinical use.
In a randomized clinical trial Fernández de las Peñas et al.2 demonstrated that patients with neck
pain related to a whiplash-associated disorder receiobg` MLF ^qi^kb^g\^] Z lb`gbÖ\Zgmer `k^Zm^k !I5')),"
reduction in pain as measured by the visual analogue scale,
than those who did not receive the thoracic manipulation.
Ma^f^Zg\aZg`^bgiZbgeôêlbgma^`khnik^\^bobg`MLF
pZl.-'*ff!L=*1'1ff"\hfiZk^]mhZf^Zg\aZg`^h_
*,'-ff!L=1'2ff"bgma^`khnighmk^\^bobg`mahkZ\b\fZnipulation. The length of follow-up was not clearly defined.
I
Self-reported levels of pain and cervical active
KHFp^k^Zll^ll^][^_hk^Zg]bff^]bZmêrZ_m^k
MLF bg +/ iZmb^gml pbma Z ikbfZkr \hfieZbgm h_
neck pain. The mean reduction in pain on an 11-point numeric pain rating scale was approximately 2 points (P.01),
which has been shown to indicate that a clinically meaningful
improvement has occurred. Significant increases in cervical
Z\mbo^KHFp^k^Zelhh[l^ko^]bgZee]bk^\mbhgl^q\îm^qm^glbhg!I5'))*"'Mabllmn]r]b]ghmbg\en]^Z\hgmkhe`khniZg]
only consisted of an immediate follow-up, but the immediate
bfikho^f^gmlbgiZbgZg]\^kob\ZeZ\mbo^KHFln``^lmmaZm
MLFfZraZo^lhf^f^kbmbgiZmb^gmlpbmag^\diZbg'/*
IV
There have been 4 case series that have incorporated thoracic spine thrust manipulation in the
multi-modal management of patients with cervical radiculopathy.+,%,2%*+)%*0/ In the first case series,39 10 of the
11 patients (91%) demonstrated a clinically meaningful imikho^f^gm bg iZbg Zg] _ng\mbhg Zm ma^ /&fhgma _heehp&ni
Z_m^kZf^Zgh_0'*iarlb\Zema^kZiroblbml'Bgma^l^\hg]\Zl^
series*0/ all patients except for 1 exhibited a significant reduction in disability. In the third case series,120 full resolution of
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 series23 that included thoracic spine thrust manipulation in the
fZgZ`^f^gmh_0iZmb^gmlpbma`kZ]^B\^kob\Ze\hfik^llbo^
myelopathy. All patients exhibited a reduction in pain and
improvement in function at the time of discharge.
IV
C
Recommendation: Thoracic spine thrust manipulation can be used for patients with primary
complaints of neck pain. Thoracic spine thrust ma-
nipulation can also be used for reducing pain and disability
in patients with neck and neck-related arm pain.
IJH;J9>?D=;N;H9?I;I
In a randomized controlled trial, Ylinen et
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^
with non-specific neck pain. At the 4 and 12 week follow-up
both groups improved but there were no significant differences between the groups related to pain. Neck pain and disability outcome measures, shoulder pain and disability outcome
measures, and neck stiffness were reduced significantly more
in those receiving manual therapy, but the clinical difference
was minimal. The authors concluded that the low-cost of
stretching exercises should be included in the initial treatment plan for patients with neck pain.
I
The authors of this clinical practice guideline have
observed that patients with neck pain often pres^gmpbmabfiZbkf^gmlh_×^qb[bebmrh_d^rfnl\e^l
related to the lower cervical and upper thoracic spine, such
as the anterior, medial, and posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, and pectoralis major,
that should be addressed with stretching exercises. One study
kîhkm^]maZmnii^kjnZkm^kfnl\e^×^qb[bebmr]^Ö\bmlp^k^
common in dental hygienists,2. an occupation that requires
frequent repetitive activities involving the shoulders, arms,
and hands. Although research generally does not support the
effectiveness of interventions that focus on stretching and
×^qb[bebmr%\ebgb\Ze^qi^kb^g\^ln``^lmlmaZmZ]]k^llbg`li^cific impairments of muscle length for an individual patient
may be a beneficial addition to a comprehensive treatment
program.
