Multimodal Management of Mechanical Neck Pain Using a Treatment Based Classification System

The purpose of this case study was twofold: 1) to illustrate the use of a treatment-based classification (TBC) system to direct the early intervention of a patient with mechanical neck pain, and 2) to show the progression of this patient with multimodal-modal intervention. The patient exhibited axial neck pain with referral into her upper extremity. Her pain peripheralized with cervical range of motion and centralized with joint mobilization placing her primarily in the centralization category. Her poor posture and associated muscle weakness along with the chronicity of symptoms placed her secondarily into the exercise and conditioning group resulting in a multi-modal treatment as the patient progressed. Although the design of this case report prevents wide applicability, this study does illustrate the effective use of the TBC system for the cervical spine as captured by accepted outcomes measures.KEYWORDS: Multi-Modal Intervention, Neck Pain, Treatment-Based ClassificationMechanical neck pain commonly arises insidiously¹ and is generally multifactorial in origin, including one or more of the following: poor posture, anxiety, depression, neck strain, and sporting or occupational activities^2,3. In an estimated 50–80% of cases involving back or neck pain, an underlying pathology cannot be definitively determined⁴. Regardless of the primary source of pain, the prognosis for individuals experiencing chronic neck pain is poor, as many patients continue to suffer from persistent pain and disability following conservative physical therapy intervention^5,6. Chronic neck pain appears to be more persistent than low back pain⁷, and it is second only to lumbar pain as the causal factor for time missed from work.Despite the prevalence, less-than optimal prognosis, associated risk of disability, and economic consequences of individuals suffering from mechanical neck pain, there remains a significant gap in the literature, which fails to provide sufficient, high-quality evidence to effectively guide the conservative treatment of this patient population⁸. This lack of quality evidence largely stems from the poorly understood clinical course of neck pain in conjunction with the inconclusive results related to the efficacy of commonly used interventions^2,9,10. Left with poorer quality trials as a guide, Physical Therapists approach the management of this pathology with a plethora of interventions such as manual therapy (MT), therapeutic exercises, manual/mechanical traction, modalities, massage, and functional training^5,10–12.One reason the outcomes in the PT literature may be less than impressive is that many of the studies looking at conservative treatments for the management of neck pain use a heterogeneous subject population¹³. Many studies also combine some or all of the following clinical manifestations into the same case mix during clinical trials: acute whiplash, subacute and chronic mechanical disorders, and chronic cervical headache. The identification of a homogeneous patient population would likely enhance the potential to initiate targeted interventions and to specifically assess treatment responses¹⁴. One solution to acquiring more homogeneous patient populations is the use of treatment-based classification (TBC) systems.Classification systems are developed with the intent of both directing treatment and improving clinical outcomes by identifying detailed combinations of treatments that specifically benefit a subgroup of patients presenting with certain characteristics^5,15. The principle supporting classification systems centers around the following notion: a decrease in uncertainty concerning appropriate, effective treatments could be observed via the linkage of an impairment diagnosis to a treatment choice¹⁶. Classification systems can also serve to improve clinical research by identifying evidence-based practice patterns for specified subgroups of patients⁵. The goal of this model is to heighten decision-making abilities of clinicians in relation to intervention strategy and prognosis¹⁶.While the classification-based strategy has been shown to yield optimal outcomes for the lumbar spine^17–20, comparatively nominal research has been performed to investigate patient outcomes using a similar classification-based approach for the cervical spine^5,16. Despite this preliminary work, research has not served to confirm the validity of such a system⁵. One recent study reported a 98% between-raters percentage agreement with the use of a proposed treatment-based classification (TBC) system (Figure ​(Figure11)⁵. This indicates that the algorithm could be applied consistently by different examiners who are considering the same patient data. With intent to assist in the validation of the outcomes using the aforementioned strategy, the purpose of this case study is to describe the use of a TBC system approach in the management of a single patient with mechanical neck pain and referred pain into the arm.Open in a separate windowFIGURE 1Proposed classification decision-making algorithm.⁵ MVA= motor vehicle accident, NDI = Neck Disability Index. Used with permission.     

