Neck Pain Revision 2017

Clinical Practice Guidelines
PETER R. BLANPIED, PT, PhD • ANITA R. GROSS, PT, MSc • JAMES M. ELLIOTT, PT, PhD • LAURIE LEE DEVANEY, PT, MSc
DEREK CLEWLEY, DPT • DAVID M. WALTON, PT, PhD • CHERYL SPARKS, PT, PhD • ERIC K. ROBERTSON, PT, DPT
Neck Pain:
Revision 2017
Clinical Practice Guidelines Linked to the
International Classification of Functioning,
Disability and Health From the Orthopaedic Section
of the American Physical Therapy Association
Downloaded from www.jospt.org by 179.81.126.183 on 07/01/17. For personal use only.
J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302
SUMMARY OF RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4
METHODS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A5
J Orthop Sports Phys Ther 2017.47:A1-A83.
CLINICAL GUIDELINES:
Impairment/Function-Based Diagnosis. . . . . . . . . . . . . . . . . . A11
Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A18
Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A25
AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS. . . . . . . A44
REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A45
REVIEWERS: Roy D. Altman, MD • Paul Beattie, PT, PhD • Eugene Boeglin, DPT
Joshua A. Cleland, PT, PhD • John D. Childs, PT, PhD • John DeWitt, DPT • Timothy W. Flynn, PT, PhD
Amanda Ferland, DPT • Sandra Kaplan, PT, PhD • David Killoran, PhD • Leslie Torburn, DPT
For author, coordinator, contributor, and reviewer affiliations, see end of text. ©2017 Orthopaedic Section, American Physical Therapy Association (APTA), Inc, and the
Journal of Orthopaedic & Sports Physical Therapy ®. The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent to the
reproduction and distribution of this guideline for educational purposes. Address correspondence to Brenda Johnson, ICF-Based Clinical Practice Guidelines Coordinator,
Orthopaedic Section, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: icf@orthopt.org
Neck Pain: Clinical Practice Guidelines Revision 2017
Summary of Recommendations*
PATHOANATOMICAL FEATURES/DIFFERENTIAL DIAGNOSIS • Neck pain with headaches (cervicogenic headache)

Clinicians should perform assessments and identify clinical • Neck pain with radiating pain (radicular)
A
findings in patients with neck pain to determine the potential
for the presence of serious pathology (eg, infection, cancer, cardiac INTERVENTIONS: NECK PAIN WITH MOBILITY DEFICITS
involvement, arterial insufficiency, upper cervical ligamentous insuffi- Acute
ciency, unexplained cranial nerve dysfunction or fracture), and refer For patients with acute neck pain with mobility deficits:
for consultation as indicated.
B Clinicians should provide thoracic manipulation, a program
of neck ROM exercises, and scapulothoracic and upper
IMAGING
extremity strengthening to enhance program adherence.
A Clinicians should utilize existing guidelines and appropriate-
ness criteria in clinical decision making regarding referral or Clinicians may provide cervical manipulation and/or
consultation for imaging studies for traumatic and nontraumatic C
mobilization.
neck pain in the acute and chronic stages.
Subacute
EXAMINATION – OUTCOME MEASURES For patients with subacute neck pain with mobility deficits:
Clinicians should use validated self-report questionnaires for B Clinicians should provide neck and shoulder girdle endurance
A
patients with neck pain, to identify a patient’s baseline status exercises.
and to monitor changes relative to pain, function, disability, and psycho-

social functioning. C Clinicians may provide thoracic manipulation and cervical
manipulation and/or mobilization.
EXAMINATION – ACTIVITY LIMITATIONS AND Chronic
PARTICIPATION MEASURES For patients with chronic neck pain with mobility deficits:
F Clinicians should utilize easily reproducible activity limitation Clinicians should provide a multimodal approach of the
and participation restriction measures associated with the B
following:
patient’s neck pain to assess the changes in the patient’s level of
function over the episode of care. • Thoracic manipulation and cervical manipulation or
mobilization
• Mixed exercise for cervical/scapulothoracic regions: neuromus-
EXAMINATION – PHYSICAL IMPAIRMENT MEASURES cular exercise (eg, coordination, proprioception, and postural
When evaluating a patient with neck pain over an episode of training), stretching, strengthening, endurance training, aerobic
B conditioning, and cognitive affective elements
care, clinicians should include assessments of impairments
of body function that can establish baselines, monitor changes over • Dry needling, laser, or intermittent mechanical/manual traction
time, and be helpful in clinical decision making to rule in or rule out
(1) neck pain with mobility deficits, including cervical active range of C Clinicians may provide neck, shoulder girdle, and trunk en-
motion (ROM), the cervical flexion-rotation test, and cervical and durance exercise approaches and patient education and
thoracic segmental mobility tests; (2) neck pain with headache, in- counseling strategies that promote an active lifestyle and address
cluding cervical active ROM, the cervical flexion-rotation test, and cognitive and affective factors.
upper cervical segmental mobility testing; (3) neck pain with radiat-
ing pain, including neurodynamic testing, Spurling’s test, the distrac- INTERVENTIONS: NECK PAIN WITH MOVEMENT
tion test, and the Valsalva test; and (4) neck pain with movement COORDINATION IMPAIRMENTS
coordination impairments, including cranial cervical flexion and neck Acute
flexor muscle endurance tests. Clinicians should include algometric For patients with acute neck pain with movement coordination
assessment of pressure pain threshold for classifying pain. impairments (including WAD):
DIAGNOSIS/CLASSIFICATION B Clinicians should provide the following:

Clinicians should use motion limitations in the cervical and • Education of the patient to
C
upper thoracic regions, presence of cervicogenic headache, - Return to normal, nonprovocative preaccident activities as
history of trauma, and referred or radiating pain into an upper ex- soon as possible
tremity as useful clinical findings for classifying a patient with neck - Minimize use of a cervical collar
pain into the following categories: - Perform postural and mobility exercises to decrease pain and
• Neck pain with mobility deficits increase ROM
• Neck pain with movement coordination impairments (including • Reassurance to the patient that recovery is expected to occur
whiplash-associated disorder [WAD]) within the first 2 to 3 months.
a2 | july 2017 | volume 47 | number 7 | journal of orthopaedic & sports physical therapy
Summary of Recommendations* (continued)
B Clinicians should provide a multimodal intervention ap- C Clinicians may provide C1-2 self-sustained natural apophyseal
proach including manual mobilization techniques plus exer- glide (self-SNAG) exercise.
cise (eg, strengthening, endurance, flexibility, postural, coordination,
aerobic, and functional exercises) for those patients expected to ex- Subacute
perience a moderate to slow recovery with persistent impairments. For patients with subacute neck pain with headache:
B Clinicians should provide cervical manipulation and

C Clinicians may provide the following for patients whose mobilization.
condition is perceived to be at low risk of progressing
toward chronicity: C Clinicians may provide C1-2 self-SNAG exercise.
• A single session consisting of early advice, exercise instruction,
and education Chronic
• A comprehensive exercise program (including strength and/or For patients with chronic neck pain with headache:
endurance with/without coordination exercises)
• Transcutaneous electrical nerve stimulation (TENS) B Clinicians should provide cervical or cervicothoracic manipu-
lation or mobilizations combined with shoulder girdle and
F Clinicians should monitor recovery status in an attempt to neck stretching, strengthening, and endurance exercise.
identify those patients experiencing delayed recovery who
may need more intensive rehabilitation and an early pain education INTERVENTIONS: NECK PAIN WITH RADIATING PAIN
program.
Acute
Chronic For patients with acute neck pain with radiating pain:
For patients with chronic neck pain with movement coordination im- Clinicians may provide mobilizing and stabilizing exercises,
pairments (including WAD): C
laser, and short-term use of a cervical collar.
C Clinicians may provide the following: Chronic
• Patient education and advice focusing on assurance, encouragement, For patients with chronic neck pain with radiating pain:
prognosis, and pain management
B Clinicians should provide mechanical intermittent cervical
• Mobilization combined with an individualized, progressive submax- traction, combined with other interventions such as stretching
imal exercise program including cervicothoracic strengthening, and strengthening exercise plus cervical and thoracic mobilization/
endurance, flexibility, and coordination, using principles of cogni-
manipulation.
tive behavioral therapy
• TENS Clinicians should provide education and counseling to

B
encourage participation in occupational and exercise
INTERVENTIONS: NECK PAIN WITH HEADACHES activities.
Acute
For patients with acute neck pain with headache:
Clinicians should provide supervised instruction in active *These recommendations and clinical practice guidelines are based
B on the scientific literature published prior to August 2016.
mobility exercise.
List of Abbreviations
ACR: American College of Radiology CROM: cervical range of motion
AMSTAR: assessment of multiple systematic CT: computed tomography
reviews GRADE: Grading of Recommendations Assessment,
APTA: American Physical Therapy Association Development and Evaluation
CCFT: cranial cervical flexion test ICC: intraclass correlation coefficient
CCR: Canadian cervical spine rule ICD: International Classification of Diseases and Related
CFRT: cervical flexion-rotation test Health Problems
CI: confidence interval ICF: International Classification of Functioning, Disability
CPG: clinical practice guideline and Health
journal of orthopaedic & sports physical therapy | volume 47 | number 7 | july 2017 | a3
List of Abbreviations (continued)

ICON: International Collaboration on Neck Pain PICOT-SD: population, problem, or patients (P),
IFOMPT: International Federation of Orthopaedic intervention (I), comparison or control (C), outcome (O),
Manipulative Physical Therapists time (T), study design (SD)
JOSPT: Journal of Orthopaedic & Sports Physical Therapy PSFS: Patient-Specific Functional Scale
LOINC: Logical Observation Identifiers Names and Codes RCT: randomized controlled trial
LR: likelihood ratio ROM: range of motion
MDC: minimal detectable change SEM: standard error of measurement
MDT: Mechanical Diagnosis and Therapy SF-36: Medical Outcomes Study 36-Item Short-Form
MRI: magnetic resonance imaging Health Survey
MVC: motor vehicle collision SIGN: Scottish Intercollegiate Guidelines Network
NDI: Neck Disability Index SNAG: sustained natural apophyseal glide
NEXUS: National Emergency X-Radiography Utilization SR: systematic review
Study TENS: transcutaneous electrical nerve stimulation
NSAID: nonsteroidal anti-inflammatory drug VAS: visual analog scale
PAIVM: passive accessory intervertebral motion WAD: whiplash-associated disorder
Introduction
AIM OF THE GUIDELINES • Provide information for patients, payers, and claims re-
The Orthopaedic Section of the American Physical Therapy viewers regarding the practice of orthopaedic physical
Association (APTA) has an ongoing effort to create evidence- therapy for common musculoskeletal conditions
based clinical practice guidelines (CPGs) for orthopaedic • Create a reference publication for orthopaedic physi-
physical therapy evaluation and management of adult pa- cal therapy clinicians, academic instructors, clinical
tients with musculoskeletal impairments described in the instructors, students, interns, residents, and fellows re-
World Health Organization’s International Classification of garding the best current practice of orthopaedic physi-
Functioning, Disability and Health (ICF).242 cal therapy
The purposes of these clinical guidelines are to: STATEMENT OF INTENT

• Describe evidence-based physical therapy practice includ- These guidelines are not intended to be construed or to serve
ing diagnosis, prognosis, intervention, and assessment of as a standard of medical care. Standards of care are deter-
outcome for musculoskeletal disorders commonly man- mined on the basis of all clinical data available for an individ-
aged by orthopaedic physical therapists ual patient and are subject to change as scientific knowledge
• Classify and define common musculoskeletal conditions and technology advance and patterns of care evolve. These
using the World Health Organization’s terminology related parameters of practice should be considered guidelines only.
to impairments of body function and body structure, activ- Adherence to them will not ensure a successful outcome in
ity limitations, and participation restrictions every patient, nor should they be construed as including all
• Identify interventions supported by current best evidence proper methods of care or excluding other acceptable meth-
to address impairments of body function and structure, ods of care aimed at the same results. The ultimate judgment
activity limitations, and participation restrictions associ- regarding a particular clinical procedure or treatment plan
ated with common musculoskeletal conditions must be made based on clinician experience and expertise in
• Identify appropriate outcome measures to assess chang- light of the clinical presentation of the patient, the available
es resulting from physical therapy interventions in body evidence, available diagnostic and treatment options, and the
function and structure as well as in activity and participa- patient’s values, expectations, and preferences. However, we
tion of the individual suggest that significant departures from accepted guidelines
• Provide a description of the practice of orthopaedic physi- should be documented in the patient’s health records at the
cal therapists to policy makers time the relevant clinical decision is made.
Methods
Content experts were appointed by the Orthopaedic Section mentation when creating the final recommendations. The
of the APTA to conduct a review of the literature and to de- potential organizational and implementation barriers in ap-
velop an updated neck pain CPG as indicated by the current plying the recommendations were discussed and consider-
state of the evidence in the field. The aims of the revision ations were folded into the expert opinion section following
were to provide a concise summary of the evidence since each evidence table. The guideline has been piloted among
publication of the original guideline and to develop new rec- end users through International Federation of Orthopaedic
ommendations or revise previously published recommenda- Manipulative Physical Therapists (IFOMPT) member orga-
tions to support evidence-based practice. The authors of this nizations, and through APTA, Inc through a public posting.
guideline revision worked with research librarians possessing
expertise in systematic reviews to perform a systematic search The guideline development group members declared rela-
for concepts associated with neck pain in articles published tionships and developed a conflict management plan that
from 2007 to August 2016 related to classification, exami- included submitting a Conflict of Interest form to the Or-
nation, and intervention strategies for neck pain consistent thopaedic Section, APTA, Inc. Articles that were authored
with previous guideline development methods related to ICF by a group member were assigned to an alternate member
classification.29 Primary electronic search methods were per- for assessment. Partial funding was provided to the CPG
formed using a standard structured approach from January development team for travel and expenses for CPG training
2007 to August 2016 in the following databases: PubMed, and development; the content of this guideline was not in-
fluenced by this funding. The CPG development team main-
Cochrane Library, Web of Science, CINAHL, ProQuest Dis-

tained editorial independence. A list of competing interests,
sertations and Abstracts, PEDro, ProQuest Nursing and Al-
conflicts of interest, and author contributions is available at
lied Health Sources, and Embase, by research librarians. The
www.orthopt.org. Group members believe the guideline pro-
search strategy guided by PICOT-SD (Population, problem,
cess and development of recommendations were free from
or patients [P], Intervention [I], Comparison or control [C],
influence from competing interests and conflicts of interest.
Outcome [O], Time [T], Study design [SD]) was designed
to locate systematic reviews, meta-analyses, or narrative re-
In the Impairment/Function-Based Diagnosis and the
views that addressed 6 clinical areas (classification, examina-
Examination sections, a narrative review is provided with
tion, intervention, harms, prognosis, and outcome measures),
emphasis placed on systematic reviews and meta-analyses
when applicable contrasting with a control or comparison when available. In the Interventions section, only systematic
treatments, and used at least 1 measurement property of an reviews and meta-analyses were considered in this revision.
outcome measure in adult patients with neck pain or mus- When there was a systematic review of reviews, those ap-
culoskeletal neck conditions in primary to tertiary settings praisals were used, and literature was searched for system-
from immediate posttreatment to long-term follow-up. The atic reviews and meta-analyses published since the end date
study designs included reviews on interventions and cohort/ of the published review of reviews. If a systematic review
case-control trials for prognosis, diagnostic, and outcome mea- or meta-analysis published prior to January 2007 and not
surement studies. Secondary reviews were identified through included in the 2008 CPG, or published after August 2016,
several grey literature sources (references within eligible cita- was identified by the authors during writing, then that ar-
tions screened for any additional references, personal files from ticle was also appraised and included using methods similar
the investigative team, and content experts). See APPENDIX A for to those recommended by Robinson et al.173 Articles contrib-
example search strategies and APPENDIX B for example search uting to recommendations were reviewed based on specified
dates and results, available at www.orthopt.org. inclusion and exclusion criteria with the goal of identifying
evidence relevant to physical therapist clinical decision mak-
In addition, the guideline revision team worked with, and ing for adult persons with noncancer (neuromusculoskel-
benefited greatly from, the efforts of members of the Inter- etal) neck pain. The titles and abstracts of each article were
national Collaboration on Neck Pain (ICON), a multidisci- reviewed independently by 2 members of the CPG develop-
plinary group currently producing an extensive review of ment team for inclusion. See APPENDIX C for inclusion and ex-
the literature on neck pain.179 Bridging methods and deci- clusion criteria (available at www.orthopt.org). The full texts
sion rules were guided by recommendations established by were then similarly appraised to obtain the final set of ar-
Whitlock et al237 and Robinson et al.173,174 Additionally, recent ticles for contribution to recommendations. The team leader
publications on the lived experiences of people with neck (P.R.B.) provided the final decision for rare (less than 10)
pain were reviewed126 as part of our deliberations and imple- discrepancies that were not resolved by the review team. The
Methods (continued)
ratings of the primary sources contained in the systematic This guideline was issued in 2017 based on the published
reviews or meta-analyses were used by the team in making literature up to August 26, 2016. This guideline will be con-
recommendations. If the systematic reviews or meta-anal- sidered for review in 2021, or sooner if new evidence becomes
yses did not provide the necessary information (eg, study available. Any updates to the guideline in the interim period
quality,77 participant characteristics, stage of disorder) or will be noted on the Orthopaedic Section of the APTA web-
there were discrepancies between the reviews, the reviewers site (www.orthopt.org).
obtained the information directly from the primary source.
Quality ratings used in the systematic reviews came from a LEVELS OF EVIDENCE
variety of tools (eg, Cochrane Risk of Bias, PEDro). Rating of Since the original neck pain CPG was published in 2008,
the body of evidence came from other tools (eg, Grading of publication of the results of a large number of trials has
Recommendations, Assessment, Development and Evalua- coincided with an increased number of systematic reviews
tion [GRADE], Cochrane Collaboration Back and Neck Re- and reviews of reviews. The current update appraises high-
view Group218), and the CPG team calibrated these ratings level systematic reviews using updated criteria for levels of
into high, moderate, low, and very low quality. Very low- evidence and recommendations consistent with contem-
quality evidence was not considered in this revision. Ratings porary research methodology. The authors encourage the
of systematic reviews came from 2 tools (AMSTAR187 or the reader to note these changes in interpreting the guideline
closely related SIGN185), and these ratings were also cali- recommendations.
brated into high, acceptable, low, and very low categories.