V
Recommendation: Flexibility exercises can be used
for patients with neck symptoms. Examination and
mZk`^m^]×^qb[bebmr^q^k\bl^l_hkma^_heehpbg`fnlcles are suggested: anterior/medial/posterior scalenes, upper
trapezius, levator scapulae, pectoralis minor, and pectoralis
major.
C
9EEH:?D7J?ED"IJH;D=J>;D?D="7D:;D:KH7D9;
;N;H9?I;I
Jull et al99 conducted a multi-centered,
randomized clinical trial (n=200) in participants
who met the diagnostic criteria for cervicogenic
headache. The inclusion criteria were unilateral or unilateral
dominant side-consistent headache associated with neck pain
and aggravated by neck postures or movement, joint tenderness in at least 1 of the upper 3 cervical joints as detected by
I
manual palpation, and a headache frequency of at least 1 per
week over a period of 2 months to 10 years. Subjects were
randomized into 4 groups: mobilization/manipulation group,
exercise therapy group, combined mobilization/manipulation
and exercise group, and a control group. The primary outcome was a change in headache frequency. At the 12-month
follow-up, the mobilization/manipulation, combined mobilization/manipulation and exercise, and the specific exercise
groups had significantly reduced headache frequency and intensity. Additionally 10% more patients experienced a complete reduction in headache frequency when treated with
mobilization/manipulation and exercise than those treated
with the alternative approaches. 99
Ma^^q^k\blîkh`kZfbgmabl\ebgb\ZemkbZe[rCnee^mZe99 used
low load endurance exercises to train muscle control of the
cervicoscapular region. The first stage consisted of specific
\kZgbh\^kob\Ze ×^qbhg ^q^k\bl^l% i^k_hkf^] bg lnibg^ erbg`%
Zbf^]mhmZk`^mma^]^îg^\d×^qhkfnl\e^l%pab\aZk^ma^
longus capitis and longus colli. Subsequently, isometric exercises using a low level of rotatory resistance were used to train
ma^\h&\hgmkZ\mbhgh_ma^g^\d×^qhklZg]^qm^glhkl'Ma^^qercise groups had significantly reduced headache frequency
and intensity when compared to the controls.
Chiu et al+1 assessed the benefits of an exercise program that focused both on motor control training of
ma^]^îg^\d×^qhklZg]]rgZfb\lmk^g`ma^gbg`':
mhmZeh_*-.iZmb^gmlpbma\akhgb\g^\diZbgp^k^kZg]hfbs^]
to either an exercise or a non-exercise control group. At week
/%ma^^q^k\bl^`khniaZ]lb`gbÖ\Zgmer[^mm^kbfikho^f^gml
in disability scores, pain levels, and isometric neck muscle
strength. However, significant differences between the 2
groups were found only in pain and patient satisfaction at
ma^/&fhgma_heehp&ni'
I
BgZkZg]hfbs^]%\ebgb\ZemkbZe%Rebg^g^mZe*1- demonstrated the effectiveness of both strengthening
exercises and endurance training of the deep neck
×^qhkfnl\e^lbgk^]n\bgìZbgZg]]blZ[bebmrZmma^*&r^Zk
_heehp&nibgphf^g!g6*1)"pbma\akhgb\%ghgli^\bÖ\g^\d
pain. The endurance training group performed dynamic neck
exercises, which included lifting the head up from the supine
and prone positions. The strength training group performed
high-intensity isometric neck strengthening and stabilization exercises with an elastic band. Both training groups
performed dynamic exercises for the shoulders and upper
extremities with dumbbells. Both groups were advised to
also do aerobic and stretching exercises 3 times a week. In a
,&r^Zk_heehp&nilmn]r%Rebg^g^mZe*1+ found that women (n =
**1"bg[hmama^lmk^g`ma^gbg`^q^k\bl^Zg]^g]nkZg\^mkZbging groups achieved long-term benefits from the 12-month
programs.
I
a22
|
HÍE^Zkr ^m Ze*+0 compared the effect of 2 specific
\^kob\Ze ×^qhk fnl\e^ ^q^k\bl^ ikhmh\hel hg bfmediate pain relief in the cervical spine of people
with chronic neck pain. They found that those performing
ma^ li^\bÖ\ \kZgbh\^kob\Ze ×^qbhg ^q^k\bl^ ]^fhglmkZm^]
greater improvements in pressure pain thresholds, mechanical hyperalgesia, and perceived pain relief during active movement.