Management of Low Back Pain: A Case Series Illustrating the Pragmatic Combination of Treatment- and Mechanism-Based Classification Systems

Abstract

This case series describes the pragmatic use of a treatment-based classification system for the management of four patients with a chief complaint of low back pain. Patients were initially classified into stabilization, manipulation, or specific exercise subgroups based on history and clinical examination. Each patient was reassessed during the course of clinical care to determine whether to continue treating according to the initially assigned subgroup or to alter management and incorporate a mechanism-based classification addressing identified impairments. Patient #1 was initially classified in the manipulation category. Within three visits, he reported being "a great deal better" on the Global Rating of Change (GROC) and had a 6-point improvement in his Oswestry Disability Index (ODI). Patient #2, classified in the specific exercise/extension category, reported being "moderately better" using the GROC and had a 22-point improvement in her ODI within six visits. Patient #3, classified in the stabilization category, reported being "a very great deal better" on the GROC and had a 30-point improvement in his ODI Index within four visits. Patient #4 was categorized initially in the manipulation category and subsequently in the specific exercise category; after five visits, he noted being "quite a bit better" using the GROC and he reported a 58-point improvement on his ODI. All four patients in this study were managed using a dynamic pragmatic treatment-based classification approach that allowed for the change of subgroup classification and treatment of impairments and all achieved a clinically meaningful improvement in pain and disability.     

Use of Multifidus Isometric for a Patient with Acute Neck Pain: A Case Report

Abstract

The purpose of this case report is to describe how a simple isometric technique was effective in treating a patient with complaints of acute neck pain. The patient was a 35-year-old female who complained of an acute onset of right cervical pain. She exhibited a significant increase in range of motion (approximately 50 degrees of right rotation) and a 50% reduction in pain level after one treatment. After two treatments, full pain-free cervical range of motion and function was restored. The report suggests that the technique can significantly increase cervical range of motion and decrease pain in one treatment session. Thrust and nonthrust manipulation techniques have been found to be effective in treating neck pain. Nonthrust techniques, however, appear to lessen the risk to the patient. The multifidus isometric is a safe, nonthrust manual therapy technique that can be effective in reducing pain and increasing range of motion in some cases of acute cervical dysfunction in as little as one treatment session.     

Physical Therapy Exercise Intervention Based on Classification Using the Patient Response Method: A Systematic Review of the Literature

Abstract

It has been suggested that inclusion into a study that categorizes patients in mutually exclusive, clinometric classifications should improve the outcome of an exercise based randomized clinical trial. This review examined the evidence regarding the effectiveness of physical therapist-directed therapeutic exercises when patients were classified using the patient response method. This systematic literature review restricted article inclusion to English-only articles that classified homogenous samples of low back pain patients using the patient response based method, demonstrated physical therapist-directed exercise interventions, and used specific outcome criteria for assessment of patient improvement. The PEDro scale was used to rate the methodological quality of the studies. Of 82 articles reviewed only 5 articles were accepted. All 5 met the PEDro standards for a high-quality study. Of the 5 articles, 4 demonstrated that physical therapy exercise intervention based on the patient response method of classification were significantly better than the pragmatic control comparisons; the remaining article indicated that exercise was less effective than manipulation. There appears to be a trend toward positive outcomes with physical therapy exercise intervention in trials restricted to the patient response method of classification; however, few studies have investigated this phenomenon.     

Biofeedback,Acupuncture and Transcutaneous Electric Nerve Stimulation in the Management of Temperomandibular Disorders: A Systematic Review

Abstract

The aim of this systematic review was to assess the efficacy of biofeedback, acupuncture and transcutaneous electric nerve stimulation in the management of temporomandibular disorders. Articles evaluating the efficacy of biofeedback, acupuncture and transcutaneous electric nerve stimulation in temporomandibular disorders were obtained from the databases Medline, Cinahl, Embase, PsycINFO and Cochrane Controlled Trials register up to May 2002. Seven controlled clinical trials met the criteria for inclusion. The patients included in the studies ranged from 19–100. Three studies assessed the efficacy of biofeedback, three studies assessed the efficacy of acupuncture and one study assessed the efficacy of transcutaneous electric nerve stimulation. A criteria list was used to assess the internal validity of these studies. The studies were considered to be of high quality if at least five of the ten criteria were fulfilled and otherwise were considered to be low quality. The results of the studies were considered positive, negative or indifferent based on the statistical significance of between-group differences. None of the seven studies were of high quality. An analysis of the degree of evidence of the results revealed no evidence for the efficacy of biofeedback, acupuncture or transcutaneous electric nerve stimulation in the management of temporomandibular disorders.     