Very low-quality reviews and findings from very low-quality Individual systematic reviews, meta-analyses, and reviews
primary sources were not considered in this revision. See of reviews were graded according to criteria adapted from
APPENDIX D for a flow chart of articles and APPENDIX E for the Centre for Evidence-Based Medicine, Oxford, United
articles included in recommendations (available at www. Kingdom for diagnostic, prospective, and therapeutic studies
orthopt.org). Articles on topics that were not immediately (www.cebm.net). In 4 teams of 2, each reviewer independently
relevant to the development of these recommendations, evaluated the quality of each article using a critical appraisal
such as shockwave therapy or injection, were not subject tool and assigned a level of evidence. A description of the grad-
to the systematic review process and were not included in ing system is provided in TABLE 1. See also APPENDIX F for evi-
the flow chart. dence level criteria details on procedures used for assigning

TABLE 1 Levels of Evidence*
Pathoanatomic/Risk/ Diagnosis/ Prevalence of

Clinical Course/Prognosis/ Diagnostic Condition/ Exam/
Level Intervention/Prevention Differential Diagnosis Accuracy Disorder Outcomes
I • High-quality SR† containing consistent • SR of prospective cohort • SR of high-quality • SR, high-quality • SR of prospec-
findings from multiple high-quality studies diagnostic studies cross-sectional tive cohort
primary sources‡ • High-quality prospective • High-quality studies studies
cohort study§ diagnostic study║ • High-quality • High-quality
with validation cross-sectional prospective
study¶ cohort study
II • High- or acceptable-quality SR contain- • SR of retrospective cohort • SR of exploratory • SR of studies that • SR of
ing mostly consistent findings from study diagnostic studies allows relevant lower-quality
generally high-quality primary sources, • Lower-quality prospective or consecutive estimate prospective
or cohort study cohort studies • Lower-quality cohort studies
• Consistent findings from at least 1 high- • High-quality retrospective • High-quality cross-sectional • Lower-quality
quality large (n>100 in each arm) RCT, cohort study exploratory study prospective
or • Consecutive cohort diagnostic studies cohort study
• Consistent findings from more than 1 • Outcomes study or ecologi- • Consecutive retro-
small, high-quality RCT cal study spective cohort
Table continues on page A7.
Methods (continued)

TABLE 1 Levels of Evidence* (continued)
Pathoanatomic/Risk/ Diagnosis/ Prevalence of

Clinical Course/Prognosis/ Diagnostic Condition/ Exam/
Level Intervention/Prevention Differential Diagnosis Accuracy Disorder Outcomes
III • High- or acceptable-quality SR contain- • Lower-quality retrospective • Lower-quality • Local nonrandom • High-quality
ing mostly consistent findings from cohort study exploratory study cross-section-
moderate primary sources, or • High-quality cross-sectional diagnostic studies al study
• Mostly consistent findings from 1 high- study • Nonconsecutive
quality RCT or more than 1 moderate- • Case-control study retrospective
quality RCT cohort
IV • High- or acceptable-quality SR where • Case series • Case-control ... • Lower-quality
higher-quality primary sources tend to study cross-section-
favor a clear direction, or al study
• Inconsistent findings from case-control
studies or retrospective studies, or
inconsistent findings from RCTs where
the higher-quality trials tend to favor a

clear direction (even when lower-quality
trials favor the opposite), or
• Consensus statements from content
experts
V • Inconsistent evidence drawn from a low- • Individual expert opinion • Individual expert • Individual expert • Individual
rated (score of 5 or below on AMSTAR opinion opinion expert opinion
or SIGN scales) SR that may indicate
the balance of evidence favoring one
direction but with very low confidence,
regardless of the quality of the primary
sources, or
• Case series or individual expert opinion,
or direct or indirect evidence from
physiology, bench research, or
theoretical constructs
Abbreviations: AMSTAR, assessment of multiple systematic reviews; RCT, randomized clinical trial; SIGN, Scottish Intercollegiate Guidelines Network;
SR, systematic review.
*Adapted from Phillips B, Ball C, Sackett D, et al. Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009). Available at: http://
www.cebm.net/index.aspx?o=1025. Accessed August 4, 2009. See also APPENDIX F.
†
SRs were rated using AMSTAR or SIGN criteria, where 8 or higher received a “high,” 6 to 7 received an “acceptable,” 4 to 5 received a “low,” and below 4
received a “ very low” score. Very low–quality reviews were not used.
‡
Quality of the primary sources was calibrated to “high,” “moderate,” “low,” and “very low” levels. Results from very low–quality primary sources were not used.
§
Quality cohort study includes greater than 80% follow-up.
║
High-quality diagnostic study includes consistently applied reference standard and blinding.
¶
High-quality prevalence study is a cross-sectional study that uses a local and current random sample or censuses.
levels of evidence (available at www.orthopt.org). Systematic Weaker diagnostic criteria and reference standards, improp-
review AMSTAR scores are available in APPENDIX G, and arti- er randomization, no blinding, and less than 80% follow-up
cles containing very low-quality primary sources are listed in may add bias and threats to validity.
APPENDIX H (available at www.orthopt.org).
When available, a second factor, the magnitude of effect
The levels of evidence were assigned with alignment to the versus harm, contributed to the recommendation, and was
definitions contained in TABLE 1. characterized according to TABLE 2.
Methods (continued)

TABLE 2 Magnitude of Effect Versus Harm: Grades of Recommendation
Beneficial Effect Neutral Effect Harmful Effect

Strong Weak None Weak Strong
Desirable consequences Desirable consequences Consequences equally Undesirable consequences Undesirable consequences
clearly outweigh undesir- probably outweigh undesir- balanced or uncertain probably outweigh clearly outweigh desirable
able consequences. This able consequences (small (none or small effect, desirable consequences consequences (small
considers the magnitude of to moderate effect, some unclear harms, unclear (probability of harms likely effect, clear probability
effect (none, small, medium, risk of harms, higher burden) outweighs any small-to- of harms or high patient
large), numbers needed to burden) moderate effect, burden burden)
treat, probability of harms, might be high)
resources and patient
burden, etc. A strong grade
requires a medium to large
effect with low risk of harms
and low patient burden

TABLE 3 Method of Assigning Confidence to Recommendations
Grade Strength of Evidence Basis of Strength Assignment

A Strong One or more level I systematic reviews support the recommendation, providing evidence for a
strong magnitude of effect
B Moderate One or more level II systematic reviews or a preponderance of level III systematic reviews or
studies support the recommendation, providing evidence for a mild to moderate magnitude
of effect
C Weak One or more level III systematic reviews or a preponderance of level IV evidence supports the
recommendation, providing minimal evidence of effect
D Conflicting Higher-quality studies conducted on this topic disagree with respect to their conclusions and
effect. The recommendation is based on these conflicting studies
E Theoretical/foundational A preponderance of evidence from animal or cadaver studies, from conceptual models or
evidence principles, or from basic science or bench research supports the recommendation, providing
theoretical/foundational evidence of effect
F Expert opinion Best practice to achieve a beneficial effect and/or minimize a harmful effect, based on the
clinical experience of the guidelines development team
GRADES OF RECOMMENDATION
The strength of the recommendation was graded according TABLE 4 Follow-up Periods
to the confidence in the evidence and the magnitude of effect
as indicated in TABLE 3.
Follow-up Time Interval
Immediate Closest to immediately following intervention
SYMPTOM STAGES AND FOLLOW-UP PERIODS Short term Closest to 1 mo
Following a review of included studies, results were assigned Intermediate term Closest to 6 mo
a stage related to symptom duration: acute (less than 6
Long term Closest to 12 mo or longer
weeks), subacute (6-12 weeks), or chronic (greater than 12
weeks). Time periods for follow-up results were characterized
according to TABLE 4.
Methods (continued)
GUIDELINE REVIEW PROCESS AND VALIDATION gov). The implementation tools planned to be available for
Experts in neck pain reviewed these CPGs’ content and patients, clinicians, educators, payers, policy makers, and
methods for integrity, accuracy, and representation of the researchers, and the associated implementation strategies,
condition. The draft was also reviewed by: (1) representa- are listed in TABLE 5.
tives of member organizations of IFOMPT and members of
the Orthopaedic Section of the APTA, Inc through a public CLASSIFICATION
posting, and (2) a panel of consumer/patient representatives The primary International Classification of Diseases-10
and external stakeholders, such as claims reviewers, medi- (ICD-10) codes and conditions associated with neck pain
cal coding experts, academic educators, clinical educators, include M54.2 Cervicalgia, M54.6 Pain in the thoracic
physician specialists, and researchers. All comments, feed- spine, R51 Cervicogenic headache, M53.0 Cervicocranial
back, and suggestions were considered for revision. Addition- syndrome, M53.1 Cervicobrachial syndrome, M53.2 Spi-
ally, a panel of experts in physical therapy practice guideline nal instability, S13.4 Sprain of ligaments of cervical spine,
methodology annually review the Orthopaedic Section of S13.8 Sprain of joints and ligaments of other parts of neck,
the APTA’s ICF-based Clinical Practice Guidelines Policies M54.1x Dorsalgia with cervical radiculopathy, M47.2x
and provide feedback and comments to the Clinical Practice Cervical spondylosis with radiculopathy, M47.1x Cervical
Guidelines Coordinator and editors to improve the APTA’s spondylosis with myelopathy, M50.x Cervical disc disor-
guidelines development and implementation processes. ders, M62.5 Muscle wasting and atrophy, M79.1 Myalgia,
and M99.01 Segmental and somatic dysfunction.241

DISSEMINATION AND IMPLEMENTATION TOOLS
In addition to publishing these guidelines in the Journal Andelic et al5 linked ICF categories to functional problems
of Orthopaedic & Sports Physical Therapy (JOSPT), these reported on the Patient-Specific Functional Scale (PSFS) by
guidelines will be posted on the CPG areas of both the JOSPT 249 participants with neck pain in Norway. Agreeing with a
and the Orthopaedic Section of the APTA websites for free previous study by Tschiesner et al,210 Andelic et al5 found that
access and will be submitted for posting on the Agency for categories linking to 10% or more functional problems were
Healthcare Research and Quality’s website (www.guideline. labeled as “more frequent” and that those linking to fewer

Planned Strategies and Tools to Support the Dissemination

TABLE 5
and Implementation of This Clinical Practice Guideline
Tool Strategy
“Perspectives for Patients” Patient-oriented guideline summary available on www.jospt.org and
www.orthopt.org
Mobile app of guideline-based exercises for patients/clients and health Marketing and distribution of app using www.orthopt.org and www.
care practitioners jospt.org
Clinician’s quick-reference guide Summary of guideline recommendations available on www.orthopt.org
Read-for-credit continuing education units Continuing education units available for physical therapists and ath-
letic trainers through JOSPT
Educational webinars for health care practitioners Guideline-based instruction available for practitioners on www.orthopt.
org
Mobile and web-based app of guideline for training of health care Marketing and distribution of app using www.orthopt.org and www.
practitioners jospt.org
Physical Therapy National Outcomes Data Registry Support the ongoing usage of data registry for common musculoskel-
etal conditions of the head and neck region
Logical Observation Identifiers Names and Codes mapping Publication of minimal data sets and their corresponding Logical
Observation Identifiers Names and Codes for the head and neck region
on www.orthopt.org
Non-English versions of the guidelines and guideline implementation Development and distribution of translated guidelines and tools to
tools JOSPT’s international partners and global audience via www.jospt.org
Methods (continued)
than 10% were labeled as “less frequent.” The more frequent position, d4158 Maintaining a body position, and d4452
categories of body function to which they were linked includ- Reaching.
ed b134 Sleep functions (27.2%) and b710 Mobility of joint
functions (26.2%). The most frequent categories of activity ICF body structure codes associated with neck pain include
and participation were d850 Remunerative employment s7103 Joints of head and neck, s7104 Muscles of head and
(15%), d640 Doing housework (14%), d920 Recreation neck region, s7105 Ligaments and fascia of head and neck
and leisure activities (13%), and d430 Lifting and carry- region, s76000 Cervical vertebral column, and s1201 Spi-
ing objects (10%).5 nal nerves.
Additional ICF body function codes associated with neck ICF codes can be accessed at http//apps.who.int/classifica-
pain are (1) sensory functions related to pain, and (2) move- tions/icfbrowser/. A comprehensive list of codes was pub-
ment functions related to joint motion and control of volun- lished in the previous guideline.29
tary movements. These body function codes include b28010
Pain in neck and head, b2803 Radiating pain in a derma-
tome, b2804 Radiating pain in a segment or region, b7101 ORGANIZATION OF THE GUIDELINES
Mobility of several joints, and b7601 Control of complex For each topic, the summary recommendation and grade of
voluntary movements. evidence from the 2008 guideline are presented, followed by
a synthesis of the recent literature with the corresponding