III
In a cross-sectional comparative study, Chiu et al29
compared the performance of the deep cervical
×^qhkfnl\e^lhgma^\kZgbh\^kob\Ze×^qbhgm^lmbg
individuals with (n = 20) and without (n = 20) chronic neck
pain. Those with chronic neck pain had significantly poorer
i^k_hkfZg\^hgma^\kZgbh\^kob\Ze×^qbhgm^lm!f^]bZgik^lsure achieved, 24 mmHg when starting at 20 mmHg) when
compared with those in the asymptomatic group (median
ik^llnk^Z\abô^]%+1ffA`pa^glmZkmbg`Zm+)ffA`"'
III
Cnee ^m Ze20 compared the effects of conventional
ikhikbh\îmbo^mkZbgbg`Zg]\kZgbh\^kob\Ze×^qbhg
training on cervical joint position error in people
with persistent neck pain. The aim was to evaluate whether
proprioceptive training was superior in improving proprioceptive acuity compared to a form of exercise that has been
shown to be effective in reducing neck pain. Sixty-four female
subjects with persistent neck pain and deficits in cervical
joint position error were randomized into 2 exercise groups:
ikhikbh\îmbo^ mkZbgbg` hk \kZgbh\^kob\Ze ×^qbhg mkZbgbg`'
>q^k\bl^ k^`bf^gl p^k^ \hg]n\m^] ho^k Z /&p^^d i^kbh]'
The results demonstrated that both proprioceptive training
Zg]\kZgbh\^kob\Ze×^qbhgmkZbgbgàZo^Z]^fhglmkZ[e^[^gefit on impaired cervical joint position error in people with
neck pain, with marginally more benefit gained from proprioceptive training. The results suggest that improved proprioceptive acuity following intervention with either exercise
protocol may occur through an improved quality of cervical
afferent input or by addressing input through direct training
of relocation sense.20
I
In a randomized, clinical trial, Taimela et al*/+ compared the efficacy of a multimodal treatment emphasizing proprioceptive training in patients with
ghg&li^\bÖ\\akhgb\g^\diZbg!g60/"'Maîkhikbh\îmbo^
treatment, which consisted of exercises, relaxation, and behavioral support was more efficacious than comparison interventions that consisted of (1) attending a lecture on the
neck and 2 sessions of practical training for a home exercise
program, and (2) a lecture regarding care of the neck with a
recommendation to exercise. Specifically, the proprioceptive
treatment group had greater reductions in neck symptoms,
improvements in general health, and improvements in the
ability to work.
I
In a randomized clinical trial, Viljanen et al*0, assessed the effectiveness of dynamic muscle training
!g6*,."%kêZqZmbhgmkZbgbg`!g6*+1"%hkhk]bgZkr
Z\mbobmr!g6*,."_hk_^fZe^hú\^phkd^klpbma\akhgb\g^\d
pain. Dynamic muscle training and relaxation training did
not lead to better improvements in neck pain compared with
ordinary activity.
I
In a randomized clinical trial, Bronfort et al22 found
that a combined program of strengthening and endurance exercises combined with manual therapy
resulted in greater gains in strength, endurance, range of motion, and long-term patient pain ratings in those with chronic neck pain than programs that only incorporated manual
therapy. Additionally, Evans et al.1 found that these results
were maintained at a 2-year follow-up.
I
In a prospective case series, Nelson et al124 followed
patients with cervical and lumbar pain and found
that an aggressive strengthening program was able
mhikô^gmlnk`^krbg,.h_ma^/)iZmb^gml!-/h_ma^/)\hfie^m^]maîkh`kZf%,1p^k^ZoZbeZ[e^_hk_heehp&ni%Zg]hger
3 reported having surgery). Despite the methodological limitations of this study, some patients that were originally given
the option of surgery were able to successfully avoid surgery
in the short term following participation in an aggressive
strengthening exercise program.
IV
In a systematic review of 9 randomized clinical triZelZg]0\hfiZkZmbo^mkbZelpbmafh]^kZm^f^mah]ological quality for patients with mechanical neck
disorders, Sarig-Bahat*-. reported relatively strong evidence
supporting the effectiveness of proprioceptive exercises and
dynamic resisted strengthening exercises of the neck-shoulder musculature for patients with chronic or frequent neck
disorders. The evidence identified could not support the effectiveness of group exercise, neck schools, or single sessions
of extension-retraction exercises.