The reliability of clinical judgments and criteria associated with mechanisms-based classifications of pain in patients with low back pain disorders: a preliminary reliability study

Abstract

Mechanisms-based classifications of pain have been advocated for their potential to aid understanding of clinical presentations of pain and improve clinical outcomes. However, the reliability of mechanisms-based classifications of pain and the clinical criteria upon which such classifications are based are not known. The purpose of this investigation was to assess the inter- and intra-examiner reliability of clinical judgments associated with: (i) mechanisms-based classifications of pain; and (ii) the identification and interpretation of individual symptoms and signs from a Delphi-derived expert consensus list of clinical criteria associated with mechanisms-based classifications of pain in patients with low back (±leg) pain disorders. The inter- and intra-examiner reliability of an examination protocol performed by two physiotherapists on two separate cohorts of 40 patients was assessed. Data were analysed using kappa and percentage of agreement values. Inter- and intra-examiner agreement associated with clinicians' mechanisms-based classifications of low back (±leg) pain was 'substantial' (kappa =0.77; 95% confidence interval (CI): 0.57–0.96; % agreement =87.5) and 'almost perfect' (kappa =0.96; 95% CI: 0.92–1.00; % agreement =92.5), respectively. Sixty-eight and 95% of items on the clinical criteria checklist demonstrated clinically acceptable (kappa ≥ 0.61 or % agreement ≥ 80%) inter- and intra-examiner reliability, respectively. The results of this study provide preliminary evidence supporting the reliability of clinical judgments associated with mechanisms-based classifications of pain in patients with low back (±leg) pain disorders. The reliability of mechanisms-based classifications of pain should be investigated using larger samples of patients and multiple independent examiners.     

Physical Therapy and Manual Physical Therapy for Patients with Non-Specific Low-Back Pain: Differences in Patient Characteristics with Implications for Diagnostic Classification

Abstract

A previous study compared socio-demographic characteristics, health problem characteristics, and primary process data between a database sample of patients referred to physical therapy (PT) versus a sample of patients referred for specific manual physical therapy (MPT) diagnosis and management. This study did not differentiate between patients based on affected body region or diagnosis. The present study is a secondary analysis of these data for patients with non-specific low-back pain (LBP). Statistical analysis indicated that the MPT patient sample was significantly (P<0.01) different from the PT database sample with regard to socio-demographic data: The MPT patients were more often male, younger, had attained a higher level of post-secondary education, and were more often gainfully employed. The MPT sample was also significantly (P<0.01) different from the PT sample with regard to health problem characteristics indicating more often acute, recurrent, non-surgical LBP of shorter duration and unknown etiology in the MPT sample. Both samples were also significantly different with regard to the most common impairments, limitations in activities, and restrictions in participation. After correction for socio-demographic differences, both samples remained significantly different for pathology, recurrence, and mechanism of injury. Diagnosis and management with MPT resulted in a significantly better outcome at discharge than PT as determined by the therapist based on patient verbal report (P=0.0000); however, data on recurrence and the unclear influence of socio-demographic data as well as the absence of more reliable, valid, and responsive outcome measures render these outcome data somewhat equivocal. Interpretation of these data with regard to their potential use in diagnostic classification of patients with non-specific LBP is discussed.     

Effectiveness of manual therapy in the treatment of non-specific neck pain: a review

Abstract

The aim of the current review was to assess the evidence for the effectiveness of cervical spine manipulation and mobilisation in the treatment of non-specific neck pain. A review of the literature was performed in a systematic format, based upon a structured search of six computerised bibliographic databases, together with manual searching of selected journals and reference lists to identify randomised clinical trials (RCTs) researching the effectiveness of manual therapy in the treatment of non-specific neck pain. The methodological quality of the studies was assessed using a set of pre-defined criteria adapted from Koes et al. (Koes BW, Assendelft WJJ, van der Heijden GJMG, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ 1991; 303 :1298–303) and updated in the light of recent literature.