Additional ICF activities and participation codes associat- evidence levels. Each topic concludes with the 2017 summary
ed with neck pain include d4108 Changing a basic body recommendation and its updated grade of evidence.
CLINICAL GUIDELINES
Impairment/Function-Based
Diagnosis
PREVALENCE incident cases, multiplied by the average duration of the con-
2008 Summary dition (average number of years that the condition lasts until
Pain and impairment of the neck is common. It is estimated remission or death), multiplied by the disability weight. In
that 22% to 70% of the population will have neck pain some this large study, neck pain ranked 21st overall in global cause
time in their lives.16,18,37,38,57,123,159 In addition, it has been sug- of disability-adjusted life years144 and fourth overall in years
gested that the incidence of neck pain is increasing.153,243 At lived with disability.230 The 2013 data indicated a worsening
any given time, 10% to 20% of the population reports neck problem, with neck pain ranking 19th overall in global cause
problems,16,39,88,215 with 54% of individuals having experi- of disability-adjusted life years.143
enced neck pain within the last 6 months.37 Prevalence of
neck pain increases with age and is most common in women In a systematic review by Haldeman et al,80 preva-
around the fifth decade of life.7,16,40,128,201 I lence depended on the definitions used; for neck
pain, the 1-year prevalence ranged from 30% to 50%
Although the natural history of neck pain appears to be fa- in the general population. For neck pain with associated dis-
vorable,48,99 rates of recurrence and chronicity are high.12,90 ability, the 1-year prevalence ranged from 2% to 11% in the
One study reported that 30% of patients with neck pain will general population, and from 11% to 14% in workers who re-
develop chronic symptoms, with neck pain of greater than 6 ported being limited in their activities because of neck pain.80
months in duration affecting 14% of all individuals who expe-
rience an episode of neck pain.16 Additionally, a recent survey March et al129 reported on neck pain without refer-
demonstrated that 37% of individuals who experience neck
pain will report persistent problems for at least 12 months.39
II ral into the upper limbs that lasted at least 1 day.
The global point prevalence in 2010 was estimated
Five percent of the adult population with neck pain will to be 4.9% (females, 5.8%; males, 4.0%).129
be disabled by the pain, representing a serious health con-
cern.16,97 In a survey of workers with injuries to the neck and Hoy et al91 published a systematic review of epide-
upper extremity, Pransky et al162 reported that 42% missed
more than 1 week of work and 26% experienced recurrence
II miologic studies of activity-limiting neck pain, in-
cluding neck-related upper-limb pain and head and/
within 1 year. The economic burden due to disorders of the or trunk pain lasting at least 1 day. The 1-year incidence of neck
neck is high, and includes costs of treatment, lost wages, and pain was 10.4% to 21.3%. The 1-year remission rate ranged
compensation expenditures.13,168 Neck pain is second only to from 33% to 65%. The 1-year prevalence of neck pain in the
low back pain in annual workers’ compensation costs in the general population was on average 25.8% (range, 4.8%-79.5%),
United States.243 In Sweden, neck and shoulder problems ac- with a point prevalence of 14.4% (range, 0.4%-41.5%).91
count for 18% of all disability payments.153 Jette et al98 report-
ed that individuals with neck pain make up approximately Goode et al67 performed a telephone survey of 141
25% of patients receiving outpatient physical therapy care.
Additionally, patients with neck pain frequently are treated
IV individuals in North Carolina, and found the esti-
mated prevalence of chronic neck pain among non-
with nonsurgical interventions by primary care and physical institutionalized individuals for the state of North Carolina
therapy providers.15,48,99 to be 2.2% (95% confidence interval [CI]: 1.7%, 2.6%). Indi-
viduals with chronic neck pain were largely middle aged
(mean age, 48.9 years) and the majority were females (56%)
EVIDENCE UPDATE and non-Hispanic whites (81%).67
The Global Burden of Disease Injuries and Risk
I Factors 2010 study measured population health
through disability-adjusted life years and years of 2017 SUMMARY
life lived in less than ideal health, measured as years lived Significant variation exists in the definition of neck pain and
with disability. Years lived with disability is the number of the research methods employed within the epidemiological
literature on neck pain. This variation limits the ability to Evidence Update
compare or combine data across studies to arrive at consen- Six systematic reviews addressed the clinical course of neck
sus; however, there is agreement that neck pain is common pain.12,25,26,78,105,165 The reviews commonly included studies us-
and increasing worldwide in both the general population and ing observational research designs in which the type of inter-
in specific subgroups. vention is not controlled; therefore, the individuals included
in these reviews can be assumed to have participated in a
range of interventions, including medical, surgical, physical
RISK FACTORS therapy, and chiropractic treatments, among others. Results
2008 Recommendation of this research can most logically be interpreted as “the av-
Clinicians should consider age greater than 40, coexisting erage rate of recovery—in this cohort—under this clinical
low back pain, a long history of neck pain, cycling as a regu- context.” It is also worth noting that reported outcomes are
lar activity, loss of strength in the hands, worrisome attitude, rarely consistent across studies (eg, pain intensity, self-rated
poor quality of life, and less vitality as predisposing factors disability scale, work status, medication usage232), rendering
for the development of chronic neck pain. (Recommendation meta-synthesis very difficult.
based on moderate evidence.)
In general, the reviews in the field have arrived at a similar
For the purposes of this CPG, the term risk will be reserved conclusion: the clinical course of neck pain is variable and
specifically for risk factors for new onset of neck pain, while not entirely favorable. Kamper et al105 used a meta-analytic
prognosis (discussed below) will refer to the predicted course approach to synthesize recovery data following acute whip-
of the condition after onset. lash-associated disorder (WAD).105 Their results indicate that
recovery is slow when the outcome is pain intensity, requiring
Evidence Update 6 months or more for average pain intensity to achieve the
McLean et al137 conducted a systematic review of risk factors clinically meaningful reduction of 20%. When self-rated dis-
for the onset of new neck pain across different populations. ability was the outcome, recovery fared no better. Standard-
Of 14 independent studies (13 rated high quality), the fol- ized mean scores did not reach 20% improvement over the
lowing risk factors for new-onset neck pain were identified: 12 months for which data were available. A similar conclu-
female sex, older age, high job demands, being an ex-smoker, sion was reached by Hush et al,94 who focused on individuals
low social or work support, and a previous history of neck or with acute idiopathic neck pain, with the additional finding
low back disorders. Paksaichol et al158 conducted a similar that idiopathic neck pain does not resolve further after the
review of 7 independent cohorts (5 rated high quality) fo- first 6.5 weeks.94 Sterling et al194 reported recovery trajecto-
cused on office workers,158 with results indicating that only ries for outcomes of neck disability and posttraumatic stress
the female sex and prior history of neck pain were strong risk following acute traumatic neck pain. Three trajectories were
factors of new-onset neck pain in this population. identified: mild disability/posttraumatic stress (40% to 45%
of individuals), initially moderate improving to mild (39%
2017 Summary to 43% of individuals), and chronic severe problems (16%
Evidence from 2 recent systematic reviews indicates that the to 17% of individuals). For neck disability and posttraumatic
female sex and prior history of neck pain are the strongest stress, recovery appears to happen most rapidly within the
and most consistent risk factors for new-onset neck pain in first 6 to 12 weeks postinjury, with the rate of recovery slow-
office workers and the general population. Older age, high ing considerably after that critical window.194 Casey et al27
job demands, smoking history, low social/work support, and conducted a similar study and again found 3 trajectories
prior history of low back pain may also be risk factors. for outcomes measured using the Functional Rating Index
(low-moderate-severe continued disability for 47%, 31%, and
22% of individuals, respectively), Pain Catastrophizing Scale
CLINICAL COURSE AND PROGNOSIS (55%, 32%, and 13%), and Mental Component Score of the
Clinical Course Medical Outcomes Study 36-Item Short-Form Health Sur-
Risk and prognosis are ideally considered in the context of vey (SF-36) (40%, 42%, and 18%, respectively).27 Casey et
the “natural course” of a condition, assuming no interven- al27 collected data at baseline, 12 months, and 24 months, so
tion, or the “clinical course” a condition can be expected to lacked the precision of the study by Sterling et al194 to iden-
take in response to a specific intervention. Clinical progno- tify important inflection points in recovery, but reported no
sis is based on 2 important pieces of information: what is further recovery between 12 and 24 months.27 The newer
known about the clinical course of the condition, and the data generally appear consistent with earlier reviews from
presence or absence of factors that may lead to deviation the Bone and Joint Decade 2000-2010 Task Force on Neck
from that course. Pain and Its Associated Disorders that approximately 50%
will fully recover within 1 year following WAD.24 It is worth many patients with acute cervical radiculopathy, the clinical
noting that these estimates may be highly dependent on the course appears favorable, with resolution of symptoms occur-
definition of recovery used.232 ring over weeks to months. As described below, monitoring
for worsening of clinical status is advised during nonsurgical
Chronic or insidious neck pain follows a clinical course de- management.
scribed best as “recurrent” or “episodic,”78 suggesting that
complete resolution of such symptoms is the exception rather
than the rule. An early review by Borghouts et al12 reported CLINICAL PROGNOSIS
the median frequency of “general improvement” in people Evidence Update
with nonspecific neck pain to be 47% (range, 37% to 95%, In the context of neck pain, prognostic factors are most
depending on outcome) within 6 months. commonly evaluated in acute trauma-related conditions (eg,
WAD). This is likely due to the ability to identify a clear start
Rao165 reported the results of a knowledge synthesis for cervi- time (time of whiplash injury) for the onset of the condition
cal myelopathy with or without radiculopathy. While much of and offers the potential to quantify the magnitude of the in-
the evidence synthesis came from very early research of the citing event (eg, motor vehicle collision [MVC]). A derived
1950s and 1960s, the most recent evidence regarding cervi- and validated clinical prediction rule for prognosis for in-
cal myelopathy suggested a course of neck pain that could dividuals with WAD exists.170,171 Insidious-onset conditions,
show periods of functional stability (neither decreasing nor such as degenerative disc disease or postural syndromes, of-
increasing) or a gradual worsening. That synthesis found that fer a less accurate onset date or magnitude of event, making
only 18% of individuals report improvements in neck dis- prognostic research more difficult.
ability, while 67% report progressive deterioration over time,
regardless of intervention. Those who underwent surgical Since the Quebec Task Force monograph of 1995,191 several pri-
management showed better outcomes than those managed mary research studies and systematic reviews on the topic of
nonsurgically.165 prognosis following WAD have been published. An overview of
systematic reviews sought to identify consistencies in the pool
Thoomes et al208 reported that little is known about the of literature from January 2000 to March 2012 and quantify
natural course of cervical radiculopathy. They reported on a confidence in the prognostic value of more than 130 different
single 1963 study of 51 patients, reporting that 43% of cases factors.233 The results of that procedure led to high or moder-
had no further symptoms after a few months, with 29% and ate confidence that each of the following were risk factors for
27% having mild and more disabling pain, respectively, at persistent problems when captured in acute or subacute WAD
a follow-up of up to 19 years.121 Across several more recent (less than 6 weeks from injury): (1) high pain intensity, (2) high
studies, Thoomes et al208 reported low-level evidence of a self-reported disability scores (Neck Disability Index [NDI]),
more favorable natural course, with resolution of symptoms (3) high posttraumatic stress symptoms, (4) strong catastrophic
over weeks to months. beliefs, and (5) cold hyperalgesia. In work-related or nonspecific
neck pain, only older age and a prior history of other musculo-
2017 Summary skeletal disorders offered the same level of confidence.
The overall balance of evidence supports a variable view of
the clinical course of neck pain. In acute traumatic condi- Factors that were not supported as useful for establishing a
tions, clinicians can expect individuals to follow 1 of 3 likely prognosis were: (1) angular deformity of the neck (eg, scolio-
trajectories: mild problems with rapid recovery (approxi- sis, flattened lordosis), (2) impact direction, (3) seating posi-
mately 45% of individuals depending on outcome), moderate tion in the vehicle, (4) awareness of the impending collision,
problems with some but incomplete recovery (approximately (5) having a headrest in place at the time of collision, (6)
40% of individuals), and severe problems with no recovery stationary versus moving when hit, and (7) older age (note
(approximately 15% of individuals). Regardless of the out- the difference between WAD and nonspecific neck pain). For
come, recovery appears to occur most rapidly in the first 6 nonspecific neck pain, a preinjury history of regular physical
to 12 weeks postinjury, with considerable slowing after that activity was not a useful prognostic factor.233
and little recovery after 12 months.194 Less evidence is avail-
able for acute nontraumatic (idiopathic) neck pain, but cli- Walton et al235 used meta-analytic techniques to quantify
nicians can still expect recovery to slow considerably after the prognostic utility of many of these factors as reported
6 to 12 weeks from onset. In chronic conditions, the course in previous primary evidence. Their results are presented in
may be stable or fluctuating, but in most cases can be best TABLE 6 below, and indicate that high pain intensity and high
classified as recurrent, characterized by periods of relative self-reported disability offer the greatest prognostic value.
improvement followed by periods of relative worsening.78 For However, this may simply be a function of research using

TABLE 6 Recommended Tools for Developing a Prognosis
Construct Recommended Tool

High pain intensity Numeric rating scale (0-10): consider score of 6 or greater a useful cut score for prognosis
High self-reported disability Neck Disability Index, original225 or shorter adaptations1: consider greater than 30% as a useful cut
score for prognosis
High pain catastrophizing Pain Catastrophizing Scale198,214: consider score of 20 or greater a useful cut score for prognosis
High acute posttraumatic stress symptoms Impact of Events Scale-Revised: consider score of 33 or greater a useful cut score for prognosis.199
High posttraumatic distress is not uncommon in acute injuries; here, this scale is used to predict
symptom chronicity, not to assess for posttraumatic stress disorder
Cold hyperalgesia The TSA-II – NeuroSensory Analyzer (Medoc Ltd, Ramat Yishai, Israel) is largely considered the
gold standard. However, the cost of such equipment may render it impractical for clinicians. Alter-
natives include the cold pressor task as a test of cold endurance (similar but not identical to cold
pain threshold), use of an ice cube,133,166 or use of cold metal bars
pain and disability as the predicted outcomes, meaning that pain at follow-up, as were lower social support and preference
the predictive value of these factors may be different when for passive coping strategies. Regarding neck pain in workers
the outcome to be predicted is something else, such as work specifically, Carroll et al24 found relatively little evidence upon
status or health care usage.235 which to base prognostic decisions. Workplace decision-mak-
ing capacity (control over work) had a small but significant

Two more narrowly focused systematic reviews in the area association with worse outcomes, and white collar workers
of traumatic neck pain prognosis were published, but not in- generally fared better than their blue collar counterparts, but
cluded in the overviews by Walton et al.235 Goldsmith et al66 the evidence was not strong for either. Poor prior health (lack
reviewed the evidence for cold hyperalgesia as a prognostic of exercise, prior neck pain, prior sick leave) showed some ad-
variable, and found consistent moderate-grade evidence (4 ditional promise as a prognostic factor.24
cohorts) that cold hyperalgesia holds prognostic value. Dae-
nen et al43 conducted a systematic review of cervical motor 2017 Summary
dysfunction as a prognostic variable and found inconclusive Moderate- to high-level evidence indicates that the female sex
results (4 cohorts), preventing endorsement of such tests as and/or prior history of neck pain are consistent risk factors
being prognostic. for new-onset neck pain. Low- to moderate-level evidence sug-
gests that older age, high job demands, being an ex-smoker,
A systematic review by Kelly et al112 explored the readiness low support, and prior history of low back pain may also be
for clinical adoption of 15 formalized prognostic clinical pre- risk factors.
diction rules for early identification of the patient at risk of
transitioning to chronic neck pain. Of those, 11 remained in Moderate- to high-level evidence indicates that clinicians
the derivation stage, lacking external validation. Four had should collect and consider pain intensity, level of self-rated
undergone some degree of external validation, but none were disability, pain-related catastrophizing, posttraumatic stress
at the stage of readiness to be endorsed for widespread clini- symptoms (traumatic onset only), and cold hyperalgesia
cal adoption.112,171 when establishing a prognosis for their patients. These con-
structs and related recommended tools are summarized in
For nontraumatic neck pain, Carroll et al25 reported that be- TABLE 6. Prior health, including regular exercise, neck pain,
tween 50% and 85% of people who experience neck pain will and sick leave, may offer some additional prognostic value,
report neck pain 1 to 5 years later, but it is unclear whether more so in nontraumatic neck pain in the general population
this is persistence of the initiating event, recurrence following or in workers. TABLE 6 offers a list of sample tools that can be
a refractory period, or new-onset neck pain. Older age was a used to capture these variables. For nonspecific neck pain,
consistent but not strong predictor of neck pain at follow-up age and prior history of musculoskeletal problems may offer
after an initial event. Generally, poor physical health showed prognostic value. There is still relatively little guidance re-
moderate association with ongoing neck pain, but this was not garding the combination of risk factors and how those should
a consistent finding. One study even found that regular cycling be interpreted and managed. New research focusing on more
was associated with worse outcomes. Similar to that in WAD, integrated complex models or prediction rules may shed light
poorer psychological health was a consistent predictor of neck on this challenge in the near future.
PATHOANATOMICAL FEATURES/ The 2012 IFOMPT “International Framework for Examina-

DIFFERENTIAL DIAGNOSIS tion of the Cervical Region for potential of Cervical Arterial
2008 Summary Dysfunction prior to Orthopaedic Manual Therapy Inter-
Although the cause of neck pain may be associated with de- vention” provides a decision-making pathway for assess-
generative processes or pathology identified during diagnostic ment of suspected arterial insufficiency and upper cervical
imaging, the tissue that is causing a patient’s neck pain is ligamentous integrity.177 Because clinicians cannot rely on
most often unknown. Thus, clinicians should assess for im- the results of any single test, including imaging,146 the frame-
paired function of muscle, connective, and nerve tissues asso- work provides a tool to guide assessment of both risk fac-
ciated with the identified pathological tissues when a patient tors and clinical presentation, and to make patient-centered,
presents with neck pain. evidence-driven decisions on management. One high-quality
systematic review by Hutting et al95 revealed poor diagnostic
Evidence Update accuracy for all upper cervical ligament integrity tests evalu-
There are numerous anatomical structures in the cervical re- ated. Generally, these tests have sufficient specificity and can
gion that can be sources of nociception, including zygapophy- rule in upper cervical ligamentous insufficiency, but extent
seal joints, vertebrae, muscles, ligaments, neural structures, of sensitivity varied.
and the intervertebral disc.42,115,165,188,239 However, evidence is
lacking to support the hypothesis that these pathoanatomi- The Valsalva maneuver, previously described in the Physical
cal features are a primary source of mechanical neck pain Impairment section of the 2008 neck pain guidelines, may
across the age spectrum in the majority of patients.86 The also be a useful screen for serious intracranial pathology in
source of neck symptoms may on occasion be something patients presenting with headache that worsens with exer-
more serious; therefore, screening for clinical conditions tion, and may be used to assist in deciding whether referral
such as cervical myelopathy, cervical ligamentous instability, for neuroimaging is appropriate (positive likelihood ratio
fracture, neoplasm, vascular insufficiency, or systemic disease [LR] = 2.3; 95% CI: 1.4, 3.8).47 Clinicians should refer to
is required.80,183,239 the American College of Radiology (ACR) Appropriateness
Criteria guidelines to decide which type of imaging to use.3
Space-occupying lesions (eg, osteophytosis or herniated cer-
vical disc) are commonly associated with cervical spondylotic Clinicians should utilize the Canadian cervical spine rule
myelopathy and central canal stenosis.206 These may be sec- (CCR)32,196,197 and/or the National Emergency X-Radiography
ondary to acquired degenerative processes, and can give rise Utilization Study (NEXUS) criteria85,160 (APPENDIX H) to rule
to signs and symptoms in the neck and/or upper or lower out the need for radiographic study in clinical conditions of
quarter as well as potentially bowel or bladder problems or suspected trauma-related fracture.
neurologic deficits. Congenital narrowing of the spinal canal

may also increase the risk for developing spinal canal stenosis The National Institute for Health and Care Excellence pro-
later in life.106 Magnetic resonance imaging (MRI) is useful duced a guideline that lists signs, symptoms, and conditions
in determining the diagnosis of myelopathy.114 Clinical tests that should be considered when deciding the need for addi-
used in the diagnostic process for cervical myelopathy gener- tional screening in patients who present with a headache in
ally have low sensitivity; therefore, they should not be used addition to neck pain.149
when screening for and diagnosing this condition.35 While
cervical disc herniation and spondylosis are most commonly 2017 Summary
linked to cervical myelopathy, the patient’s ultimate presen- Direct pathoanatomical causes of mechanical neck pain are
tation may reflect pain mechanisms beyond these discrete rarely identifiable. Clinicians should inquire and test for
pathoanatomical findings.2,80,106 clinical findings (red flags) in patients with neck pain to help
determine the potential for the presence of serious pathology,
Little consensus exists on the definition of cervical radicu- such as infection, cancer, and cardiac involvement,65 and the
lopathy related to the exact location, intensity, or duration of need for referral. Clinicians should also be alert for and assess
painful symptoms in patients. Therefore, it is suggested that patients with neck pain for signs and symptoms of serious
pain radiating into the arm coupled with motor, reflex, and/ pathology, including suspected arterial insufficiency, upper
or sensory changes in the upper limb, including paresthesia cervical ligamentous insufficiency, unexplained cranial nerve
or numbness, be considered in making clinical determina- dysfunction, and fracture. Clinicians should utilize existing
tion for cervical radiculopathy.207 Limited evidence suggests guidelines and appropriateness criteria (CCR, NEXUS, and
that neurodynamic testing of the median nerve, but not the ACR recommendations) in clinical decision making regard-
radial nerve, is clinically useful in determining the presence/ ing imaging studies for traumatic and nontraumatic neck
absence of cervical radiculopathy.150 pain in the acute and chronic stages.
2017 Recommendation ultrasonography, CT, and MRI, in patients without neuro-