II
In a randomized clinical trial, Chiu et al30 found
bgiZmb^gmlpbma\akhgb\g^\diZbg!g6+*1"%maZm
Z /&p^^d mk^Zmf^gm h_ mkZgl\nmZg^hnl ê^\mkbcal nerve stimulation or exercise had a better and clinically
relevant improvement in disability, isometric neck muscle
strength, and pain compared to a control group. All the improvements in the intervention groups were maintained at
ma^/&fhgma_heehp&ni'
I
Hammill et al0- used a combination of postural
education, stretching, and strengthening exercises
to reduce the frequency of headaches and improve
disability in a series of 20 patients, with results being maintained at a 12-month follow-up.
IV
BgZlrlm^fZmb\kôb^p%DZr^mZe103 concluded that
specific exercises may be effective for the treatment
of acute and chronic mechanical neck pain, with or
without headache.
I
A recent Cochrane review/2 concluded that mobilization and/or manipulation when used with
exercise are beneficial for patients with persistent
mechanical neck disorders with or without headache. However, manual therapy without exercise or exercise alone were
not superior to one another.
I
Although evidence is generally lacking, postural
correction and body mechanics education and
training may also be indicated if clinicians identify
ergonomic inefficiencies during either the examination or
treatment of patients with motor control, movement coordination, muscle power, or endurance impairments.
V
A
Recommendation: Clinicians should consider the
use of coordination, strengthening, and endurance
exercises to reduce neck pain and headache.
9;DJH7B?P7J?EDFHE9;:KH;I7D:;N;H9?I;I
Kjellman and colleagues104 randomly assigned
00iZmb^gmlpbmag^\diZbg!+2h_pab\aik^l^gm^]
with cervical radiculopathy) to general exercise,
F\D^gsb^f^mah]h_^qZfbgZmbhgZg]mk^Zmf^gm%hkZ\hgmkhe
`khni!ehpbgm^glbmrnemkZlhng]Zg]^]n\Zmbhg"'Ma^F\D^gzie method of treatment consists of patient positioning, specific repeated movements, manual procedures, and patient
education in self management in case of recurrence.*)-%**1 The
kî^Zm^]li^\bÖ\fho^f^gmlpbmama^F\D^gsb^f^mah]bgtend to centralize (promote the migration of symptoms from
an area more distal to location more proximal) or reduce
pain.**1 At the 12 month follow-up all groups showed significant reductions in pain intensity and disability but no significant difference between groups existed. Seventy-nine percent
of patients reported that they were better or completely relmhk^]Z_m^kmk^Zmf^gm%Zemahnà.*kîhkm^]\hglmZgm(]Zber
pain. All 3 groups had similar recurrence rates.
I
Fnkiar^mZe122bg\hkihkZm^]F\D^gsbîkh\^]nk^l
to promote centralization in the management of a
cohort of 31 patients with cervical radiculopathy.
These patients also received cervical manipulation or muscle
energy techniques and neural mobilization. Seventy-seven
percent of patients at the short-term follow-up and 93% of
patients at the long-term follow-up exhibited a clinically important improvement in disability. However, specific details
regarding the number of patients receiving procedures to
promote centralization was not reported.
III
There has not been a clinical trial that recruited patients with
only cervical radiculopathy. Therefore, it is not possible to
\hff^gmhgma^^ú\Z\rh_ma^F\D^gsb^f^mah]hkma^nl^
of centralization procedures and exercises for this particular
subgroup of patients.31
Recommendation: Clinicians should consider the
use of upper quarter and nerve mobilization procedures to reduce pain and disability in patients with
neck and arm pain.
Recommendation: Specific repeated movements or
procedures to promote centralization are not more
beneficial in reducing disability when compared to
other forms of interventions.
JH79J?ED
KFF;HGK7HJ;H7D:D;HL;CE8?B?P7J?ED
FHE9;:KH;I
MZàb ChàZmZ^b ^m Ze93 randomly assigned 30 patients to receive a treatment program consisting
of ultrasound and exercise with or without mechanical intermittent cervical traction for 10 sessions. The
group receiving traction exhibited greater improvements
bg`kbilmk^g`ma%maîkbfZkrhnm\hf^f^Zlnk^%Z_m^k.l^lsions. However, no statistically significant difference between groups existed at the time of discharge from physical
therapy.93
C
Allison et al2 examined the effectiveness of
2 different manual therapy techniques (neural
mobilization and cervical/upper quadrant mobilization) in the management of cervico-brachial syndrome.