A total of 12 RCTs met the selection criteria. The scores achieved for methodological quality of the studies ranged from 25 points to 67 points out of a possible 100 points. Only four RCTs scored above 50 points: two of these reached a positive conclusion about the effectiveness of spinal manual therapy in the treatment of non-specific neck pain, and two a negative conclusion. Eight RCTs scored below 50 points; six of these reached a positive conclusion and two a negative conclusion.

RCTs researching the effectiveness of manual therapy for non-specific neck pain demonstrate methodological shortcomings in both design and reporting. The effectiveness of spinal manual therapy on non-specific neck pain remains inconclusive. The available evidence favoured spinal manual therapy when it was used in conjunction with exercise, particularly in the treatment of patients with chronic non-specific neck pain. Further, well-designed RCTs are needed to draw valid conclusions about the effectiveness of spinal manual therapy on nonspecific neck pain. In such future RCTs, placebo treatments should be designed to be indistinguishable (as far as possible) from manual therapy, and without the specific effects of active therapy. Furthermore, psychosocial factors should be considered prior to randomisation of patients by using appropriate measures.     

Classification of non-specific low back pain: a review of the literature on classifications systems relevant to physiotherapy

Abstract

A literature search identified eight classification systems that subdivide non-specific low back pain. These eight systems were selected on the basis of the following criteria: they were all developed for the purpose of guiding choice of physiotherapeutic treatments, and they were all based on symptoms and clinical tests. A critical appraisal was performed using a systematic approach including evaluation of validity, reliability, feasibility, and generalizability. None of the classification systems fulfilled all of the requirements and none were considered to have included all relevant categories separated in a way suitable for the purpose. Studies concerning reliability and validity were rarely reported. Generally aspects of validity and reliability were only tested for a few of the criteria used for categorizing patients and construct validity and reliability of the classification systems as a whole were not tested. Future studies ought to focus on the evaluation of existing classification systems and/or the development of new ones, which are capable of meeting basic measurement criteria.     

Thumb Pain in Physiotherapists: Biomechanical Causes of Pain and Alternate Methods of Preventing Distress in Treatment

Abstract

Many therapists have been burdened with the danger of developing trauma of the thumb following continuous mobilizing with the thumb. This paper discusses the anatomical and arthrokinematic implications of using longitudinal pressure through the thumbs in manual therapy. Alternative methods performed not using the thumb in this manner may be of more benefit to the therapist. The use of arthrokinematic principles may assist the therapist to minimize strength of force required to achieve the same results.     

Prolotherapy in the Treatment of Chronic Low Back Pain: A Literature Review

Abstract

Exercise programs are advocated for the treatment of chronic low back pain, but the client often lacks the appropriate ligamentous support that is optimal for an exercise program to be effective. Once injured, ligaments have a limited capacity for recovery and recovery can be related to the degree of ligament injury. Clients that fail to progress adequately with stabilization programs may require further intervention before exercise therapy can achieve optimal results. Prolotherapy is an example of one intervention that may prove beneficial. Prolotherapy is the injection of a proliferant solution into the osseoligamentous junction of the incompetent ligaments in order to induce a healing response that will help strengthen the ligaments and provide more passive support to the joints. A review of the literature is presented that outlines the benefits of prolotherapy in low back pain.     