Clinicians should perform assessments and identify logic insult (or deficits) or other disease processes may not
A clinical findings in patients with neck pain to deter-
mine the potential for the presence of serious pa-
be warranted.147
thology (eg, infection, cancer, cardiac involvement, arterial Following are issues in imaging specific to the subcategories
insufficiency, upper cervical ligamentous insufficiency, unex- of neck pain. Neck pain classification categories are discussed
plained cranial nerve dysfunction, or fracture), and refer for later in these clinical guidelines.
consultation as indicated.
Neck Pain With Mobility Deficits
As this is described in terms of acute or chronic neck pain, in
IMAGING STUDIES the absence of red flag signs, no imaging is indicated.80
As noted in the 2008 CPG, alert and stable adult patients
with cervical pain precipitated by trauma should be classified Neck Pain With Radiating Pain
for risk level based on the CCR197 or the NEXUS criteria69 Patients with normal radiographs and with neurologic signs
(APPENDIX H). The ACR Appropriateness Criteria should also or symptoms should undergo cervical MRI that includes the
be used for suspected spine trauma and chronic neck pain.148 cranial cervical junction and the upper thoracic region. If
According to the CCR, patients are considered high risk if there is a contraindication to the MRI examination such as,
they (1) are greater than 65 years of age, (2) have had a dan- but not limited to, a cardiac pacemaker or severe claustro-
gerous mechanism of injury, or (3) have paresthesias in the phobia, CT myelography with multiplanar reconstruction is
extremities. Those classified as high risk should undergo recommended.3
computed tomography (CT) or cervical radiography. Further-
more, the following low-risk factors indicate that safe cervi- Magnetic resonance imaging is usually the preferred first im-
cal range of motion (ROM) assessment can be done: if the aging modality for patients with nonresolving radiculopathy
patient (1) is able to sit in the emergency department, (2) has or progressing myelopathy. Gadolinium contrast administra-
had a simple rear-end MVC, (3) is ambulatory at any time, tion is preferred when oncological, infectious, inflammatory,
(4) has had a delayed onset of neck pain, or (5) does not have or vascular causes of myelopathy are suspected.148
midline cervical spine tenderness. Finally, if able to actively
rotate the head 45° in each direction, the patient is classified In the case of traumatic myelopathy, the priority is to assess
as low risk. Imaging in the acute stage is not required for mechanical stability of the spine. While radiographs are use-
those who are classified as low risk. ful for this purpose, a higher probability of identifying bony
injury or ligamentous disruption in the cervical spine is real-
The NEXUS low-risk criteria suggest that cervical spine ra- ized with CT.148 Magnetic resonance imaging is usually ap-
diography is indicated for patients with trauma unless they propriate for problem solving or operative planning, and is
meet the following: (1) no posterior midline cervical spine most useful when injury is not explained by bony fracture.3
tenderness; (2) no evidence of intoxication; (3) a normal
level of cognition, orientation, and alertness; (4) no focal Neck Pain With Movement Coordination Impairment
neurologic deficit; and (5) no painful distracting injuries. Johansson et al100 investigated imaging changes in individu-
A recent systematic review suggests that the CCR appears als with acute WAD from an MVC. They assessed whether the
to have better diagnostic accuracy than the NEXUS criteria presence of a cervical spine kyphotic deformity on MRI in the
(APPENDIX H).139 acute stage (approximately 10 days following the MVC) was
associated with greater severity of baseline symptoms and a
While this section focuses on imaging in the adult population, worse 1-year prognosis as compared to lordotic or straight
noteworthy is the paucity of available literature to help guide postures following a whiplash injury. Findings suggest that
decision making for imaging in the pediatric population. Adult kyphotic deformity is not significantly associated with chron-
risk classification features should be applied in children great- ic whiplash-associated pain.
er than 14 years of age. Due to the added radiation exposure of
CT, the ACR recommends plain radiography (3 views) in those High-resolution proton density-weighted MRI has identi-
under 14 years of age, regardless of mental status.148 fied abnormal signal intensity (indicative of tissue damage)
in both the alar and transverse ligaments in some individu-
Guidelines on use of diagnostic imaging in patients with als with chronic WAD.117 Separate studies initially indicated
acute or chronic (traumatic or nontraumatic) neck pain ex- a strong relationship between alar ligament damage, head
ist.148 However, in view of the frequency of abnormal findings, position (turned) at time of impact, and disability levels (as
and the lack of prognostic value,147 routine imaging, such as measured with the NDI).101,102,116 However, a 2011 study by
Vetti et al227 demonstrated that alar and transverse ligament sectional area was believed to represent larger amounts of
signal within 1 year of injury most likely reflected normal fatty infiltrate. Effectively, removal of fat signal from the MRI
variation. More recent evidence suggests that MRI signal measures in these patients revealed that the majority of the
changes of alar and transverse ligaments are not caused by muscles were not larger; rather, they were atrophied when
whiplash injury, and MRI examination of alar and transverse compared with healthy controls and those with idiopathic
ligaments should not be used as the routine workup of pa- neck pain.56 In contrast, others have shown that atrophy of
tients with whiplash injury.122,145,146,228 the neck muscles with MRI is not associated with long-term
functional outcomes.6,131,213
Previous work in chronic WAD from an MVC demonstrated
that female patients (18-45 years of age) with persistent WAD Longitudinal observations (10 years or more) of modic signs
(grade II Quebec Task Force rating: neck pain, tenderness to (degenerative changes of the vertebral bone marrow adjacent
palpation, and limited neck ROM) have increased fat infil- to the end plates) and degenerative changes in the cervical
tration of the neck extensors50 and flexors55 on conventional intervertebral discs are common in patients with WAD. How-
MRI. These changes in muscle structure were significantly ever, they occur with a similar frequency in healthy controls
less in individuals with chronic insidious-onset neck pain or and are not significantly associated with changes in clinical
healthy controls,53 suggesting that traumatic factors may play symptoms, suggesting they may be more the result of the
a role. The differential development of neck muscle fatty infil- physiological aging process rather than pathological findings
trates was observed in individuals with varying levels of func- related to the whiplash injury.96,132
tional recovery following whiplash injury. Findings identified
longitudinal structural muscle pathology with T1-weighted 2017 Summary
MRI. These findings were used to differentiate between Clinicians should utilize existing guidelines and appropri-
those with varying levels of functional recovery, establishing ateness criteria (CCR, NEXUS, and ACR recommendations)
a relationship between muscle fat at 6 months postinjury, in clinical decision making regarding imaging studies for
and initial pain intensity, as well as signs/symptoms of posttraumatic and nontraumatic neck pain in the acute and
traumatic stress disorders. Posttraumatic stress disorders chronic stages. Imaging studies often fail to identify any
have been identified as a strong factor in the prediction of structural pathology related to symptoms in patients with
recovery following whiplash, and these findings were recently whiplash injury. Although MRI can easily visualize ligamen-
replicated in a separate longitudinal study in Australia.52 In tous structures in the upper cervical spine, there is little
a later study, the receiver operating characteristic analysis evidence that MRI examination of alar and transverse liga-
indicated that muscle fat levels of 20.5% or above resulted ments should be used as the routine workup of patients with
in a sensitivity of 87.5% and a specificity of 92.9% for pre- whiplash injury. Evidence is available for changes in muscle
dicting level of recovery at 3 months.54 These results provide morphology; however, more high-quality prospective and
further evidence that muscle degeneration occurs in tandem cross-sectional research is needed to confirm these changes
with known predictive risk factors (older age, pain-related and to identify potential underlying causes and influence
disability, and posttraumatic stress). An independent cross- on recovery rates.46 Magnetic resonance imaging is the
sectional replication study from Sweden suggests similar preferred choice of imaging in painful and traumatic my-
findings.107 The mechanisms by which changes in muscle elopathy. In the absence of neurological signs or symptoms,
structure occur, or respond to rehabilitation strategies, re- patients with normal radiographic findings or evidence of
main largely unknown. spondylosis need no further imaging studies.
There remains uncertainty about whether changes in the 2017 Recommendation

relative cross-sectional area (square millimeters) of the cervi- Clinicians should utilize existing guidelines and ap-
cal paraspinal musculature are related to functional recovery
following whiplash injury. Elliott et al51 observed a consistent
A propriateness criteria in clinical decision making
regarding referral or consultation for imaging stud-
pattern of larger cross-sectional area with MRI in the multifi- ies for traumatic and nontraumatic neck pain in the acute
dus muscles of those with persistent WAD. The larger cross- and chronic stages.
CLINICAL GUIDELINES
Examination
OUTCOME MEASUREMENT et al60 found that the NDI, along with the Neck Bournemouth
2008 Recommendation Questionnaire and the Neck Pain and Disability scale, dem-
Clinicians should use validated self-report ques- onstrated a balanced distribution of items across the ICF
A tionnaires, such as the NDI and the PSFS, for pa-
tients with neck pain. These tools are useful for
components.
identifying a patient’s baseline status relative to pain, func- Fairbairn et al58 used a thematic analysis technique
tion, and disability and for monitoring a change in a patient’s
status throughout the course of treatment.
II to map patient-generated items on the PSFS to ICF
components. From 283 neck-related items on the
PSFS, they classified 29.3% of the items into body functions
Evidence Update and structures, 57.6% of the items into activity, 8.5% into
Outcome tools can be used for at least 3 purposes: (1) evalua- participation, and 4.6% into a combination of activity and
tion (including determining change over time), (2) prognosis, participation.
and (3) diagnosis. Tools for evaluation are addressed below,
tools for prognosis are described in the section on risk, and While not a measure of function, pain has an effect
tools for diagnosis are described in the section on diagnosis. V on function and can be used as an evaluative tool.
Fillingim et al61 recommended assessing 4 compo-

Many patient-reported outcome tools for neck pain nents of pain: (1) pain intensity (eg, numeric pain-rating
II are described in the literature. For the most part,
these are not validated and the measurement prop-
scale84), (2) other perceptual qualities of pain (eg, asking the
patient to describe the character of the pain), (3) bodily dis-
erties of these scales remain uncertain. A notable exception tribution of the pain (eg, by using a body chart), and (4) tem-
is the most commonly used patient-reported functional out- poral features of pain (eg, asking the patient how the pain
come tool, the NDI.127 In a 2012 moderate-quality systematic fluctuates with activity and rest, and over a day, week, or
review of patient-reported outcome measures, Schellinger- month). In some patients, Fillingim et al61 also recommended
hout et al181 focused on 8 different tools. Of these, the NDI considering the use of a mechanism-based approach, such as
was the most extensively studied over a variety of neck pain screening tools for neuropathic pain. Quantitative sensory
conditions and has been translated into many languag- testing, including tuning forks, monofilaments,61 and tools
es.180,181,224 The NDI was also extensively assessed for its psy- for cold hyperalgesia described earlier, also could play a role
chometric properties. Schellingerhout et al181 found the in the assessment of a patient’s pain. Finally, Fillingim et al61
measurement properties of the NDI to be adequate, except recommended that pain assessment be combined with other
for reliability, and provisionally recommended its use. In an domains such as physical and psychosocial functioning. A
earlier low-quality review, Holly et al87 found the NDI, the review by Turk et al212 provides an overview of measures and
PSFS, and the North American Spine Society scale to be reli- procedures to assess a set of key psychosocial and behavioral
able, valid, and responsive for assessing radiculopathy for factors that could be important in chronic pain.
nonsurgical interventions. Further, a high-quality clinical
guideline strongly recommended the use of the NDI, SF-36, 2017 Recommendation
Medical Outcomes Study 12-Item Short-Form Health Survey Clinicians should use validated self-report question-
(SF-12), and visual analog scale (VAS) for assessing treatment
of cervical radiculopathy arising from degenerative disor-
A naires for patients with neck pain, to identify a pa-
tient’s baseline status and to monitor changes relative
ders.11 Other scales, including the modified Prolo, the Modi- to pain, function, disability, and psychosocial functioning.
fied Million Index, the PSFS, the Health Status Questionnaire,
the Sickness Impact Profile, the McGill Pain Scores, and the
Modified Oswestry Disability Index, were rated lower, but ACTIVITY LIMITATION AND PARTICIPATION
were still recommended outcome measures for assessing RESTRICTION MEASURES
treatment of cervical radiculopathy arising from degenerative Evidence Update
disorders. An acceptable-quality review by Horn et al89 found The Spinal Function Sort tool is used to measure a
the PSFS to have greater reliability than the NDI in patients
with cervical dysfunction or cervical radiculopathy. Ferreira
III person’s perceived ability to engage in functional
activities by rating his or her ability on a series of
50 functional tasks graphically depicted and simply de- accessory intervertebral motion (PAIVM) from C0 to C3, and
scribed.130 Each task is rated on a 0-to-4-point scale, yielding the cervical flexion-rotation test (CFRT), and the authors de-
a range of scores from 0 to 200. Although the Spinal Func- termined that all of these tests demonstrated good utility in
tion Sort tool shows promise in predicting return to work in differential diagnosis of headache. The CFRT exhibited the
people with chronic low back pain,14,154 it was not useful in strongest diagnostic metrics; kappa values ranged from 0.67
predicting return to work at follow-up periods longer than 1 to 0.85, and intraclass correlation coefficients (ICCs) were
month in people with subacute WAD.209 0.95 (95% CI: 0.90, 0.98) for CFRT right and 0.97 (95% CI:
0.94, 0.99) for CFRT left. Sensitivity/specificity ranged from
The measures identified in the 2008 neck pain CPG 0.70/0.70 to 0.91/0.91, with positive and negative LRs of 2.3
V continue to be options that a clinician may use to
assess changes in a patient’s level of function over
to 10.65 and 0.095 to 0.43. The authors suggest that given
the high specificity and positive LR, clinicians should use the
an episode of care. In addition, clinicians may ascertain activ- CFRT near the end of the examination to rule in cervicogenic
ity limitations or participation restrictions through a physical headache. Reliability and diagnostic accuracy were also re-
task analysis approach on activities associated with the indi- ported for C0-C3 PAIVM testing in identifying cervicogenic
vidual’s daily living, employment, and leisure pursuits. headache. Kappa values ranged from 0.53 to 0.72, and the
most common symptomatic segment was C1-2. Values for
2008 and 2017 Recommendation sensitivity were between 0.59 and 0.65, specificity between
Clinicians should utilize easily reproducible activ- 0.78 and 0.87, positive LR from 2.9 to 4.9, and negative LR
F ity limitation and participation restriction mea-
sures associated with the patient’s neck pain to
from 0.43 to 0.49. Interestingly, 1 high-quality study in the
review clustered cervical active ROM, PAIVMs, and the cra-
assess the changes in the patient’s level of function over the nial cervical flexion test (CCFT), with a resulting sensitivity
episode of care. of 0.94 and specificity of 1.00.176
A high-quality review by Stanton et al192 examined

PHYSICAL IMPAIRMENT MEASURES
Evidence Update
I evidence of impaired proprioception in individuals
with chronic, idiopathic neck pain and concluded
In a high-quality review, Snodgrass et al189 studied that these individuals are worse than asymptomatic controls
I cervical ROM as an outcome measure following
cervical mobilization/manipulation. Of 36 studies,
at head-to-neutral repositioning tests. However, due to a lack
of studies evaluating the diagnostic accuracy of the reposi-
they found the cervical range of motion (CROM) device (Per- tioning tests, the authors did not draw conclusions about
formance Attainment Associates, Lindstrom, MN), the stan- these measures.192
dard goniometer, and the inclinometer to be the most

commonly used tools to measure cervical ROM. It was sug- In an acceptable-quality systematic review of 7 ar-
gested, based on limited evidence, that cervical ROM assess-
ment was potentially a valuable tool in the screening/
II ticles,217 the interexaminer reliability of determin-
ing passive intervertebral motion of the cervical
diagnostic process related to cervicogenic headache, cervical spine was poor to fair, and assessment of C1-2 and C2-3 mo-
radiculopathy, and cervical spinal injury. tion segments was fair. Reliability tended to be higher (per-
cent agreement ranging from 68% to 90%) when assessed on
In a 2010 acceptable-quality review, Williams et al238 symptomatic versus asymptomatic individuals.
I reviewed 46 articles on reliability and 21 articles on
validity of cervical ROM assessment, finding “good” An acceptable-quality systematic review by Rubin-
reliability and validity for the CROM device, the single incli-
nometer method, and the Spin-T goniometer. However, it
II stein et al175 evaluated the Spurling test, neck dis-
traction test, Valsalva test, shoulder abduction test,
should be noted that 32 of the 46 articles included in this re- and the neurodynamic test [upper-limb tension test] for the
view used asymptomatic individuals; application of these re- median nerve. A positive Spurling test (sensitivity, 0.50;
sults to patients with neck pain should be done cautiously. specificity, 0.86-0.93), traction/neck distraction test (sensi-
tivity, 0.44; specificity, 0.90-0.97), and Valsalva test (sensitiv-
An acceptable-quality review by Rubio-Ochoa et ity, 0.22; specificity, 0.94) may suggest cervical radiculopathy,
I al176 included 9 studies that assessed diagnostic util-
ity of physical examination measures in individuals
while a negative neurodynamic test (sensitivity, 0.17-0.78;
specificity, 0.72-0.83) may rule it out. Caution should be used
with cervicogenic headache compared to asymptomatic con- when considering any of these physical impairment measures
trols or individuals with other headache types. The most independently. Clinicians should look for patterns between
commonly used measures were cervical active ROM, passive patient-reported and physical examination findings that rule
in or rule out a particular diagnostic classification for a • Units of measurement: pressure (eg, N/cm2, psi, or kPa)
patient. • Measurement properties: reference values are established
for patients with acute and chronic neck pain. Lowered
This revision of the neck pain CPGs adds 2 additional physi- values seen locally (about the neck) suggest a local me-
cal impairment measures to the list presented in the 2008 chanical hypersensitivity. Widespread lowered values (eg,
guidelines: the CFRT and algometric assessment of pressure about the neck and lower extremity) raise the possibility
pain threshold. of a central nociceptive processing disorder. Reliability is
excellent for intrarater agreement (ICC2,1 = 0.96; 95% CI:
Cervical Flexion-Rotation Test 0.91, 0.98),236 interrater agreement (0.89; 95% CI: 0.83,
• ICF category: measurement of impairment of body func- 0.93),234,236 and 2- to 4-day test-retest reliability (0.83; 95%
tion; movement of several joints CI: 0.69, 0.91)234
• Description: measurement of passive rotation ROM at the - SEM intrarater, 20.5 kPa; interrater, 50.3 kPa234,236
C1-2 segment - MDC90 intrarater, 47.2 kPa; interrater, 117-156 kPa236,234
• Measurement method: the patient lies supine while the cli-
nician passively flexes the cervical spine maximally to end 2017 Recommendation
range. The clinician then passively rotates the head left and When evaluating a patient with neck pain over an
right. The end ROM in rotation is determined either by pa-
tient report of onset of pain or firm resistance felt by the
B episode of care, clinicians should include assess-
ments of impairments of body function that can
clinician, whichever comes first. The clinician quantifies the establish baselines, monitor changes over time, and be
ROM either by visual estimate or use of the CROM device. helpful in clinical decision making to rule in or rule out (1)
A positive test has been defined as a restriction of rotation neck pain with mobility deficits, including cervical active
ROM with a cutoff of less than 32° of rotation,81,155 or a 10° ROM, the cervical flexion-rotation test, and cervical and
reduction in the visually estimated range to either side.82 thoracic segmental mobility tests; (2) neck pain with head-
• Nature of variable: continuous ache, including cervical active ROM, the cervical flexion-
• Units of measurement: degrees rotation test, and upper cervical segmental mobility
• Measurement properties: mean ROM was 39° to 45° in testing; (3) neck pain with radiating pain, including neu-
healthy individuals and 20° to 28° in patients with cervi- rodynamic testing, Spurling’s test, the distraction test, and
cogenic headache.81,82,155 Reliability was excellent, as indi- the Valsalva test; and (4) neck pain with movement coor-
cated by interrater agreement (κ = 0.81)155 and test-retest dination impairments, including cranial cervical flexion
reliability (ICC2,1 = 0.92).82 The standard error of measure- and neck flexor muscle endurance tests. Clinicians should
ment (SEM) is 2 ° to 3°, with a minimal detectable change include algometric assessment of pressure pain threshold
(MDC90) of 4.7° to 7°.82 for classifying pain.