:eeiZmb^gmlk^\^bo^]mk^Zmf^gm_hk1p^^dlbgZ]]bmbhgmh
a home exercise program. The results demonstrated that
both manual therapy groups exhibited improvements in
pain and function. At the final data collection there existed no difference between the manual therapy groups
for function but a significant difference between groups
for reduction in pain was identified in favor of the neural
mobilization group.
II
In a randomized clinical trial, Coppieters et al41
assigned 20 patients with cervico-brachial pain to
receive either cervical mobilization with the upper
extremity in an upper limb neurodynamic position or therapeutic ultrasound. The group receiving the mobilizations
exhibited significantly greater improvements in elbow range
of motion during neurodynamic testing as well as greater reductions in pain compared to the ultrasound group.
II
Fnkiar^mZe122 incorporated neural mobilization in
the management of a cohort of patients with cervical radiculopathy. Seventy seven percent of patients
at the short-term follow-up and 93% of patients at the long
term follow-up exhibited a clinically important decrease in
disability. However, no specifics were provided relative to
which patients received neural mobilization procedures.
III
Cleland et al39 described the outcomes of a consecutive series of patients presenting to physical
therapy who received cervical mobilization (cervical lateral glides) with the upper extremity in a neurodynamic position as well as thoracic spine manipulation,
cervical traction, and strengthening exercises. Ten of the
11 patients (91%) demonstrated a clinically meaningful
bfikho^f^gmbgiZbgZg]_ng\mbhg_heehpbg`Zf^Zgh_0'*
physical therapy visits.
IV
a24
|
B
A systematic review by Graham and colleagues/0 reported that there is moderate evidence
to support the use of mechanical intermittent cervical traction.
I
II
Saal et al143 bgo^lmb`Zm^] ma^ hnm\hf^l h_ +/ \hgsecutive patients who fit the diagnostic criteria for
herniated cervical disc with radiculopathy who received a rehabilitation program consisting of cervical traction
and exercise. Twenty-four patients avoided surgical intervention and 20 exhibited good or excellent outcomes.
III
In a prospective cohort design Cleland et al,/ identified predictor variables of short-term success for
patients presenting to physical therapy with cervical radiculopathy. One of the predictor variables for patients
who exhibited a short-term success included a multimodal
physical therapy approach consisting of manual or mechanical traction, manual therapy (cervical or thoracic mobilizambhg(fZgbineZmbhg"%Zg]]^îg^\d×^qhklmk^g`ma^gbg`'Ma^
pretest probability for the likelihood of short-term success
pZl.,'Ma^f^Zg]nkZmbhgh_f^\aZgb\ZemkZ\mbhgnl^]hg
iZmb^gmlbgmabllmn]rpZl*0'1fbgnm^lpbmaZgZo^kZ`^_hk\^
of pull of 11 kg (24.3 pounds). The positive likelihood ratio
for patients receiving the multimodal treatment approach
(excluding other predictor variables) was 2.2, resulting in a
ihlm&m^lmikh[Z[bebmrh_ln\\^llh_0*' ,/
II
Raney et al*,0 recently developed a clinical prediction rule to identify patients with neck pain likely
to benefit from cervical mechanical traction. Sixty^bàmiZmb^gml!,1_^fZe^"p^k^bg\en]^]bg]ZmZZgZerlblh_
pab\a,)aZ]Zln\\^ll_nehnm\hf^':eeiZmb^gmlk^\^bo^]/
sessions of mechanical intermittent cervical traction startbg`pbmaZ_hk\^h_inee[^mp^^g-'.&.'-d`!*)&*+ihng]l"
_hkZ]nkZmbhgh_*.fbgnm^l'Ma^_hk\^h_ineeikh`k^llboêr
II
increased based on centralization of symptoms at each subl^jn^gm l^llbhg' : \ebgb\Ze ik^]b\mbhg kne^ pbma . oZkbZ[e^l
was identified:
IZmb^gmkîhkm^]i^kbia^kZebsZmbhgpbmaehp^k\^kob\Zelibg^
!<-&0"fh[bebmrm^lmbg`
Ihlbmbo^lahne]^kZ[]n\mbhglb`g
:`^l..r^Zkl
Ihlbmbo^nii^kebf[m^glbhgm^lm!f^]bZgg^ko^[bZlnmbebsbg`lahne]^kZ[]n\mbhgmh2)"
Kêb^_h_lrfimhflpbmafZgnZe]blmkZ\mbhgm^lm
bg?ng\mbhgZeKZmbg`Bg]^ql\hk^lpZl+/_khfZ[Zlêbg^
of 44%.
