NECK PAIN WITH/WITHOUT HEADACHE

Evidence validates that PTs can help your patients….

WITHOUT NARCOTICS OR SURGERY!

Problem: Neck Pain with/without Headache

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

(Childs et al, 2008)

INTERVENTION

• Manual Therapy for Thoracic and Cervical Spine• Specific Exercise for the Upper Quarter• Intermittent Cervical Traction• Patient Education and Counseling  

INTERVENTION: MANUAL THERAPYThrust and non-thrust techniques at the Thoracic and Cervical Spine1-7

1. Cleland et al. Phys Ther. 2007;87(4):431-440.2. Gonzalez-Iglesias et al.  J Orthop Sports Phys Ther. 2009;39(1):20-27.3. Cleland et al.  Phys Ther.  2010;90(9):1239-1250.4. Lau et al.  Man Ther.  2011;16:141-147.5. Walker et al.  Spine. 2008;33(22):2371-2378.6. Jull et al. Spine. 2002;27(17):1835-1843.7.Childs et al. J Orthop Sports Phys Ther. 2008;38(9):A1-A34 8. Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC. www.evidenceinmotion.com, all rights reserved . 

              

 

 

INTERVENTION: MANUAL THERAPYCervical Spine Mobilization with Upper Limb Neurodynamics Positioning1, 2

 

 

 

 

 

 

 

   

  1. Cleland JA et al. J Orthop Sports Phys Ther. 2005.2. Childs et al. J Orthop Sports Phys Ther. 2008. 

INTERVENTION: SPECIFIC EXERCISE

Deep Neck Flexor Retraining and Endurance1, 2

 

 

 

 

 

 

 

 1. Jull et al. Spine. 2002.2. Childs et al. J Orthop Sports Phys Ther. 2008.3. Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC. www.evidenceinmotion.com, all rights reserved .

INTERVENTION: SPECIFIC EXERCISE

Scapular Stabilizer Strengthening1,2

1. Jull et al. Spine. 2002.2. Childs et al. J Orthop Sports Phys Ther. 2008.3.Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC. www.evidenceinmotion.com, all rights reserved .

INTERVENTION: SPECIFIC EXERCISE

Stretching as indicated1,2

   

1. Jull et al. Spine. 2002.2. Childs et al. J Orthop Sports Phys Ther. 2008.3. Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC. www.evidenceinmotion.com, all rights reserved .

EVIDENCE - MANUAL THERAPY + EXERCISE

A. Manual therapy & exercise - indicated for patients with neck pain, +/- headache, & +/- arm pain. B. Mobilization and/or manipulation and exercise is more effective than either alone. (Level 1 evidence, systematic review, Gross et al. Spine. 2004) 

NNT = 2 with Manual Therapy and Exercise to achieve one additional successful outcome than would have occurred with an alternative treatment approach

A. Walker et al, Spine, 2008 – RCT, MTE vs MIN intervention• Disability, UE pain, & patient perceived recovery significantly better

at 3 week, 6 week, and 1 year follow-up in the MTE group.

B. Bronfort et al, Spine, 2001 – RCT, Manip + low tech TEX, high tech TEX, Manip alone• 1 year follow-up: Manip + low tech TEX group demonstrated

significantly greater satisfaction with care• Pain better in both exercise groups vs. manip alone

EVIDENCE - MANUAL THERAPY + EXERCISELONG-TERM RESULTS

  C. Evans et al, Spine, 2002 – 2 yr f/u of Bronfort et al• Satisfaction maintained @ 2 yrs; Imp pain with both exercise

groups maintained 

EVIDENCE: MANUAL THERAPY + EXERCISEHOVING ET AL, ANN INTERN MED, 2002

A. RCT – Man Ther (no thrust, 6 visits) vs Ex/Stretch (12 visits) vs Meds/Advice (1 visit, more optional)    B. Outcomes @ 7 week follow-up    1. Patient Perceived Recovery (defined a priori)        Man Ther 68%; Ex/Stretching 51%; Meds/Advice 36%    2. Pain - Manual Therapy > Ex/Stretch > Meds/Advice C. Other Noteworthy Items    1. Man Ther & Ex/Stretching took less analgesics    2. Man Ther - missed less work    3. NNT with Manual Therapy is 3 