- Sensitivity, 0.90-0.9581,82,155; negative LR = 0.11-0.2781,155
- Specificity, 0.90-0.9781,82,155; positive LR = 9.0-9.481,155
• Instrument variations: clinicians may use visual estimate DIAGNOSIS/CLASSIFICATION
or goniometry The 2008 neck pain clinical practice guidelines classified
neck pain into 4 categories linked to the treatment-based
Algometric Assessment of Pressure Pain Threshold model proposed by Fritz and Brennan62: (1) neck pain with
• ICF category: measurement of impairment of body func- mobility deficits, (2) neck pain with movement coordination
tion; pain in head and neck impairments, (3) neck pain with headache, (4) neck pain
• Description: measurement of local pressure pain threshold with radiating pain. Classification/diagnostic criteria were
in the upper trapezius described in the 2008 recommendations.
• Measurement method: the patient is seated. A digital pres-
sure algometer is applied perpendicular to the muscle at the Evidence Update
angle of the upper fibers of the trapezius muscle (approxi- In a high-quality systematic review of 5 trials, Ta-
mately 5 to 8 cm superomedial to the superior angle of the
scapula), with pressure increasing at a rate of approximately
II kasaki and May202 compared the effectiveness of the
Mechanical Diagnosis and Therapy (MDT) ap-
4 to 5 N/s (40-50 kPa/s). Patients are instructed to push a proach to other therapeutic approaches or a “wait and see”
button or tell the examiner the precise moment the sensation approach in a wide variety of types of neck pain. Treatments
changes from pressure to pain. The examiner then repeats were provided by therapists who had moderate training in
the test on the opposite side, and 3 tests of each site are con- the MDT approach. Results on pain intensity and function
ducted, with a minimum 30-second interval between tests had wide CIs, and the authors concluded that any benefit
• Nature of variable: continuous from the MDT approach over other therapeutic approaches
or a “wait and see” approach may not be clinically relevant for properly, (2) it must be tested or validated, and (3) it must
pain, and was not clinically relevant for function.202 pass a clinical impact phase.135 The 2008 neck pain CPG de-
scribed clinical prediction rules at the derivation phase for
Bergström et al9 studied the effectiveness of differ- manipulation of the cervical spine,211 for manipulation of the
III ent types of intervention on patients with cervico-
thoracic or low back pain. They classified patients
thoracic spine,31 and for the use of cervical spine traction.164
using the Swedish version of the Multidimensional Pain In- A systematic review by Kelly et al112 explored the
ventory into the following categories: adaptive copers (n =
62), interpersonally distressed (n = 52), and dysfunctional (n
II readiness for adoption of 11 formalized prescriptive
clinical prediction rules in the development or vali-
= 80). The types of intervention were: (1) behavioral-oriented dation stage for early identification of patients response to a
physical therapy for approximately 20 hours per week; (2) certain intervention for neck pain, including the 3 identified
cognitive behavioral therapy for approximately 14 hours per in the 2008 neck pain CPG. The authors concluded none of
week; (3) behavioral medicine rehabilitation, which was a the identified prescriptive clinical prediction rules were at the
combination of the other 2 interventions, for approximately stage of readiness to be endorsed for clinical adoption.112
40 hours per week; and (4) treatment as usual, consisting of
no treatment offered. The outcome measure was sickness ab- 2017 Recommendation
sence measured in days. Overall attendance rate for treat- Clinicians should use motion limitations in the cer-
ment alternatives was 62%. Outcomes indicated that the
multidisciplinary behavioral medicine rehabilitation inter-
C vical and upper thoracic regions, presence of cervi-
cogenic headache, history of trauma, and referred
vention resulted in decreased sickness absence more than or radiating pain into an upper extremity as useful clinical
treatment as usual in the adaptive coper and interpersonally findings for classifying a patient with neck pain into the fol-
distressed groups. lowing categories:

• Neck pain with mobility deficits
In a retrospective analysis, Verhagen et al222 failed • Neck pain with movement coordination impairments
III to find significant differences in outcomes or prog-
nostic factors between nonspecific neck pain asso-
(including WAD)
• Neck pain with headaches (cervicogenic headache)
ciated with traumatic (WAD) and nontraumatic neck pain. • Neck pain with radiating pain (radicular)
Patients with headache were included in both the WAD
(prevalence, 49/63) and nontraumatic (prevalence, 268/395) With recognition that these categories will not be exclusive or
groups. Patients received an individualized, nonstandardized exhaustive, the assignation of an individual patient into the
program, which could include medication, advice, education, category that “best fits” the patient’s current clinical picture
exercises, modalities, and/or manual therapy. Based on non- relies on clinical reasoning and judgment of the clinician.
significant differences in outcomes or prognostic factors, Ver-
hagen et al222 concluded that patients postwhiplash should The proposed model for examination, diagnosis, and treat-
not be considered a separate subgroup from patients with ment planning for patients with neck pain uses the follow-
nontraumatic neck pain. ing components111: (1) evaluation/intervention component 1,
medical screening; (2) evaluation/intervention component
Similar to a previously developed classification sys- 2, classify condition through evaluation of clinical findings
V tem for WAD, Guzman et al78 classified all neck
pain into 4 categories depending on signs, symp-
suggestive of musculoskeletal impairments of body function-
ing (ICF) and associated tissue pathology/disease (ICD); (3)
toms, and the extent of interference with activities of daily evaluation/intervention component 3, determination of con-
living. Currently, this classification system does not have the dition stage (acute/subacute/chronic); (4) evaluation/inter-
level of specificity necessary to guide decisions on choice of vention component 4, intervention strategies for patients
interventions.78 with neck pain. This model is depicted in the FIGURE.
Component 1111
TREATMENT-BASED CLINICAL PREDICTION Medical screening incorporates the findings of the history
RULES FOR NECK PAIN and physical examination to determine whether the patient’s
Clinical prediction rules may prove helpful toward identify- symptoms originate from a condition that requires referral to
ing patients who may respond well to a certain treatment. another health care provider. The 2012 IFOMPT International
However, clinical prediction rules must go through a 3-step Framework for Examination of the Cervical Region, the CCR,
validation process before a clinician can use them with high and the NEXUS criteria, all discussed earlier, are examples of
confidence in clinical practice: (1) the rule must be derived tools that may be helpful in this decision-making process. In
Evaluation/Intervention Component 1: medical screening
Appropriate for physical therapy Appropriate for physical therapy Not appropriate for physical therapy
evaluation and intervention evaluation and intervention along evaluation and intervention
versus with consultation with another versus
health care provider
Evaluation/Intervention Component 2: classify condition through evaluation of clinical Consultation with appropriate health
findings suggestive of musculoskeletal impairments of body functioning (ICF) and the care provider
associated tissue pathology/disease (ICD)
Neck Pain With Neck Pain With Movement Neck Pain With Headache Neck Pain With Radiating Pain
Mobility Deficits Coordination Impairments (WAD) (Cervicogenic)* (Radicular)
Common symptoms Common symptoms Common symptoms* Common symptoms
• Central and/or unilateral neck • Mechanism of onset linked to • Noncontinuous, unilateral neck • Neck pain with radiating (narrow
pain trauma or whiplash pain and associated (referred) band of lancinating) pain in the
• Limitation in neck motion that • Associated (referred) shoulder headache involved extremity
consistently reproduces girdle or upper extremity pain • Headache is precipitated or • Upper extremity dermatomal
symptoms • Associated varied nonspecific aggravated by neck movements paresthesia or numbness, and
• Associated (referred) shoulder concussive signs and symptoms or sustained positions/postures myotomal muscle weakness
girdle or upper extremity pain • Dizziness/nausea
may be present • Headache, concentration, or Expected exam findings Expected exam findings
memory difficulties; confusion; • Positive cervical flexion- • Neck and neck-related radiating
Expected exam findings hypersensitivity to mechanical, rotation test pain reproduced or relieved with
• Limited cervical ROM thermal, acoustic, odor, or light • Headache reproduced with radiculopathy testing: positive
• Neck pain reproduced at end stimuli; heightened affective provocation of the involved test cluster includes upper-limb
ranges of active and passive distress upper cervical segments nerve mobility, Spurling’s test,
motions • Limited cervical ROM cervical distraction, cervical
• Restricted cervical and thoracic Expected exam findings • Restricted upper cervical ROM
segmental mobility • Positive cranial cervical flexion segmental mobility • May have upper extremity
• Intersegmental mobility testing test • Strength, endurance, and sensory, strength, or reflex
reveals characteristic restriction • Positive neck flexor muscle coordination deficits of the neck deficits associated with the
• Neck and referred pain endurance test muscles involved nerve roots
reproduced with provocation of • Positive pressure algometry
the involved cervical or upper • Strength and endurance deficits
thoracic segments or cervical of the neck muscles
musculature • Neck pain with mid-range
• Deficits in cervicoscapulotho- motion that worsens with
racic strength and motor control end-range positions
may be present in individuals • Point tenderness may include
with subacute or chronic neck myofascial trigger points
pain • Sensorimotor impairment may
include altered muscle
activation patterns, propriocep-
tive deficit, postural balance or
control
• Neck and referred pain
reproduced by provocation of
the involved cervical segments
Figure continues on page A23.
FIGURE. Proposed model for examination, diagnosis, and treatment planning for patients with neck pain. *Clinicians are encouraged to refer to the International Classification
of Headache Disorders83 for a more inclusive list of headache types/classifications (https://www.ichd-3.org/how-to-use-the-classification/), and to The National Institute for
Health and Care Excellence149 for signs, symptoms, and conditions that should be considered in patients who present with a headache in addition to neck pain.
Evaluation/Intervention Component 3: determination of condition stage (acute/subacute/chronic)
Acute, subacute, and chronic stages are time-based stages helpful in classifying patient conditions. Time-based stages are helpful in making
treatment decisions only in the sense that in the acute phase, the condition is usually highly irritable (pain experienced at rest or with initial to
mid-range spinal movements: before tissue resistance); in the subacute phase, the condition often exhibits moderate irritability (pain
experienced with mid-range motions that worsen with end-range spinal movements: with tissue resistance); and chronic conditions often have
a low degree of irritability (pain that worsens with sustained end-range spinal movements or positions: overpressure into tissue resistance).
There are cases where the alignment of irritability and the duration of symptoms does not match accordingly, requiring clinicians to make
judgments when applying time-based research results on a patient-by-patient basis
Evaluation/Intervention Component 4: intervention strategies for patients with neck pain
Neck Pain With Neck Pain With Movement Neck Pain With Headache Neck Pain With Radiating Pain
Mobility Deficits Coordination Impairments (WAD) (Cervicogenic) (Radicular)
Acute Acute if prognosis is for a quick Acute Acute
• Thoracic manipulation and early recovery • Exercise: C1-2 self-SNAG • Exercise: mobilizing and
• Cervical mobilization or • Education: advice to remain stabilizing elements
manipulation active, act as usual Subacute • Low-level laser
• Cervical ROM, stretching, and • Home exercise: pain-free • Cervical manipulation and • Possible short-term collar use
isometric strengthening exercise cervical ROM and postural mobilization
• Advice to stay active plus home element • Exercise: C1-2 self-SNAG Chronic
cervical ROM and isometric • Monitor for acceptable progress • Combined exercise: stretching
Chronic and strengthening elements plus
exercise • Minimize collar use • Cervical manipulation
• Supervised exercise, including manual therapy for cervical and
Subacute if prognosis is for a • Cervical and thoracic thoracic region: mobilization or
cervicoscapulothoracic and manipulation
upper extremity stretching, prolonged recovery trajectory manipulation

• Education: activation and • Exercise for cervical and • Education counseling to
strengthening, and endurance scapulothoracic region:
training counseling encourage participation in
• Combined exercise: active strengthening and endurance occupational and exercise
• General fitness training (stay exercise with neuromuscular
active) cervical ROM and isometric activity
low-load strengthening plus training, including motor control • Intermittent traction
Subacute manual therapy (cervical and biofeedback elements
• Cervical mobilization or mobilization or manipulation) • Combined manual therapy
manipulation plus physical agents: ice, heat, (mobilization or manipulation)
• Thoracic manipulation TENS plus exercise (stretching,
• Cervicoscapulothoracic • Supervised exercise: active strengthening, and endurance
endurance exercise cervical ROM or stretching, training elements)
strengthening, endurance,
Chronic
neuromuscular exercise
• Thoracic manipulation including postural, coordination,
• Cervical mobilization and stabilization elements
• Combined cervicoscapulotho-
racic exercise plus mobilization Chronic
or manipulation • Education: prognosis,
• Mixed exercise for cervicoscapu- encouragement, reassurance,
lothoracic regions—neuromus- pain management
cular exercise: coordination, • Cervical mobilization plus
proprioception, and postural individualized progressive
training; stretching; strengthen- exercise: low-load cervicoscapu-
ing; endurance training; aerobic lothoracic strengthening,
conditioning; and cognitive endurance, flexibility, functional
affective elements training using cognitive
• Supervised individualized behavioral therapy principles,
exercises vestibular rehabilitation,
• “Stay active” lifestyle eye-head-neck coordination,
approaches and neuromuscular coordination
• Dry needling, low-level laser, elements
pulsed or high-power • TENS
ultrasound, intermittent
mechanical traction, repetitive
brain stimulation, TENS,
electrical muscle stimulation
FIGURE. Proposed model for examination, diagnosis, and treatment planning for patients with neck pain. *Clinicians are encouraged to refer to the International Classification
of Headache Disorders83 for a more inclusive list of headache types/classifications (https://www.ichd-3.org/how-to-use-the-classification/), and to The National Institute for
Health and Care Excellence149 for signs, symptoms, and conditions that should be considered in patients who present with a headache in addition to neck pain.
addition to these conditions, clinicians should screen for the neck pain often exhibit signs and symptoms that fit more
presence of psychosocial issues that may affect prognostica- than 1 classification, and that the most relevant impairments
tion and treatment decision making for rehabilitation. For ex- of body function and the associated intervention strategies
ample, elevated scores on the Impact of Events Scale have been often change during the patient’s episode of care. Thus, con-
associated with other severe symptoms and a longer recovery tinual re-evaluation of the patient’s response to treatment
in individuals with neck pain after whiplash injury.195 Accord- and the patient’s emerging clinical findings is important for
ingly, identifying cognitive behavioral tendencies during the providing the optimal interventions throughout the patient’s
patient’s evaluation can direct the therapist to employ specific episode of care.
patient education strategies to optimize patient outcomes to
physical therapy interventions and potentially provide indica- Component 3111
tions for referring the patient for consultation with another For research purposes, acute, subacute, and chronic stages
medical or mental health practitioner.8 are time-based stages helpful in classifying patient condi-
tions and in making treatment decisions. In part, they de-
Component 2111 fine the stage of healing: in the acute phase, the condition is
Differential evaluation of musculoskeletal clinical findings is usually more irritable; in the subacute phase, the condition
used to determine the most relevant physical impairments often exhibits moderate irritability; chronic conditions often
associated with the patient’s reported activity limitations and have a lower degree of irritability. There are cases where the
medical diagnosis. Clusters of these clinical findings, which alignment of irritability and the duration of symptoms does
commonly coexist in patients, are described as impairment not match, requiring clinicians to make judgments when ap-
patterns in the physical therapy literature4 and for neck pain plying time-based research results on a patient-by-patient
are classified according to the key impairment(s) of body basis. Irritability is a term used by rehabilitation practitio-
function, along with the characteristic and distribution of ners to reflect the tissue’s ability to handle physical stress,142
pain associated with that classification. The ICD-10 and pri- and is presumably related to physical status and the extent
mary and secondary ICF codes associated with neck pain are of inflammatory activity that is present. Assessment of tissue
provided in the 2008 ICF-based neck pain CPG.29 These clas- irritability relies on clinical judgment, and is important for
sifications are useful in determining interventions focused guiding the clinical decisions regarding treatment frequency,
on normalizing the key impairments of body function, which intensity, duration, and type, with the goal of matching the
in turn strive to improve the movement and function of the optimal dosage of treatment to the status of the tissue being
patient and lessen or alleviate pain and/or activity limita- treated. There are other biopsychosocial elements that may
tions. Key clinical findings to differentiate the classifications relate to staging of the condition, including, but not limited
are shown in the FIGURE. In addition, when it comes to neck- to, the level of disability reported by the patient, extent of in-
related headaches, clinicians are encouraged to refer to the terrupted sleep, medication dosage, and activity avoidance.34
International Classification of Headache Disorders83 for a
more inclusive list of headache types/classifications (https:// Component 4
www.ichd-3.org/how-to-use-the-classification/), and to The Interventions are listed by category of neck pain, and ordered
National Institute for Health and Care Excellence149 for ad- by stage (acute/subacute/chronic). Because irritability level
ditional signs, symptoms, and conditions that should be often reflects the tissue’s ability to accept physical stress, clini-
considered in patients who present with a headache in addi- cians should match the most appropriate intervention strate-
tion to neck pain. Overall, classification is critical for match- gies to the irritability level of the patient’s condition.34,45,110,111
ing the intervention strategy that is most likely to provide Additionally, clinicians should attend to influences from psy-
the optimal outcome for a patient’s condition. However, it chosocial86 and altered pain processing elements151 in patients
is important for clinicians to understand that patients with with conditions in all stages of recovery.
CLINICAL GUIDELINES
Interventions
The literature concerning nonsurgical interventions for neck in randomized controlled trials are ostensibly absent. None-
pain rarely describes subject populations with terms synony- theless, clinicians should apply a benefit to harm screening
mous with the 4 categories of the 2008 neck pain CPG29 and protocol, such as the IFOMPT framework for risk assess-
carried forward in this revision. As such, the results of the ment,177 prior to performing any intervention.
literature can rarely be applied exclusively and exhaustively
to these separate categories. Additionally, the evidence is very
weak regarding the differential effectiveness of many inter- NECK PAIN WITH MOBILITY DEFICITS
ventions for neck pain based on subpopulations (eg, age, sex, 2008 Recommendations
ethnicity). Reporting of intervention dosage in terms of in- The intervention literature analyses were not specifically
tensity, duration, and frequency is variable and may not allow aligned to the neck pain categories, but the recommendations
confident translation into practice. One method of arriving were made for cervical mobilization/manipulation, thoracic
at possible intervention dosage is to combine original trial mobilization/manipulation, stretching exercises, and coordi-
dosage descriptions with clinical judgment, including prin- nation, strengthening, and endurance exercises.
ciples of exercise, movement, and pain science, and patient
preferences. Evidence Update
Identified were 43 systematic reviews investigating physical