AZobg` Zm e^Zlm , hnm h_ . oZkbZ[e^l ik^l^gm k^lnem^] bg Z
ihlbmboêbdêbahh]kZmbh^jnZemh-'1*!2.<B6+'*0&**'-"%
increasing the likelihood of success with cervical traction
_khf--mh02'+'B_Zme^Zlm-hnmh_.oZkbZ[e^lp^kîk^l^gm%maîhlbmboêbdêbahh]kZmbhpZl^jnZemh**'0!2.<B
6+')2&/2'.1"%bg\k^Zlbg`maîhlm&m^lmikh[Z[bebmrh_aZobg`
improvement with cervical traction to 90.2%.
F7J?;DJ;:K97J?ED7D:9EKDI;B?D=
Three separate case series,2%*+)%*0/ describe the management of patients with cervical radiculopathy,
where the interventions included traction. In these
case series, the patients were treated with a multimodal treatment approach and the vast majority of patients exhibited
improved outcomes. In the first report, Cleland et al39 described the outcomes of a consecutive series of 11 patients
presenting to physical therapy with cervical radiculopathy
and managed with the use of manual physical therapy, cervi\ZemkZ\mbhg%Zg]lmk^g`ma^gbg`^q^k\bl^l':m/fhgma_heehp&
up, 91% demonstrated a clinically meaningful improvement
bgiZbgZg]_ng\mbhg_heehpbg`Zf^Zgh_0'*iarlb\Zema^kZir
visits. Similarly, Waldrop*0/mk^Zm^]/iZmb^gmlpbma\^kob\Ze
radiculopathy with mechanical intermittent cervical traction,
thoracic thrust joint manipulation, and range of motion and
lmk^g`ma^gbg`^q^k\bl^l_hkma^\^kob\Zelibg^'Nihg]bl\aZk`^
!f^Zgmk^Zmf^gm*)oblbml%kZg`^.&*1oblbml4]nkZmbhg,,]Zrl%
kZg`^*2&./]Zrl"%ma^k^pZlZk^]n\mbhgbg]blZ[bebmr[^mp^^g
*,Zg]11'Bgma^mabk]\Zl^l^kb^l%Fh^mbZg]FZk\a^mmb120
investigated the outcomes associated with cervical traction,
neck retraction exercises, scapular muscle strengthening,
and mobilization/manipulation techniques (used for some
iZmb^gml"_hk*.iZmb^gmlpbma\^kob\ZekZ]b\nehiZmar'Ma^l^
Znmahklkîhkm^]_neek^lhenmbhgh_iZbgbg.,h_iZmb^gmlZm
the time of discharge.
IV
Browder and colleagues23 investigated the effectiveness of a multimodal treatment approach in
ma^fZgZ`^f^gmh_0_^fZeîZmb^gmlpbma`kZ]^B
cervical compressive myelopathy. Patients were treated with
intermittent mechanical cervical traction and thoracic magbineZmbhg _hk Z f^]bZg h_ 2 l^llbhgl ho^k Z f^]bZg h_ ./
]Zrl'Ma^f^]bZg]^\k^Zl^bgiZbgl\hk^lpZl._khfZ[Zlêbg^h_/!nlbg`Z)&*)iZbgl\Ze^"%Zg]f^]bZgbfikho^f^gm
IV
Recommendation: Clinicians should consider
the use of mechanical intermittent cervical traction, combined with other interventions such as
manual therapy and strengthening exercises, for reducing
pain and disability in patients with neck and neck-related
arm pain.