 

EVIDENCE - MANUAL THERAPY + EXERCISE

A. Korthals-de Bos, BMJ, 2003• Cost effectiveness analysis of Hoving et al RCT• Over 1 yr, patients with neck pain treated with 6 visits

of Manual Physical Therapy and Exercise incurred an average cost of $402, compared to exercise alone ($1,167) or Meds/Advice group ($1241)

COST EFFECTIVENESS

Evidence - Manual Therapy + Exercise Cervicogenic Headache (CGHA)

A. Cervicogenic Headache Criteria - Sjstaad et al, Headache, 1998• Unilateral or unilateral dominant side-consistent headache associated with neck pain

and aggravated by neck postures or movement• Tenderness with palpation in at least one of the upper 3 cervical segments• Headache frequency of at least one per week over a period of 2 months to 10 years

 B. Results of Jull et al, Spine, 2002•  Man Ther & Exercise - most effective in treating CGHA , outcomes lasting up to 1 yr• Patients :less additional care sought, reduction in headache duration, neck pain,

headache intensity, & frequency, reduction on medication intake (93% decrease in MT with Ex,100% decrease in Ex/MT only)

• Average length of headaches was 6.1 years with moderate intensity headaches; Jull et al did not find chronicity to be a prognostic factor

• 10% better chance of having a good to excellent outcome with combined therapies

INTERVENTION: TRACTION

I. Types of traction   A. Manual vs. Mechanical   B. Continuous vs. Intermittent

1. Kisner, 1996.

II. Effects of traction may include:   A. Separation of vertebral bodies   B. Distraction/Gliding of facet joints   C. Widening of the intervertebral foramen   D. Straightening of spinal curves   E. Stretching of spinal musculature

2. Graham N, 2006.

EVIDENCE: TRACTION

A. Mechanical traction for the cervical spine involves a tractive force applied to the neck via a mechanical system    - Intermittent or Continuous

B. Indications: radicular sxs, sx with distraction test, fit CPR by Raney et al

C. Systematic review, mod evidence of benefit for intermittent traction for acute @ chronic neck pain (Level 1 Evidence) (Graham, J Rehabil Med. 2006.)

Evidence: Traction CPR                                                                           Raney et al, Eur Spine J, 2009

A. Developed CPR to determine who would respond to traction1. 68 patients/30 positive outcomes included in analysis

B. 5 variable CPR identified2. Age >553. Positive shoulder abduction test4. Positive ULTT A5. Symptom peripheralization with central posterior–anterior motion

testing at lower cervical (C4–7) spine6. Positive neck distraction test

C. 3/5 variables present= +LR of 4.8

D. 4/5 variables present= +LR of 11.7 and post-test probability of     90.2% of having improvement 

INTERVENTION: PATIENT EDUCATION AND COUNSELING

• Early return to pain-free activity, active role in recovery1  • Yellow Flags - Psychosocial factors that indicate risk for

chronicity, potential work losso Pain Neurophysiology Education in presence of yellow flags2 o Multidisciplinary Approach: Referral to appropriate discipline

(psychologist, vocational specialist, pharmaceutical) as indicated by presence of yellow flags1,3

 

1. Childs et al. J Orthop Sports Phys Ther. 2008.2. Nijs et al.  Man Ther. 2011. Available at: http://www.ncbi.nlm.nih.gov/pubmed/216322733. Sterling M. Man Ther. 2009.

EVIDENCE: PATIENT EDUCATION AND COUNSELINGA. RCT for patients with whiplash

Encouragement to exercise/move vs collar Exercise/move advice - outcomes/ pain vs collar

(Crawford 2004)B. RCT for patients with whiplash

Early PT/education vs collar PT/education - long term outcomes vs collar (Rosenfeld 2003))

- High quality evidence supports manual physical therapy and exercise for neck pain of gradual or sudden onset (ie trauma) that is provoked by movement, +/- associated headaches.