This CPG attempts to differentiate the effects of interven- therapy interventions on patients who could be classified as
tions as they may be applied to the categories of neck pain. having neck pain with mobility deficits. Levels of evidence
When available, information regarding stage (acute, less than assigned to systematic reviews in this section were assessed
6 weeks; subacute, 6 to 12 weeks; or chronic, greater than 12 according to TABLE 1. Primary sources were generally of high
weeks), comparison group, and follow-up (immediate, within or moderate methodological quality with low risk of bias, but
1 day; short term, closest to 4 weeks; intermediate term, clos- had numbers of participants that were considered small. This
est to 6 months; and long term, closest to 12 months) is pro- resulted in downgrading the strength of the evidence by 1
vided. The concepts of immediate, short, intermediate, and or 2 levels due to imprecision and limited directness (TABLE
long-term follow-up are research-based periods and do not 1).63 TABLE 7 details the levels of evidence of included studies
represent duration of care, but do provide an estimate of the with underpinning evidence statements. Consideration of the
duration of the treatment effects. Similarly, the concepts of trade-offs between desirable and undesirable consequences
acute, subacute, and chronic stages represent unequal peri- (important adverse events) was made. Adverse events or side
ods, and it is acknowledged that the duration of symptoms effects were rarely reported in the studies, and when reported
may be less relevant than the characteristics of the condition were minor, transient, and of short duration. For manual ther-
to a patient’s progression from one stage to the next stage. apy or exercise, the only consistently reported problem was a
mild transient exacerbation of symptoms.36,93 For manipula-
The 2008 intervention recommendations and literature syn- tion, rare but serious adverse events such as stroke or seri-
theses were not specifically aligned to the ICF-based neck ous neurological deficits were not reported in any of the trials.
pain categories, but some guidance in this regard can be Serious but rare adverse events for manipulation are known
gained from TABLE 4 of that document.29 In this revision, the to occur.23 Graham et al68 reported mild adverse events equal
tables presenting the evidence update are organized first by in treatment and placebo groups, including tiredness, nausea,
intervention type (eg, manual therapy, exercise, multimodal, headache, and increased pain following laser treatment.
education, and physical agents), then by stage (eg, acute, sub-
acute, and chronic), and finally by comparison group and ef- The following are expert opinions of the CPG de-
fect (eg, benefit compared to control, benefit compared to
an alternate treatment, no benefit compared to control, and
V velopment group:
• Clinicians should integrate the recommenda-
no benefit compared to an alternate treatment). In general, tions below with consideration of the results of the patient
the interventions described below have a low risk profile for evaluation (eg, physical impairments most related to the
causing adverse events. While major adverse events can and patient’s reported activity limitation or concerns, severity
do occur on a patient-by-patient basis, as evidenced by case and irritability of the condition, patient values and motivat-
reports and medicolegal documents, reports of serious events ing factors).

Intervention Evidence for Neck Pain With Mobility Deficits by
TABLE 7 Intervention Type, Stage, Level of Evidence, Evidence of Benefit
or No Benefit, and Comparison
Manual Therapy
Stage/Level Study Evidence Statement
Acute
III Brown et al21 For patients with acute neck pain with mobility deficits, there was a benefit compared to control for
Cross et al41 using multiple sessions of thoracic manipulation for reducing pain over the immediate and short
Furlan et al64 term.21,41,64,72,92,93,182 This finding was consistent over the intermediate term but the magnitude of effect
Gross et al72 was small for pain, function, and quality of life.72
Huisman et al92
Hurwitz et al93
Scholten-Peeters et al182
IV Coronado et al36 For patients with acute neck pain with mobility deficits, there was a benefit compared to control for
Gross et al73 using 1 to 4 sessions of a single cervical manipulation for reducing pain over the immediate term but
Gross et al72 not short term.36,72,73
IV Gross et al72 For patients with acute and chronic neck pain with mobility deficits, there is conflicting evidence sup-
porting the use of multiple sessions of cervical manipulation as a stand-alone therapy.72
II Clar et al30 For patients with acute and chronic neck pain with mobility deficits, there was no benefit compared
Furlan et al64 to cervical mobilization, in using multiple sessions of cervical manipulation for reducing pain and
Gross et al72 improving function, quality of life, global perceived effect, and patient satisfaction over the immediate,
Hurwitz et al93 short, and intermediate term.30,64,72,93,229
Vincent et al229
III Leaver et al119 For patients with acute to subacute neck pain with mobility deficits, there was a benefit compared to
only using cervical manipulation or only using cervical mobilization, in using combinations of manual
therapies for providing analgesic benefits over the short term.119
III Gross et al72 For patients with acute to subacute neck pain with mobility deficits, there was a benefit compared to
Vincent et al229 varied oral medication combinations (oral analgesic, opioid analgesic, NSAID, muscle relaxant), in
using multiple sessions of cervical manipulation for reducing pain and improving function over the
long term.72,229
IV Furlan et al64 For patients with acute to subacute neck pain with mobility deficits, there was a benefit when compared
Vernon et al226 to control, in using cervical mobilization and ipsilateral, but not contralateral, cervical manipulation
for reducing pain over the immediate term. 64,226
Subacute
IV Furlan et al64 For patients with subacute neck pain with mobility deficits, there was a benefit when compared to
Huisman et al92 control, in using:
Young et al244 • A single session of thoracic manipulation for reducing pain and improving ROM over the short
term92,244
• A single session of thoracic manipulation for reducing disability over the immediate term64
III Cross et al41 For patients with subacute to chronic neck pain with mobility deficits, there was no benefit, when
compared to a control, in using a single session of thoracic manipulation for reducing pain over the
immediate term.41
IV Coronado et al36 For patients with subacute to chronic neck pain with mobility deficits, there was no benefit, when
compared to a control, in using a single session of cervical manipulation for reducing pain over the
immediate term.36
III Leaver et al119 For patients with subacute to chronic neck pain with mobility deficits, there was no benefit in using 2 weeks
of cervical manipulation compared to 2 weeks of cervical mobilization (low velocity, oscillating passive
movements) on improving function or reducing pain, disability, or days to perceived recovery.119
III Hurwitz et al93 For patients with subacute to chronic neck pain with mobility deficits, there was no benefit in using
cervical manipulation alone or with advice and home exercises, compared to cervical mobilization
and strengthening exercises, or instrumented manipulation, for reducing pain and disability over the
short or long term.93
IV Furlan et al64 For patients with subacute to chronic neck pain with mobility deficits, there was no benefit in using
cervical mobilization, when compared to usual care, for reducing pain over the intermediate term.64

or No Benefit, and Comparison (continued)
Manual Therapy
Chronic
III Furlan et al64 For patients with chronic neck pain with mobility deficits, there was a benefit, when compared to a
Gross et al73 control, in using a single session of thoracic manipulation on pain over the immediate term.64,73,93
Hurwitz et al93
IV Cross et al41 For patients with chronic neck pain with mobility deficits, there was a benefit, when compared to a
Damgaard et al 44 control in using
Furlan et al64 • A single session of supine thoracic manipulation on pain over the immediate term41,64,73,92,93,119,182,231
Gross et al73 • 8 sessions of thoracic manipulation, for reducing pain and disability over the immediate and interme-
Huisman et al92 diate term44,92,229
Hurwitz et al93
Leaver et al119
Scholten-Peeters et al182
Vincent et al229
Walser et al231
IV Gross et al72 For patients with chronic neck pain with mobility deficits, there was a benefit in using the following
Young et al244 techniques:

• Upper thoracic manipulation, when compared to cervical manipulation, for reducing pain over the
immediate term244
• 12 sessions over 4 wk of anterior-posterior unilateral accessory movement procedures, when
compared to a rotational or transverse accessory movement procedures, for reducing pain over the
immediate term72
III Furlan et al64 For patients with chronic neck pain with mobility deficits, there was no benefit in using cervical manipu-
Gross et al72 lation, when compared to medication (NSAIDs, Celebrex, Paracetamol) for reducing pain or improving
function over the short term.64,72
IV Gross et al72 For patients with chronic neck pain with mobility deficits, there was no benefit in using cervical mobili-
zation, when compared to exercise, laser, pulsed ultrasound, acupuncture, and massage for reducing
pain, improving function, and improving quality of life over the immediate to intermediate term.72
IV Gross et al72 For patients with chronic neck pain with mobility deficits, there was no benefit in using the following
mobilization techniques:
• Mobilization at the most symptomatic segment when compared to mobilization at a randomly chosen
segment
• Central PA passive accessory movement mobilization technique when compared to random PAs at the
same segment
• Ipsilateral PAs when compared to a randomly selected PAs at the same segment
• Mobilization perpendicular to the facet plane at most symptomatic segment when compared to the
same mobilization 3 levels above, for reducing pain over the immediate term72
Exercise
Acute
III Bertozzi et al10 For patients with acute to chronic neck pain with mobility deficits, there was a benefit, when compared
Gross et al71 to a control, in using scapulothoracic and upper extremity strengthening for reducing pain over the
Kay et al109 short term.10,71,109
III Gross et al71 For patients with acute to chronic neck pain with mobility deficits, there was a benefit, when compared
Kay et al109 to a control, in using the following:
O’Riordan et al157 • Scapulothoracic and upper extremity endurance training for reducing pain over the immediate
Southerst et al190 term71,109,157,247
Zronek et al247 • Stretching exercises plus education for reducing pain and disability and improving quality of life over
the short term190

Exercise
IV Bertozzi et al10 For patients with acute to chronic neck pain with mobility deficits, there was a benefit, when compared
Kay et al109 to a control, in using:
Gross et al71 • General fitness training for reducing pain over the immediate and short term.10,71,109
• Deep neck flexor recruitment combined with upper extremity strengthening/endurance exercises for
reducing pain over the immediate term.71
III Southerst et al190 For patients with acute to subacute neck pain with mobility deficits, there was a benefit in using a home
Zronek et al247 exercise program of daily cervical ROM exercises, education, and advice, when compared to medica-
tion, for reducing pain and disability for the intermediate term.190,247
III Schroeder et al184 For patients with acute neck pain with mobility deficits, there was a benefit in using stretching, strength-
ening, ROM /flexibility, and relaxation exercise, when compared to soft tissue and cervical joint
mobilization plus coordination, stabilization, and postural exercise.184
IV Schroeder et al184 For patients with acute to subacute neck pain with mobility deficits, there was no benefit in using a
Southerst et al190 home exercise program of daily cervical ROM exercises, education, and advice, when compared to
Zronek et al247 cervical and thoracic manipulation, for reducing pain or improving function over the immediate and
long term.184,190,247
Subacute
III Hurwitz et al93 For patients with subacute to chronic neck pain with mobility deficits, there was no benefit in using neck
and shoulder endurance exercises, when compared to neck and shoulder strengthening exercises, for
reducing pain or improving function or global perceived effect over the short and long term.93
Chronic
III Bertozzi et al10 For patients with chronic neck pain with mobility deficits, there was a benefit, when compared to a
Gross et al71 control, in using the following:
Kay et al109 • Neuromuscular exercise (eg, proprioception, eye-head-neck coordination) for reducing pain and
Leaver et al119 improving function over the short term, but not intermediate or long term, and for improving global
Monticone et al141 perceived effect over the intermediate term109,119,141
Nunes and Moita152 • Cervical stretching and strengthening for reducing pain and improving function over the immediate
Southerst et al190 and intermediate term109,190

Verhagen et al221 • Combined cervical and scapulothoracic stretching and strengthening for reducing pain and improving
function over the intermediate and long term.71,109 However, there is conflicting evidence when these
exercises are combined with other elements of exercise152,221
• Deep neck flexor isometric strengthening for reducing pain and disability over the immediate and
short term10
IV Gross et al71 For patients with chronic neck pain with mobility deficits, there was a benefit, when compared to a
Kay et al109 control, in using the following:
Lee et al120 • A combination of stretching, strengthening, endurance training, and balance/coordination exercises
O’Riordan et al157 and aerobic conditioning, with a cognitive/affective component (Qigong) exercise for reducing pain
Southerst et al190 and improving function over the immediate, short, and intermediate terms.71,109,120,190 Conflicting results
reported by Lee et al120 are due to a combination of different primary sources
• Postural and isometric exercise added to the use of a cervical pillow for reducing pain and improving
function over the immediate and short term71,109
• Isometric neck flexion exercise, plus upper extremity strengthening and stretching for reducing pain
and improving function over the immediate term157
• Whole body group exercise of cardiovascular training with coordination and extensibility exercise for
reducing pain over the immediate term109
III Hurwitz et al93 For patients with chronic neck pain with mobility deficits, there was a benefit in using strengthening
exercises alone or in combination with manipulation, when compared to manipulation alone, for
reducing pain and disability over the long term93

Exercise
IV Damgaard et al44 For patients with chronic neck pain with mobility deficits, there was a benefit in using the following:
Haines et al79 • Stretching combined with upper body and neck strengthening on pain, when compared to a program
Kay et al108 of manipulation, massage, and sham micro-current, over the long term125,184,229
Macaulay et al125 • Cervical stretching and strengthening, when compared to Qigong exercise, for improving function over
Monticone et al141 the intermediate term190
Nunes and Moita152 • A 1-year home exercise program of 3 times per week neck flexion endurance exercise, plus upper
O’Riordan et al157 extremity strengthening and stretching, when compared to aerobic exercise, for reducing pain and
Schroeder et al184 improving function and health related quality of life over the immediate term44,157,247
Southerst et al190 • Cervical stretching or strengthening or endurance, when compared to a stress management program,
Verhagen et al221 for reducing pain over the immediate, but not long term152
Vincent et al229 • Supervised exercise programs of neck and upper body strengthening and stretching, when compared
Zronek et al247 to an individualized home exercise program of neck and shoulder mobilization, advice, and education,
for reducing pain and improving global perceived effect over the short and long term44,157,190
• Methods to increase physical activity at work and leisure (eg, bike to work, take stairs, general
strengthening and conditioning exercise, and advice), when compared to specific exercise (eg, pos-
tural exercise, strengthening exercise for neck and shoulder, body awareness training), for reducing
pain over the short term.221 There was no difference for function, or on pain and function over the long
term221
• Deep neck flexor recruitment and strengthening, when compared to infrared radiation and advice, for
reducing pain over the immediate term. There was no effect on function over the immediate term, or
on pain or function over the intermediate term157
• Individualized home exercise programs of stabilization, relaxation, and postural control, compared to
written advice to stay active, for reducing pain and improving function over the intermediate term, but
not over the long term79,108,141,157
• Supervised group yoga, when compared to unsupervised home exercise program of postural exercise
and neck and shoulder stretching and strengthening, for reducing pain and disability over the short
term190
III Bertozzi et al10 For patients with chronic neck pain with mobility deficits, there was no benefit, when compared to a
Gross et al71 control, in using upper extremity and trunk strengthening exercise,10,71,157 and upper extremity stretch-
Leaver et al119 ing and endurance training,71 and aerobic conditioning,119 for reducing pain and improving function
O’Riordan et al157 over the immediate, short, and long term.
IV Bertozzi et al10 For patients with chronic neck pain with mobility deficits, there was no benefit, when compared to a
Kay et al109 • A strengthening component added to a home based stretching program for reducing pain and dis-
Leaver et al119 ability, over the long term157
O’Riordan et al157 • Breathing exercises for reducing pain and improving function and quality of life, over the immediate
term71
• McKenzie stretch/ROM plus dynamic stabilization exercises for reducing pain and disability over the
immediate through long term71,109,119
• Stretching exercise either before or after a manipulation for reducing pain and improving function over
the immediate term71,109
• General endurance, flexibility, coordination, and postural awareness training (Feldenkrais) for reducing
pain over the short and long term10,109
• Combination of strengthening, stretching, endurance, postural, and coordination exercise not specific
to the neck, for reducing pain over the short term10,109
• General strengthening for reducing pain and improving function or quality of life over the long term157