B
There is a paucity of high quality evidence
surrounding efficacy of treatments for whiplashassociated disorder (WAD). However, existing research supports instructing patients in active interventions,
such as exercises, and early return to regular activities as a
means of pain control. Rosenfeld et al142 compared the longterm efficacy of active intervention with that of standard intervention and the effect of early versus delayed initiation
of intervention. Patients were randomized to an intervention using frequent active cervical rotation range of motion
exercises complemented by assessment and treatment ac\hk]bg`mhF\D^gsb^Ílikbg\bie^lhkmhZgbgm^ko^gmbhgmaZm
promoted initial rest, soft collar utilization, and gradual selfmobilization. In patients with WAD, early active intervention was more effective in reducing pain intensity and sick
leave, and in retaining/regaining total range of motion than
intervention that promoted rest, collar usage, and gradual
self-mobilization. Patient education promoting an active approach can be carried out as home exercises and progressive
return to activities initiated and supported by appropriately
trained health professionals.
I
An often prescribed intervention for acute whiplash
injury is the use of a soft cervical collar. Crawford
et al-.ikhli^\mboêrbgo^lmb`Zm^]*)1\hgl^\nmbo^
patients following a soft tissue injury of the neck that resulted from motor vehicle accidents. Each patient was randomized to a group instructed to engage in early mobilization
using an exercise regime or to a group that was instructed to
utilize a soft cervical collar for 3 weeks followed by the same
exercise regime. Patients were assessed clinically at 3, 12,
Zg].+p^^dbgm^koZel_khfbgcnkr'Bgm^ko^gmbhgmaZmnmbebs^]
a soft collar was found to have no obvious benefit in terms
of functional recovery after neck injury and was associated
with a prolonged time period off work. Other investigations
have reported similar results.*-1%*0) Interventions that instruct
patients to perform exercises early in their recovery from
whiplash type injuries have been reported to be more effective in reducing pain intensity and disability following
whiplash injury than interventions that instruct patients to
use cervical collars.*-1%*0)
I
Existing research supports active interventions and
early return to regular activities but it has largely
been unknown as to which type of active intervention would yield the most benefit. Brison et al21 assessed the
efficacy of an educational video in the prevention of persistent WAD symptoms following rear-end motor vehicle collisions. The video provided reassurance, and education about
posture, return to regular activities, specific exercises, and
pain management. Patients were randomized to receive either an educational video plus usual care or usual care alone.
The primary outcome was presence of persistent WAD symptoms at 24 weeks post injury, based on the frequency and
severity of neck, shoulder, or upper back pain. The group receiving the instructional video demonstrated a trend toward
less severe WAD symptoms suggesting that the ‘act as usual’
recommendation that is often prescribed as a management
strategy for patients with WAD is not sufficient and, in fact,
may exacerbate their symptoms if such activities are provocative of pain.21
I
A reduction in pain alone is not sufficient to address the neuromuscular control deficits in patients
with chronic symptoms,*.0 as these deficits require
specific rehabilitation techniques.99 For example, persistent
sensory and motor deficits may render the patient at risk for
symptom persistence.*..%*./ Support for specificity in rehabilitation can be indirectly found from a recent populationbased, incidence cohort study evaluating a government policy
of funding community and hospital-based fitness training and
multidisciplinary rehabilitation for whiplash.+/ No supportive
evidence was found for the effectiveness of this general rehabilitation approach. Therefore, only addressing the lack of
fitness and conditioning in this patient population may not
be the most efficacious approach to treatment.
III
Ferrari et al/) studied whether an educational intervention using a pamphlet provided to patients
in the acute stage of whiplash injury might improve the recovery rate. One hundred twelve consecutive
subjects were randomized to 1 of 2 treatment groups: educational intervention or usual care. The education intervention group received an educational pamphlet based on the
current evidence, whereas the control group only received
usual emergency department care and a standard non-directed discharge information sheet. Both groups underwent
follow-up by telephone interview at 2 weeks and 3 months.
The primary outcome measure of recovery was the patient’s
k^lihgl^mhma^jn^lmbhg%ÊAhppêe]hrhn_^êrhnZk^k^\ho^kbg`_khfrhnkbgcnkb^l8Ë:m,fhgmalihlm\heeblbhg%+*'1
in the education intervention group reported complete recovery compared with 21.0% in the control group (absolute risk
]bü^k^g\^%)'142.<B6&*-'-mh*/')"':m,fhgmal%
there were no clinically or statistically significant differences
I
a26
|
between groups in severity of remaining symptoms, limitations in daily activities, therapy use, medications used, lost
time from work, or litigation. This study concluded that an
evidence-based educational pamphlet provided to patients at
discharge from the emergency department is no more effective than usual care for patients with grade I or II WAD./)
Cnee ^m Ze99 conducted a preliminary randomized
\hgmkhee^]mkbZepbma0*iZkmb\biZgmlpbmai^klblm^gm
neck pain following a motor vehicle accident to explore whether a multimodal program of physical therapies
was an appropriate management strategy compared to a selfmanagement approach. Participants were randomly allocated
to receive either a multimodal physical therapy program or
a self-management program (advice and exercise). Furthermore, participants were stratified according to the presence
or absence of widespread mechanical or cold hyperalgesia.