Evidence-Based Approach to the Physical Therapy Diagnosis and Management of Neck and Upper Extremity Pain using Cervical and Thoracic Spine Thrust Manipulation: A Case Report

Abstract

Neck and upper extremity pain are common medical diagnoses for patients seeking physical therapy care. The purpose of this case report is to describe an evidence-based approach to the physical therapy diagnosis and management of a 46-year-old female reporting insidious onset neck pain and bilateral upper extremity paraesthesiae of two years duration. Evaluation of examination data, based on research data with regard to diagnostic accuracy of the tests and measures used, indicated a diagnosis of cervical radiculopathy. Management was based on a treatment-based classification approach and focused on restoring mobility by way of thrust manipulations directed at the thoracic and cervical spine. At the completion of the physical therapy plan of care (8 visits), the patient rated her perceived improvement on the Global Rating of Change Scale as "a very great deal better." The Numerical Pain Rating Score improved from 6/10 to 0/10. Patient-perceived disability, as measured by the Neck Disability Index, improved from 26% to 0%, and the patient's score on the modified Oswestry Disability Index improved from 30% to 0%. Bilateral upper extremity paraesthesiae also had completely resolved. These clinically meaningful improvements in pain and perceived disability were maintained six weeks after discharge. While a cause-and-effect relationship cannot be inferred from a case report, it is plausible that an orthopaedic manual physical therapy approach in the management of patients with both neck and upper extremity pain may result in decreased pain and improved function. Further clinical trials are needed to test this hypothesis.     

Effectiveness of a Multimodal Treatment Program for Somatoform Pain Disorder

Chronic pain conditions are highly prevalent, with somatoform pain disorder accounting for a large proportion. However, the psychological forms of treatment currently used achieve only small to medium effect sizes. This retrospective study investigated the effectiveness of a 5‐week multimodal pain program for patients with somatoform pain disorder. The diagnosis of somatoform pain disorder was confirmed by a specialist for anesthesiology and pain management and a specialist for psychosomatic medicine. Therapy outcome was evaluated with a Numeric Rating Scale (NRS), the Pain Disability Index (PDI), and the Pain Perception Scale. Within the study sample (n = 100), all parameters showed a significant and clinically relevant improvement at the end of therapy (P values < 0.001). The highest effect sizes (d) were found for reduction in average pain rating (NRS: d = 1.00) and the affective items of the Pain Perception Scale (SES‐A: d = 0.07). The lowest effect sizes were found for improvement of pain‐related disabilities (PDI: d = 0.42) and sensory items of the Pain Perception Scale (SES‐S: d = 0.50). Despite high chronification of pain condition, with average pain duration of greater than 8 years, the multimodal treatment program showed medium to large effect sizes on the outcome of patients with somatoform pain disorder. Compared with previous data with small to moderate effect sizes, a multimodal program seems to be more effective than other interventions to address somatoform pain disorder.     

Manipulation in the Treatment of Acute Low Back Pain

Abstract

Study Design. This prospective research project statistically analyses the difference between two randomized groups of patients, one receiving manipulation plus exercises for acute low back pain of mechanical origin, the other receiving an exercise program alone. Objectives. To determine if orthopaedic manipulation is beneficial in treating acute low back pain of mechanical origin. Summary of Background Data. Orthopaedic manipulative physiotherapists have frequently observed dramatic results including elimination of pain and restoration of pain-free range of movement following manipulation of the acute locked back. Spinal manipulative therapy is a widely used method of treating lower back pain with millions of patient treatments performed each year, the majority in Western societies. Trials have emphasized the immediate and short-term symptomatic relief of low back pain following manipulation; however, the longterm difference in effects between manipulated and control groups has required further evaluation. Methods. A sample of convenience of acute low back pain participants were randomly assigned to two groups. A pre-test/post-test experimental design approach was used with 29 participants. This design included three dependent variables (pain, range of movement, and disability assessment) and one independent variable (15 participants in Group I received an exercise program with manipulation and 14 participants in Group II received an exercise program only). Participants were assessed for pain, range of movement, and disability before treatment. Participants were reassessed weekly for four weeks, then at two months and three months after initiation of treatment. Results. The findings of this study illustrate a statistically significant difference between the two treatments (p = <0.0005). Univariate post hoc tests concluded that the two treatment regimens had significantly different effects at three months on disability (p = 0.001), pain (p = <0.0005), and ROM (p = <0.0005). As well as being statistically significant, the magnitude of the relationships was strong, with 42.8% of the variability attributed to the disability measure, 64.3% of the variability attributed to the pain measure, and 65.9% of the variability attributed to the ROM measure. Conclusion. Patients who receive orthopaedic manipulation with an exercise program for acute low back pain of mechanical origin are likely to improve more than patients who receive an exercise program alone.     