Exercise
IV Gross et al71 For patients with chronic neck pain with mobility deficits, there was no benefit in using:
McCaskey et al134 • Active ROM, stabilization, and postural exercises specific to the neck, when compared to generalized
O’Riordan et al157 exercises to the body, for reducing disability over the short term190
Southerst et al190 • Neck and upper extremity endurance training plus stretching, when compared to aerobic conditioning
plus stretching, for reducing pain and improving function over the immediate term, and for improving
global perceived effect over the long term157
• General endurance, flexibility, coordination, and postural awareness training (Feldenkrais), when com-
pared to physiotherapy intervention (lumbopelvic stabilization, whole body strengthening, coordina-
tion, endurance and flexibility exercise, advice and home exercise program), for reducing pain over the
long term71
• Proprioceptive training, compared to stretching and strengthening exercise on pain and function over
the short term134
• Deep neck flexor training with pressure biofeedback, when compared to strength training of the neck
flexor muscles with weights, for reducing pain and disability over the immediate term157
Multimodal: Exercise and Manual Therapy

Acute No update evidence identified
Subacute No update evidence identified
Chronic
III Gross et al75 For patients with chronic neck pain with mobility deficits, with or without radiating pain, and with or
without headache there was a benefit, compared to control, in using mobilization or manipulation
combined with stretching and strengthening for reducing pain over the short and long term, and func-
tion over the long term.75
III Miller et al140 For patients with chronic neck pain with mobility deficits, there was a benefit in using a combination
of exercise plus manipulation or mobilization, compared to manipulation or mobilization alone, for
reducing pain and improving quality of life over the long term.140
III McCaskey et al134 For patients with chronic neck pain with mobility deficits, there was a benefit in using a multimodal
intervention including proprioceptive elements, compared to no intervention, on reducing pain over
the immediate term.134
Education

Subacute
IV Monticone et al141 For patients with subacute neck pain with mobility deficits, there was a benefit in cognitive behavioral
therapy in reducing pain and improving disability, compared to manipulation and mobilization plus
exercise plus advice over the long term, but the difference was not clinically meaningful.141
Chronic No update evidence identified
Physical Agents


Physical Agents
Chronic
III Cagnie et al22 For patients with chronic neck pain with mobility deficits, there was a benefit, when compared to a
Damgaard et al44 control, in using the following:
Graham et al68 • Dry needling for reducing pain over the immediate113,124 and short22,124 term
Gross et al74 • 830-nm laser for reducing pain and improving function, global perceived effect, and quality of life over
Kadhim-Saleh et al104 the immediate, short, and intermediate terms44,68,74,104
Kietrys et al113 • Pulsed ultrasound for reducing pain, but was inferior to mobilization over the immediate term68
Liu et al124 • Mechanical traction of the intermittent type, but not the continuous type, for reducing pain over the
short term68
• A variety of noninjection inserted needle treatment approaches for reducing pain over the immediate
or short term68
III Graham et al68 For patients with chronic neck pain with mobility deficits, there was a benefit, when compared to a
Nunes and Moita152 • Laser for reducing pain over the immediate74 and short term,74,152, but not over the intermediate
term.152 Gross et al74 reported that the super-pulse type of laser drive technology may improve out-
comes in patients with chronic myofascial pain syndrome

• TENS and repetitive magnetic stimulation for reducing pain over the immediate and short term.68
• TENS combined with infrared, hot pack/exercise, and collar/exercise/analgesic interventions for
reducing pain and disability, and improving function over the immediate and short term68
• Electric muscle stimulation for reducing pain over the intermediate term68
IV Cagnie et al22 For patients with chronic neck pain with mobility deficits, there was a benefit, in using dry needling
when compared to another treatment, over the short term:
• Non–trigger point dry needling on reducing pain and improving function22
• Standard acupuncture on reducing pain and improving function22
III Liu et al124 For patients with chronic neck pain with mobility deficits, there was no benefit, in using dry needling
when compared to wet needling for reducing pain over the immediate or intermediate term. However,
wet needling showed a benefit over dry needling in the short term.124
IV Graham et al68 For patients with chronic neck pain with mobility deficits, there was no benefit, when compared to a
Kroeling et al118 control, in using a static magnetic necklace for reducing pain over the immediate term68,118
IV Cagnie et al22 For patients with chronic neck pain with mobility deficits, there was no benefit, in using dry needling
when compared to another treatment, over the short term:
• Miniscalpel needling on reducing pain22
• Lidocaine injection on reducing pain22
• Lidocaine on reducing pain, but equal in terms of improving quality of life22
• Nonsteroidal anti-inflammatory drugs (NSAID) for quality of life22
IV Liu et al124 For patients with chronic neck pain with mobility deficits, there was no benefit, in using dry needling
when compared to wet needling for reducing pain over the intermediate term124
IV Graham et al68 For patients with chronic neck pain with mobility deficits associated with osteoarthritis, there was
conflicting evidence of benefit, when compared to a control, for using pulsed electromagnetic field for
reducing pain over the immediate term.68
III Ong and Claydon156 For patients with chronic neck pain with mobility deficits, there was no benefit in using dry needling on
myofascial trigger points when compared to lidocaine injections, for reducing pain over the immediate
through intermediate terms, and for improving function over the immediate term.156

Physical Agents
III Graham et al68 For patients with chronic neck pain with mobility deficits, there was no benefit in using the following:
Kietrys et al113 • Dry needling (as long as it elicited a localized twitch response), when compared to lidocaine injection
for reducing pain in the immediate term. However, lidocaine injections were more effective than dry
needling for reducing pain over the short term113
• A hot pack, when compared to mobilization, manipulation, or electric muscle stimulation, for reducing
pain and improving function over the intermediate term68
• Infrared light, when compared to sham TENS, for reducing pain and improving function over the short term68
IV Graham et al68 For patients with chronic neck pain with mobility deficits, there was no benefit in using the following:
Parreira et al161 • Electric muscle stimulation, when compared to manual therapy, TENS, or heat for reducing pain over
the intermediate term68
• Evaporative cooling spray and stretch, when compared to active control, placebo, or active treatment
(heat, education, or exercise), for pain over the immediate term68
• TENS, when compared to manual therapy or ultrasound, for reducing pain over the immediate and
short term68
• Kinesio Tape when compared to cervical manipulation on pain over the immediate term161
Abbreviations: NSAID, nonsteroidal anti-inflammatory drug; PA, posterior to anterior; ROM, range of motion; TENS, transcutaneous electrical nerve
stimulation.
• Clinicians should utilize a multimodal approach in manag- For patients with subacute neck pain with mobility
ing patients with neck pain with mobility deficits.
• In the subacute to chronic stage, the benefit of manual
C deficits, clinicians may provide thoracic manipula-
tion and cervical manipulation and/or
therapy appears to decrease. Manipulation may not offer mobilization.
any benefit over mobilization, and may be associated with
transient discomfort. Chronic
• Exercise targeting cervical and scapulothoracic regions is a For patients with chronic neck pain with mobility
necessary component of managing patients with subacute B deficits, clinicians should provide a multimodal ap-
and chronic neck pain with mobility deficits. proach of:

• Available adherence strategies (eg, McLean et al 136) for • Thoracic manipulation and cervical manipulation or
adoption and maintenance of home exercise should be mobilization
integrated to maximize clinical benefit over the long • Mixed exercise for cervical/scapulothoracic regions: neu-
term. romuscular exercise (eg, coordination, proprioception,
and postural training), stretching, strengthening, endur-
2017 Recommendations ance training, aerobic conditioning, and cognitive affective
Acute elements
For patients with acute neck pain with mobility • Dry needling, laser, or intermittent traction
B deficits, clinicians should provide thoracic manipu-
lation, a program of neck ROM exercises, and For patients with chronic neck pain with mobility
scapulothoracic and upper extremity stretching and strength-
ening exercises to enhance program adherence.
C deficits, clinicians may provide neck, shoulder gir-
dle, and trunk endurance exercise approaches and
patient education and counseling strategies that promote an
For patients with acute neck pain with mobility active lifestyle and address cognitive and affective factors.
C deficits, clinicians may provide cervical manipula-
tion and/or mobilization.
NECK PAIN WITH MOVEMENT
Subacute COORDINATION IMPAIRMENTS
For patients with subacute neck pain with mobility 2008 Recommendation
B deficits, clinicians should provide neck and shoul-
der girdle endurance exercises.
The 2008 neck pain CPG intervention literature analyses
were not specifically aligned to the neck pain categories or
staging, but the recommendations were made for coordi- focus on identifying risk factors for chronicity and predicting
nation, strengthening, and endurance exercises, stretching the most likely course of recovery for that patient. This prog-
exercises, and patient education and counseling that (1) pro- nostic subgrouping is conspicuously absent from many RCTs
motes early return to normal, nonprovocative preinjury ac- evaluated for these guidelines, but makes clinical sense.
tivities, and (2) provides reassurance to the patient that good While early intervention may impede recovery in the quick
prognosis and full recovery commonly occur. and early recovery group, it is likely more appropriate for the
severe and nonrecovered group. The available evidence pro-
Evidence Update vides little guidance for treatment recommendations based
Identified were 27 systematic reviews investigating physical on anticipated trajectories. In light of this gap in knowl-
therapy interventions on patients who could be classified as edge, we endorse early, informed risk-based assessment and
having neck pain with movement coordination impairments. prognosis from which treatment recommendations should
All of the studies in this section were on WAD. Levels of evi- flow naturally. An aggressive search for the pain-generating
dence assigned to systematic reviews in this section were as- “tissue at fault” is currently unlikely to be productive in the
sessed according to TABLE 1. Primary sources were generally of acute stage of injury.
high or moderate methodological quality with low risk of bias,
but had numbers of participants that were considered small. Low Risk for Chronicity/Quick and Early Recovery Expected
This resulted in downgrading the strength of the evidence by 1 As mentioned in the Clinical Course section in these guide-
or 2 levels due to imprecision and limited directness (TABLE 1).63 lines, a significant portion of clients with acute neck pain
TABLE 8 details the levels of evidence of included studies with with movement coordination impairments should expect
underpinning evidence statements. Consideration was made to recover significantly within the first 2 to 3 months. For
for the trade-offs between desirable and undesirable conse- those clients whose condition is perceived to be at low risk of
quences (important adverse events). Adverse events or side progressing into chronicity, clinicians should provide early
effects were rarely reported in the studies, and when reported advice, education, and counseling that includes reassurance
were minor, transient, and of short duration. of the expected course of recovery, encouragement to remain
active at a level similar to prior to the current episode, and
In a 2015 systematic review of CPGs, Wong et al240 training in home exercises to maintain/improve movement of
III found all guidelines to recommend education and
exercise in the management of acute WAD, with
the neck within a comfortable range. Helpful information can
be found at an Australian government-sponsored website.193
most guidelines recommending education and exercise for
the subacute and chronic stages as well. The components of A supervised exercise program (minimum 1 session, and 1
education were: emphasis on remaining active, advice on follow-up session) is preferable over an unsupervised pro-
management and coping, reassurance about the prognosis, gram (verbal instruction or pamphlet). Intensive exercise or
and functional improvement goals. Further, this review work-hardening programs are not recommended in the early
found recommendations for mobilization or manipulation, a acute or subacute phases.
multimodal approach, and recommendations against the use
of a cervical collar.240 Unclear Risk for Chronicity/Moderate to Slow Recovery,
With Lingering Impairments Expected
The following are expert opinions of the CPG de- Repeated or ongoing examination may be required to make
V velopment group:
an informed assessment, which should be utilized to guide
management decisions. Impairment-based treatment should
tions below with consideration of the results of the patient flow naturally from evaluation findings. This group is more
evaluation (eg, physical impairments most related to the suitable for responding to a more intensive nonsurgical
patient’s reported activity limitation or concerns, severity program combined with low-level pharmaceuticals. Clients
and irritability of the condition, patient values, and moti- should be monitored closely. The timing and achievement
vating factors). of defined favorable outcomes are often undetermined and
• Existing evidence indicates that recovery from neck pain unpredictable.
with movement coordination impairments is most likely to
follow 1 of 3 trajectories: quick and early recovery, moderate High Risk for Chronicity/Poor Recovery,
to slow recovery with lingering impairments, and poor re- With Severe Disability Expected
covery with severe disability.172 A patient’s course of recovery In consideration of the factors discussed in “Risk, Prognosis,
within and between trajectories may not be fixed, as there and Clinical Course” and in “Imaging,” some patients may be
are many factors that can influence the course of recovery. perceived to be at a higher risk of developing chronic prob-
Appropriate evaluation of the acutely injured patient should lems and poor functional recovery. For those patients, a more

Intervention Evidence for Neck Pain With Movement Coordination
TABLE 8 Impairments by Intervention Type, Stage, Level of Evidence,
Evidence of Benefit or No Benefit, and Comparison
Manual Therapy

Exercise

Acute
III Drescher et al49 For patients with acute neck pain with movement coordination impairments, there was a benefit in using
neck postural/stabilization exercise, when compared to use of a cervical collar, for reducing pain over the
short through long term.49
IV Teasell et al204 For patients with acute neck pain with movement coordination impairments, there was a benefit in using
Verhagen et al223 supervised exercise (endurance, stretch, stabilization, coordination), when compared to unsupervised
exercise, for reducing pain and disability, and improving self-efficacy over the short but not intermediate
term.204,223
IV Conlin et al33 For patients with acute neck pain with movement coordination impairments, there was no benefit in using
Drescher et al49 neck kinesthetic and coordination exercise, when compared to advice to stay active, for reducing pain over
the short and intermediate term.33,49
Subacute
IV Teasell et al204 For patients with subacute neck pain with movement coordination impairments, there was no benefit in using
Verhagen et al223 strengthening of the cervical and shoulder muscles, or balance and postural exercises, when compared
to a control, for reducing pain or improving the ability to perform work activities, over the short and long
term.204,223
Chronic
IV Damgaard et al44 For patients with chronic neck pain with movement coordination impairments, when compared to a control,
Gross et al71 there was a benefit in using the following:
Kabisch103 • An individualized, progressive submaximal exercise program and pain education including strengthening,
Kay et al109 endurance, flexibility, coordination, aerobic, and functional exercise using cognitive behavioral therapy
O’Riordan et al157 principles, for reducing pain and improving function over the immediate, but not long term44,71,103,109,157,190,205
Southerst et al190 • Vestibular rehabilitation for improving Dizziness Handicap Inventory scores, but not for reducing pain, over
Teasell et al205 the short term71,205
• Eye-head-neck coordination exercise for improving head repositioning accuracy over the short term. An im-
provement in pain was realized, but the magnitude of the effect is questionable given the group differences
in initial pain scores71,205
IV Teasell et al205 For patients with chronic neck pain with movement coordination impairments, there was no benefit in using
cervical rotation strength training, when compared to endurance training, for reducing pain, improving
muscle strength, and improving SF-36 physical function scores, over the short term.205
Acute
IV Kay et al108 For patients with acute neck pain with movement coordination impairments, there was a benefit in using a
home program consisting of cervical ROM exercise, advice, physical agents, and limited collar use, when
compared to a control, for reducing pain over the short term.108

Evidence of Benefit or No Benefit, and Comparison (continued)

III Conlin et al33 For patients with acute neck pain with movement coordination impairments, there was a benefit in using the
Drescher et al49 following:
Hurwitz et al93 • Intensive physical therapy program (including, manual therapy, cervical ROM and isometric strengthening
Kay et al109 exercise, advice, and physical agents), when compared to 1 session of physical therapy consisting of home
Miller et al140 exercise instruction and advice, for reducing pain and work days lost, and improving self-perceived benefit,
Shaw et al186 over the intermediate term. These differences were statistically significant but of small magnitude, and
Sutton et al200 thus, possibly not clinically relevant200,245
Teasell et al203 • Cervical mobilization or manipulation combined with active cervical ROM exercise when compared to rest,
Verhagen et al223 use of a collar and/or analgesic medications and/or advice, for reducing pain,140 but there was no difference
Yu et al245 in function, over the short term33,49,93,109,140,186,203,223
IV Kabisch103 For patients with acute neck pain with movement coordination impairments, there was a benefit in using the
Teasell et al203 following:
• Massage, active and resisted exercise of the neck and shoulder, and heat, when compared to collar use, for
reducing pain and disability over the intermediate term203
• Cervical mobilization plus low intensity active kinesthetic, postural and ROM exercise, when compared
to a self-managed exercise and education program, for reducing pain and disability, over the immediate
term103,205
IV Haines et al79 For patients with acute neck pain with movement coordination impairments, there was no benefit in using
Hurwitz et al93 massage plus mobilization plus active ROM exercises, when compared to collar use or advice to stay
Teasell et al203 active, for affecting pain disability, work capacity, and quality of life, over the long term.79,93,203
IV Kay et al108 For patients with acute neck pain with movement coordination impairments who received intensive multi-
Verhagen et al223 modal physical therapy, a higher percentage reported symptoms after 2 years, as compared with those
who received a single session of physical therapy consisting of home active cervical ROM exercise and
advice.108,223
Chronic
IV Kabisch103 For patients with chronic neck pain with movement coordination impairments, there was a benefit in using
cervical mobilization combined with low load cervical and scapular muscle activation and kinesthetic train-
ing, when compared to a booklet on education and exercise, for reducing pain and improving function over
the immediate term.103
Education
Acute
III Gross et al76 For patients with acute neck pain with movement coordination impairments, there was a benefit in using an
Gross et al70 educational video, when compared to the following:
• No treatment, for reducing pain over the short, intermediate, and long term76
• Control, for improving muscular activation over the intermediate term but not the long term70
III Meeus et al138 For patients with acute neck pain with movement coordination impairments, there was a benefit in using the
Teasell et al203 following:
• Instructions to decrease the use of a cervical collar, improve posture, and perform mobilizing exercises,
when compared to only receiving rest and analgesics, to increase ROM and decrease pain, over the inter-
mediate term138
• Advice to act as usual, when compared to use of a soft collar, for reducing pain over the intermediate and
long term203