The intervention period was 10 weeks and outcomes were assessed immediately following treatment. Even with the pres^g\^ h_ l^glhkr ari^kl^glbmbobmr bg 0+'. h_ ln[c^\ml% [hma
groups reported some relief of neck pain and disability, measured using Neck Disability Index scores, and it was superior
in the group receiving multimodal physical therapy (P=.04).
However, the overall effects of both programs were mitigated
in the group presenting with both widespread mechanical
and cold hyperalgesia. Further research aimed at testing the
validity of this sub-group observation is warranted. 21
I
A comprehensive review**0 of the available scientific
evidence produced a set of unambiguous patient
centered messages that challenge unhelpful beliefs
about whiplash, promoting an active approach to recovery.
The use of this rigorously developed educational booklet
(The Whiplash Book) was capable of improving beliefs about
whiplash and its management for patients with whiplashassociated disorders.**0
II
BgZlfZee \Zl^l^kb^l% Lh]^keng] Zg]Ebg][^k`*.,
reported that physical therapy integrated with
cognitive behavioral components decreased pain
intensity in problematic daily activities in 3 individuals with
chronic WAD.
IV
Predictors of outcome following whiplash injury
have been limited to socio-demographic and factors of symptom location and severity, which are
not readily amenable to intervention. However, evidence
exists to demonstrate that psychological factors are present soon following injury and play a role in recovery from
whiplash injury.21%*..%*.1 These factors can be as diverse as
the physical presentation and can include affective disturbances, anxiety, depression, and fear of movement.*+,%*,+%*01
Furthermore, post-traumatic stress disorder112 has also been
II
observed in both the acute.+ and chronic conditions and has
been shown to be prognostic.*0* Identifying these factors in
patients may assist in the development of relevant subgroups
and appropriately matched education and counseling strategies that practitioners should utilize in management of patients with WAD.
J78B;*
?cfW_hc[dj#8Wi[Z9Wj[]eho
M_j^?9:#'&7iieY_Wj_edi
Recommendation: To improve the recovery in patients with whiplash-associated disorder, clinicians
should (1) educate the patient that early return to
normal, non-provocative pre-accident activities is important,
and (2) provide reassurance to the patient that good prognosis and full recovery commonly occurs.
A
Neck Pain Impairment/Function-based Diagnosis, Examination and
Intervention Recommended Classification Criteria*
Iocfjeci
?cfW_hc[djie\8eZo<kdYj_ed
?dj[hl[dj_edi
D[YafW_dm_j^ceX_b_joZ[ÓY_j
9[hl_YWb]_W
FW_d_djêhWY_Yif_d[
Kd_bWj[hWbd[YafW_d
D[Yacej_edb_c_jWj_edi
Edi[je\iocfjeci_ie\j[d
b_da[ZjeWh[Y[djkd]kWhZ[Z%
WmamWhZcel[c[djehfei_j_ed
7iieY_Wj[Zh[\[hh[Zkff[h
[njh[c_jofW_dcWoX[fh[i[dj
B_c_j[ZY[hl_YWbhWd][e\cej_ed
D[YafW_dh[fheZkY[ZWj[dZ
hWd][ie\WYj_l[WdZfWii_l[
cej_edi
H[ijh_Yj[ZY[hl_YWbWdZjêhWY_Y
i[]c[djWbceX_b_jo
D[YaWdZd[Ya#h[bWj[Zkff[h
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CLINICAL GUIDELINES
Summary of Recommendations
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Summary of
Recommendations (continued)
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Decades of Beverage Innovation - Fachzeitschrift FLÜSSIGES OBST

the world`s toughest

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Scarica

KJKH - The Association for Perioperative Practice

NEW 500PLAN TPARTY

setting the pace - SLE Lupus Foundation

s associate art director spends three sleepless