Patients' Perception of Postoperative Pain Management: Validation of the International Pain Outcomes (IPO) Questionnaire

PAIN OUT is a European Commission-funded project aiming at improving postoperative pain management. It combines a registry that can be useful for quality improvement and research using treatment and patient-reported outcome measures. The core of the project is a patient questionnaire—the International Pain Outcomes questionnaire—that comprises key patient-level outcomes of postoperative pain management, including pain intensity, physical and emotional functional interference, side effects, and perceptions of care. Its psychometric quality after translation and adaptation to European patients is the subject of this validation study. The questionnaire was administered to 9,727 patients in 10 languages in 8 European countries and Israel. Construct validity was assessed using factor analysis. Discriminant validity assessment used Mann-Whitney U tests to detect mean group differences between 2 surgical disciplines. Internal consistency reliability was calculated as Cronbach's alpha. Factor analysis resulted in a 3-factor structure explaining 53.6% of variance. Cronbach's alpha at overall scale level was high (.86), and for the 3 subscales was low, moderate, or high (range, .53–.89). Significant mean group differences between general and orthopedic surgery patients confirmed discriminant validity. The psychometric quality of the International Pain Outcomes questionnaire can be regarded as satisfactory.     

Effectiveness of Neural Mobilization in the Treatment of a Patient with Lower Extremity Neurogenic Pain: A Single-Case Design

Abstract

It is postulated that neural tissue mechanosensitivity contributes to symptoms associated with peripheral neurogenic pain disorders. However, there is a paucity of literature regarding the most effective clinical practices for managing pain of peripheral neurogenic origin. As clinical use of neural mobilization continues to flourish in the management of these pain syndromes, it is imperative to document outcomes associated with these techniques. The purpose of this single-case A1-B1-A2-B2 design was to investigate the effectiveness of neural mobilization in the management of a 29-year-old female patient with symptoms suggestive of peripheral neurogenic involvement. The intervention phases (B1 and B2) consisted of neural mobilizations specifically directed at the sciatic continuum. Outcome measures (degrees of hip flexion during the straight-leg-raise and pain) demonstrated both visual improvement and statistically significant improvements following implementation of the neural mobilization techniques. This single-case design provides a measure of scientific support for the use of neural mobilizations with patients presenting with lower extremity neurogenic pain disorders. However, generalizability is poor, and further methodologically sound clinical trials are necessary to investigate the effectiveness of neural mobilization in a larger patient population.     

Use of Anterior Tibial Translation in the Management of Patellofemoral Pain Syndrome in Older Patients: A Case Series

Abstract

The currently most plausible pathophysiologic theory for the etiology of pain in patients with patellofemoral pain syndrome involves abnormal mechanical stress to the patellofemoral joint. At this time, there is no consensus nor is there a sufficient body of research evidence to guide management of patients with patellofemoral pain syndrome. This means that clinicians have to rely to some extent on a mechanism-based approach. Decreased quadriceps flexibility and muscular endurance have been identified as possibly relevant impairments in patients with patellofemoral pain syndrome. Surgical anterior translation of the tibial tuberosity with the Maquet procedure has a proven positive effect on patellofemoral contact forces. This case series studied the effects of a physical therapy management approach that included translating the tibia anteriorly while performing open kinetic chain quadriceps training and manual muscle stretching of the rectus femoris muscle. Outcome measures used included the numeric pain rating scale and goniometric measurement of rectus femoris muscle length in a standardized test position. Anterior tibial translation reduced pain during both interventions and also produced clinically and statistically significant pre- to post-intervention improvements in pain during manual muscle testing and rectus femoris length testing in addition to statistically significant pre- to post-intervention increases in rectus femoris muscle length. The results of this quasi-experimental study indicate the need for future experimental study. Future study should include functional in addition to impairment-based outcome measures, standardization and blinding for the rectus femoris muscle length test (should future researchers chose to again use this outcome measure), a pilot study establishing reliability of outcome measures collected by the therapist, younger subjects, and the collection of longer-term outcome data.