-Send to PT with“Evaluate and Treat” option checked.

-You will receive a copy of your patient’s initial note as well as a copy of the discharge note summarizing their outcome.

REFER: WHO, WHY AND HOW TO REFER

References 

• Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine. 1994;19:1307–1309.• Bronfort G, Evans R, Nelson B, et al.  A randomized clinical trial of exercise and spinal manipulation

for patients with chronic neck pain.  Spine.  2001;26(7):788-799.• Childs JD, Cleland JA, Elliott JM, et al. Neck pain: Clinical practice guidelines linked to the

International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9):A1-A34.

• Cleland JA, Whitman JM, Fritz JM, Palmer JA. Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: a case series. J Orthop Sports Phys Ther. 2005;35(12):802-811.

• Cleland JA, Glynn P, Whitman JM, et al. Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Phys Ther. 2007;87(4):431-440.

• Cleland JA, Mintken PE, Carpenter K, et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi-center randomized clinical trial. Phys Ther. 2010;90(9):1239-1250.

• Cote P, Cassidy JD, Carroll L. The epidemiology of neck pain: what we have learned from our population-based studies. J Can Chiropract Assoc. 2003;47:284–290.

• Crawford et al. Early management and outcome following soft tissue injuries of the neck - a randomised controlled trial. Injury. 2004;35(9):891-5.

• Evans R, Bronfort G, Nelson B, Goldsmith CH.  Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain.  Spine.  2002;27(21):2383-2389.

• Gonzalez-Iglesias J, Fernandez-de-las-Penas C, Cleland JA, Gutierrez-Vega Mdel R. Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial. J Orthop Sports Phys Ther.  2009;39(1):20-7.

• Graham N, Gross AR, Goldsmith C.  Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med 2006;38(3):145-152. 

REFERENCES• Gross AR, et al.  A Cochrane Review of Manipulation and Mobilization for Mechanical Neck

Disorders.  Spine.  2004;29(14):1541-1548.oving JL, Koes BW, de Vet HCW, et al.  Manual therapy, physical therapy, or continued care by general practitioner for patients with neck pain: a randomized controlled trial.  Ann Intern Med.  2002;136:713-722.

• Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002;27(17):1835-1843; discussion 1843.

• Kisner C, Colby LA. The spine: traction procedures. In: Therapeutic exercise: foundations and techniques 3rd edn. Philadelphia: FA Davis Co.; 1996, p. 575-591.

• Korthals-de Bos IBC, Hoving JL, van Tulder MW, et al.  Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial.  BMJ.  2003;326:911.

• Lau HMC, Chiu TTW, Lam TH.  The effectiveness of thoracic manipulation on patients with chronic mechanical neck pain - a randomized controlled trial.  Man Ther.  2011;16:141-147.

• Linton SJ, Hellsing AL, Hallden K. A population-based study of spinal pain among 35-45-year-old individuals. Prevalence, sick leave, and health care use. Spine 1998;23(13):1457-6.

• Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with “unexplained” chronic musculoskeletal pain: Practice guidelines. Man Ther. 2011. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21632273. Accessed August 11, 2011.

• Raney NH, Petersen EJ, Smith TA, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009; 18(3):382.

• Rosenfeld et al. Active intervention in patients with whiplash-associated disorders improves long-term prognosis: a randomized controlled clinical trial. Spine. 2003;28(22):2491-8.

• Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: Diagnostic criteria. Headache. 1998;38:442-445.

 

REFERENCES• Sterling M. Physical and psychological aspects of whiplash: important considerations for primary care

assessment, part 2--case studies. Man Ther. 2009;14(1):e8-12.• Walker MJ, Boyles RE, Young BA, et al.  The effectiveness of manual physical therapy and exercise

for mechanical neck pain.  Spine.  2008;22:2371-2378.• Wright A, Mayer T, Gatchel R. Outcomes of disabling cervical spine disorders in compensation

injuries: a prospective comparison to tertiary rehabilitation response for chronic lumbar disorders. Spine. 1999; 24:178–183.