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.