Neck Pain

Classification Strategies for Patients with Neck Pain

Neck pain is a common source of pain and disability and is a frequent reason for referral to outpatient physical therapy. Patients with neck pain often cannot be given a structural diagnosis, which makes it difficult for physical therapists to determine which treatments are most likely to benefit an individual patient.

An alternative approach to structural diagnosis is the classification process. Classification seeks to group patients based on clusters of examination findings instead of structural pathology. Each group, or classification, is then associated with a particular management approach that is believed to be most effective for patients in that classification.

An effective classification system would provide a basis for clinical decision-making, and improve clinical research by establishing relevant subgroups of patients. There is presently little information on how patients with neck pain might be classified in a manner that would lead to more effective management.

There is some evidence that patients with neck pain experience smaller improvements with physical therapy than patients with other musculoskeletal conditions. Research has shown improved outcomes for patients with low back pain when treatments are based on a classification method, and therefore the development of a classification system for patients with neck pain may help to improve outcomes in these patients as well.
Dr. Julie Fritz, PhD, PT, ATC heads a team of investigators examining classification strategies for patients with neck pain treated by physical therapists. The overall aim of the research of this team is to examine a classification method for patients with neck pain in physical therapy practice settings. Development of classification systems requires an examination of both the diagnostic tests and measures used by therapists, the outcomes of various interventions, and the identification of examination findings prognostic of success with each of these interventions.

Current Projects

Classification and management of patients with neck pain

This project is a collaborative effort between Dr. Fritz, the University of Utah, the Rehab Agency of Intermountain Health Care, and the Intermountain Research and Medical Foundation (formerly, The Deseret Foundation). This project is a prospective, longitudinal study of patients receiving physical therapy for neck pain at outpatient physical therapy facilities of the Rehab Agency at Intermountain Health Care.

At the initiation of therapy, all patients with a chief complaint of neck pain are evaluated using standard baseline data collection procedures. Patients are followed throughout their physical therapy episode of care. Standardized information regarding interventions and clinical outcomes are collected weekly.

Treatment decision-making is left to the discretion of the physical therapist. Data analysis is focused on examining the baseline examination data for clusters that support the existence of classification categories within the broader group of patients with neck pain. Relationships among baseline classification, interventions and outcomes of care will also be examined.

Identifying patients with neck pain who respond to cervicothoracic manipulation

This project is an effort led by Josh Cleland, DPT, OCS at Franklin Pierce College, Concord, New Hampshire. The goal of this project is to identify a cluster of signs and symptoms that accurately predict which patients with neck pain will experience large reductions in pain and disability with a cervicothoracic manipulation intervention. Patients with a chief complaint of neck pain without signs of radiculopathy are evaluated using a standardized examination.

All patients are then treated with a standardized program of cervicothoracic manipulation and range of motion exercise. Success is determined from patient self-report of improvement. Using univariate significance tests followed by multi-variate regression modeling, the most robust set of predictors of success with manipulation will be identified. The project also examines the inter-rater reliability of commonly-used examination procedures for patients with neck pain.

Collaborators

• • Gerard Brennan, PT, PhD
  • Director of Clinical Quality and Outcomes
  • Intermountain Health Care
  • Salt Lake City, Utah
• • John Childs, PT, PhD, MBA, OCS, FAAOMPT
  • Assistant Professor and Director of Research
  • US Army-Baylor University Doctoral Program in Physical Therapy
  • San Antonio, Texas
• • Josh Cleland, DPT, OCS
  • Assistant Professor
  • Franklin Pierce College
  • Concord, New Hampshire
• • Julie M. Whitman, PT, DSc, OCS, FAAOMPT
  • Assistant Professor
  • Regis University
  • Denver, Colorado

Key Publications

1. Cleland J, Childs JD, Fritz JM. The reliability and construct validity of the neck disability index and patient specific functional scale in patients with cervical radiculopathy. Spine. In press
2. Childs JD, Fritz JM, Piva SR, Whitman JM. Proposal of a classification system for patients with neck pain. J Orthop Sports Phys Ther, 2004;34:686-700.
3. Cleland J, Whitman JM, Fritz JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis. J Orthop Sports Phys Ther 2004;34:713-724.
4. Wainner RM, Fritz JM, Irrgang JJ, Boninger ML, Delitto A. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine, 2003;28;52-62.