Education

IV Meeus et al138 For patients with acute neck pain with movement coordination impairments, there was no benefit in using
Gross et al76 the following:
• Verbal education on the mechanism of injury to reduce fear and uncertainty, and advice to remain active,
when compared to the use of a semi-rigid collar or active mobilization, for reducing neck pain, headache
disability, and improving work ability over the long term138
• Instructions to decrease the use of a cervical collar, improve posture and perform mobilizing exercise,
when compared to active physiotherapy, for improving cervical ROM and reducing pain intensity over the
intermediate term138
• Advice to act as usual, when compared to use of a Philadelphia collar plus manual therapy plus exercise,
on improving pain, function, or quality of life over the long term76
• Whiplash pamphlet focusing on activity, when compared to a generic information sheet, on reducing pain
or improving function over the short term76
IV Gross et al70 For patients with acute neck pain with movement coordination impairments, there was no benefit in using a
pamphlet focusing on activity, when compared to generic information provided in the emergency depart-
ment, for reducing pain or improving function over the short term.70

Chronic
IV Meeus et al138 For patients with chronic neck pain with movement coordination impairments, there was a benefit in using
verbal education focusing on prognosis, encouragement, assurance, and activity integrated with exercise,
when compared to a control, for reducing pain and disability over the short term.138
IV Gross et al76 For patients with chronic neck pain with movement coordination impairments, there was no benefit in adding
cognitive behavioral training to a physical therapy program, on reducing pain or improving disability over
the short term.76
Physical Agents
Acute
IV Gross et al76 For patients with acute neck pain with movement coordination impairments, there was a benefit in using
Parreira et al161 Kinesiotape when compared to sham Kinesio Tape on reducing pain over the immediate term. The
Vanti et al216 difference was small and possibly not clinically meaningful.76,161,216
IV Graham et al68 For patients with acute neck pain with movement coordination impairments, there was no benefit, when
compared to a control, in using the following:
• Laser for reducing pain over the immediate or intermediate term68
• Pulsed ultrasound on function or global perceived effect over the immediate term68
• Iontophoresis for reducing pain over the immediate term68
IV Graham et al68 For patients with acute neck pain with movement coordination impairments, there was no benefit in using
iontophoresis, when compared to interferential current, and was inferior to a multimodal treatment of
traction, exercise, and massage, for reducing pain over the immediate term.68
Chronic
IV Graham et al68 For patients with an unspecified duration of neck pain with movement coordination impairments, there was a
benefit, when compared to a control, in using transcutaneous electrical nerve stimulation for reducing pain
over the immediate term.68
Abbreviations: ROM, range of motion; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey.
concerted multimodal treatment program that could include strengthening, endurance, flexibility, and coordination,
medical and psychological consultation would be indicated. using principles of cognitive behavioral therapy
• TENS
• Available adherence strategies (eg, McLean et al136) for
adoption and maintenance of home exercise should be in- NECK PAIN WITH HEADACHE
tegrated to maximize clinical benefit over the long term 2008 Recommendation
The intervention literature analyses were not specifically
2017 Recommendation aligned to the neck pain categories or staging, but recom-
Acute mendations were made for coordination, strengthening, and
For patients with acute neck pain with movement coordina- endurance exercises to reduce neck pain and headache.
tion impairments (including WAD):
Evidence Update
Clinicians should provide the following: Identified were 17 systematic reviews investigating physical
B 1. Education of the patient to
• Return to normal, nonprovocative preaccident
therapy interventions for neck pain with cervicogenic head-
ache. Levels of evidence assigned to systematic reviews in this
activities as soon as possible section were assessed according to TABLE 1. Primary sources
• Minimize use of a cervical collar were generally of high or moderate methodological quality,
• Perform postural and mobility exercises to decrease pain that is, with low risk of bias, but had numbers of participants
and increase ROM that were considered small. This resulted in downgrading the
2. Reassurance to the patient that recovery is expected to oc- strength of the evidence by 1 or 2 levels due to imprecision
cur within the first 2 to 3 months. and limited directness (TABLE 1).63 TABLE 9 details the levels
of evidence of included studies with underpinning evidence

Clinicians should use a multimodal intervention statements. Considerations were made of the trade-offs be-
B approach including manual mobilization tech-
niques plus exercise (eg, strengthening, endurance,
tween desirable and undesirable consequences (important
adverse events). Adverse events or side effects were poorly
flexibility, postural, coordination, aerobic, and functional ex- reported in the studies, and when reported were minor, tran-
ercises) for those patients expected to experience a moderate sient, and of short duration. For manual therapy or exercise,
to slow recovery with persistent impairments. the only consistently reported problem was local discom-
fort or dizziness. For manipulation, rare but serious adverse
Clinicians may provide to patients whose condition events such as stroke or serious neurological deficits were not
C is perceived to be at low risk of progressing toward reported in any of the trials. Serious but rare adverse events
chronicity: for manipulation are known to occur.23

• A single session consisting of early advice, exercise instruc-
tion, and education The following are expert opinions of the CPG
• A comprehensive exercise program (including strength
and/or endurance with/without coordination exercises)
V development group:
• TENS tions below with consideration of the results of the patient
evaluation (eg, physical impairments most related to the
Clinicians should monitor recovery status in an at- patient’s reported activity limitation or concerns, severity
F tempt to identify those patients experiencing de-
layed recovery and who may need more intensive
and irritability of the condition, patient values, and moti-
vating factors).
rehabilitation and an early pain education program. • With patients in this category, clinicians should follow
the screening and assessment procedures outlined in the
Chronic IFOMPT framework before implementing interventions.
For patients with chronic neck pain with movement coordi- • Treatments for subgroups of patients having neck pain with
nation impairments (including WAD): headache need further research, including patients post-
concussion and patients experiencing symptoms related to
Clinicians may provide the following: the temporomandibular joint.
C • Patient education and advice focusing on reas-
surance, encouragement, prognosis, and pain
• Craniocervical strength training may be of particular
benefit.
management • Available adherence strategies (eg, McLean et al136) for
• Mobilization combined with an individualized, progressive adoption and maintenance of home exercise should be
submaximal exercise program including cervicothoracic integrated to maximize clinical benefit over the long term.

Intervention Evidence for Neck Pain With Headache
TABLE 9 by Intervention Type, Stage, Levels of Evidence,
Manual Therapy

Subacute
III Chaibi and Russell28 For patients with subacute to chronic neck pain with headache, there was a benefit, when
Fernández-de-las-Peñas et al59 compared to a control, in using cervical manipulation and mobilization for reducing neck pain,
Hurwitz et al93 headache intensity, and headache frequency over the immediate through long term.28,59,93,163
Racicki et al163
Chronic
III Brønfort et al20 For patients with chronic neck pain with headache, there was a benefit in using the following:
Chaibi and Russell28 • Cervical manipulation done 3 or 4 times per week for 12 to 18 sessions, when compared to
Fernández-de-las-Peñas et al59 cervical manipulations done 1 time per week for 3 to 8 sessions, for reducing headache pain
Gross et al72 and frequency over the short term.21,57 This benefit was not maintained over the intermediate
Racicki et al163 term28,72
• Multiple sessions of cervical or cervicothoracic manipulation, when compared to multiple
sessions of massage or placebo treatments, for reducing pain and improving function over the
short and intermediate term28,59,163

• Cervical manipulation, when compared to cervical mobilization, for reducing pain, over the
immediate, but not the short term20
III Brønfort et al20 For patients with chronic neck pain with headache, there was no benefit in using the following:
Chaibi and Russell28 • Cervical manipulation and mobilization, when compared to exercise alone or manipulation plus
Gross et al72 exercise, affecting neck pain and headache intensity, frequency, and duration, over the long
Hurwitz et al93 term.20,93,220 However 2 other reviews reported a small advantage in using manual therapy and
Macaulay et al125 exercise, when compared to manipulation alone, for reducing pain and improving function,
Racicki et al163 with a 69% advantage in global perceived effect, over the long term71,125
Varatharajan et al220 • Cervical manipulation alone, when compared to laser and massage, for reducing headache
intensity or duration, over the immediate term28,163
Exercise
Acute
III Gross et al76 For patients with acute whiplash with neck pain with headache, there was a benefit for active mo-
bility exercise (physical therapist provided instruction, then home exercise), when compared to
collar use, in reducing pain and disability over the short term, and pain over the intermediate
term.76
IV Gross et al71 For patients with acute to subacute neck pain with headache, there was a benefit, when com-
Kay et al109 pared to a control, in C1-2 self-SNAG for reducing pain and headache intensity163 over the short
Racicki et al163 and long term.71,109,163,247
Zronek et al247
Chronic
III Gross et al75 For patients with chronic neck pain with headache, there was a benefit, when compared to a
Gross et al71 control, in using cervicoscapular strengthening and endurance exercise including craniocervi-
Kay et al109 cal flexion training with pressure biofeedback for reducing pain and function, and improving
Racicki et al163 global perceived effect, over the long term.71,75,109,163,220
Varatharajan et al220
III Bronfort et al19 For patients with chronic neck pain with headache, there was no benefit in using endurance, iso-
Gross et al71 metric, and stretching exercise, when compared to manipulation, for reducing pain, headache
Kay et al109 frequency, or headache duration, over the short and long term.19,71,109

Intervention Evidence for Neck Pain With Headache
TABLE 9 by Intervention Type, Stage, Levels of Evidence,

Chronic
III Brønfort et al20 For patients with chronic neck pain with headache, there was a benefit, when compared to a
Chaibi and Russell28 control, in using mobilization, manipulation, and exercise (stretching, strengthening, and
Fernández-de-las-Peñas et al59 endurance), for reducing pain, headache frequency, headache intensity, and improving
Gross et al75 function and global perceived effect, over the short and long term.20,28,59,75,93,140,163,167
Hurwitz et al93
Miller et al140
Racicki et al163
Reid and Rivett167
III Gross et al75 For patients with mechanical neck pain, with or without radiating pain, and with or without
headache there was a benefit, compared to control, in using mobilization or manipulation
combined with stretching and strengthening to reduce pain over the short and long term,
sand improve function over the long term.75

IV Chaibi and Russell28 For patients with chronic neck pain with headache who also report at least 1 sign of temporoman-
dibular dysfunction (eg, pain in the area of the jaw [or face, or ear], a click or pop heard when
opening or closing the mouth, restrictions or deviations of jaw motion, or pain in the muscles of
mastication), there was a benefit, when compared to manual therapy and exercise focused on the
craniocervical region, in using manual therapy and exercise interventions focused on the temporo-
mandibular joint, for reducing pain and improving function over the short and intermediate term.28
Abbreviations: SNAG, sustained natural apophyseal glide.
2017 Recommendation shoulder girdle and neck stretching, strengthening, and en-
Acute durance exercise.
For patients with acute neck pain with headache,
B clinicians should provide supervised instruction in
active mobility exercise. NECK PAIN WITH RADIATING PAIN
2008 Recommendation
Clinicians may utilize C1-2 self-sustained natural Clinicians should consider the use of upper-quar-
C apophyseal glide (self-SNAG) exercise. B ter and nerve mobilization procedures to reduce
pain and disability in patients with neck and arm
Subacute pain.
For patients with subacute neck pain with head-
B ache, clinicians should provide cervical manipula- Specific repeated movements or procedures to pro-
tion and mobilization. C mote centralization are not more beneficial in re-
ducing disability when compared to other forms of
Clinicians may provide C1-2 self-SNAG exercise. interventions.
C Clinicians should consider the use of mechanical
Chronic
For patients with chronic neck pain with headache,
B intermittent cervical traction, combined with other
interventions such as manual therapy and strength-
B clinicians should provide cervical or cervicothoracic
manipulation or mobilizations combined with
ening exercises, for reducing pain and disability in patients
with neck and neck-related arm pain.

Intervention Evidence for Neck Pain With Radiating Pain
TABLE 10 by Intervention Type, Stage, Level of Evidence,
Manual Therapy

Acute
IV Boyles et al17 For patients with acute to chronic neck pain with radiating pain, there was no benefit from using the following:
combined cervical lateral glides, thoracic mobilizations, and nerve mobilization procedures for the median
nerve, when compared to general strengthening, for reducing pain and disability, over the immediate term17
Chronic
IV Zhu et al246 For patients with chronic neck pain with radiating pain, there was a benefit in using cervical manipulation on
pain, compared to mechanical traction over the immediate term.246
Exercise
Acute
IV Southerst et al190 For patients with acute neck pain with radiating pain, there was a benefit, when compared to a control, in
Kay et al109 using cervical mobilizing and stabilizing exercises for reducing pain but not for improving function over
Salt et al178 the immediate term. The benefit for relief of pain was not sustained over the short190 or intermediate
Gross et al71 term.71,109,178,247

Zronek et al247
IV Southerst et al190 For patients with acute to subacute neck pain with radiating pain, there was no benefit in using cervical
Salt et al178 stretching and strengthening exercises, when compared to wearing a semi-hard cervical collar, for reducing
pain and improving function, over the immediate, short, and intermediate term.178,190


Chronic
III Gross et al75 For patients with mechanical neck pain, with or without radiating pain, and with or without headache, there
was a benefit, when compared to a control, in using mobilization or manipulation combined with stretching
and strengthening exercises for reducing pain over the short and long term, and for improving function over
the long term.75
III Salt et al178 For patients with chronic neck pain with radiating pain, there was no benefit in using manual therapy plus
exercise, when compared to advice plus sham ultrasound, or when compared to manual therapy, or when
compared to exercise alone, for reducing pain or improving function, over the short and long term.178
IV Salt et al178 For patients with chronic neck pain with radiating pain, there was no benefit in using manual therapy plus
Boyles et al17 exercise, when compared to rigid or soft collar, or when compared to surgery, for reducing pain or improv-
ing function, over the immediate and long term.17,178
Education

Chronic
III Salt et al178 For patients with chronic neck pain with radiating pain, there was a benefit, when compared to a control, for
using patient education and counseling that encourage exercise and moderate to heavy physical activities
related to work, for reducing pain, but not for improving function or reducing disability over the long term.178

Intervention Evidence for Neck Pain With Radiating Pain
TABLE 10 by Intervention Type, Stage, Level of Evidence,
Education

IV Varatharajan For patients with chronic neck pain with radiating pain, there was no benefit, when compared to a control, for
et al219 adding job stress education to ergonomic interventions for reducing pain, ergonomic risk, or work stress,
or for improving function, over the intermediate and long term.219
Physical Agents
Acute
IV Graham et al68 For patients with acute neck pain with radiating pain, there was a benefit, when compared to a control, in
Gross et al76 using the following:
Kadhim-Saleh • 905-nm laser for reducing pain, improving function, global perceived effect, and quality of life over the im-
et al104 mediate and intermediate term.68,76,104 Graham et al68 reported mild adverse events equal in treatment and
Thoomes et al208 placebo groups, including tiredness, nausea, headache, and increased pain following laser treatment
• A cervical collar for reducing arm pain over the short but not intermediate term76,208
IV Rhee et al169 For neck pain with radiating pain and a diagnosis of mild cervical myelopathy, there was a benefit, compared
to surgery, in using multimodal nonsurgical management (intermittent use of collar or bed rest, medica-
tions, and activity modification) for improving gait speed over the long term, but no difference in neurologi-
cal status or performance of daily living activities as compared to surgical management.169 Rhee et al169
also strongly recommended that traction, as part of nonsurgical management, should not be routinely
prescribed for patients with moderate to severe cervical myelopathy.
IV Gross et al76 For patients with acute neck pain with radiating pain, there was no benefit, when compared to a control, in
using a semi-rigid collar for improving function over the short, intermediate, or long term.76
III Graham et al68 For patients with acute and chronic neck pain with radiating pain, there was no benefit, when compared
Thoomes et al208 to a control, in using continuous traction for reducing pain or disability over the immediate, short, and
intermediate term.68,208
IV Thoomes et al208 For patients with acute and chronic neck pain with radiating pain, there was no benefit in using a collar, when
compared to multimodal physical therapy, for reducing pain over the short term.208

Chronic
III Graham et al68 For patients with chronic neck pain with radiating pain, there was a benefit, when compared to a control, in
using intermittent traction for reducing pain in the short term.68
IV Graham et al68 For patients with chronic neck pain with radiating pain, there was no benefit, when compared to a control,
in using electric muscular stimulation, or modified galvanic current for reducing pain over the immediate
term.68
Evidence Update events or side effects were poorly reported in the studies, and
Identified were 15 systematic reviews investigating physical when reported were minor, transient, and of short duration.
therapy interventions for neck pain with radiating pain. Levels
of evidence assigned to systematic reviews in this section were The following are expert opinions of the CPG de-
assessed according to TABLE 1. Primary sources were generally V velopment group:
• Clinicians should integrate the recommendations
of high or moderate methodological quality, that is, with low
risk of bias, but had numbers of participants that were con- below with consideration of the results of the patient evalu-
sidered small. This resulted in downgrading the strength of ation (eg, related impairments, severity, and irritability of
the evidence by 1 or 2 levels due to imprecision and limited the condition, and values). Clinicians have a responsibility
directness (TABLE 1).63 TABLE 10 details the levels of evidence of to make appropriate referrals if signs and symptoms are
included studies with underpinning evidence statements. Con- not resolving or are worsening.
sideration of the trade-offs between desirable and undesirable • Since the 2008 neck pain CPG, there has been little ad-
consequences (important adverse events) was made. Adverse vancement in our knowledge of how to nonsurgically
treat neck pain with radiating pain. While 1 meta-analysis

2017 Recommendation
showed benefit from manual therapy and exercise in a
Acute
population that included a mixture of neck pain categories,
For patients with acute neck pain with radiating
other studies that were selective to neck pain with radiat-
ing pain were not able to show similar benefits from this C pain, clinicians may utilize mobilizing and stabiliz-
ing exercises, laser, and short-term use of a cervical
approach.
collar.
• Clinicians should monitor symptom irritability, and
adjust treatment accordingly, when applying manual Chronic
therapy and exercise approaches applied to patients with For patients with chronic neck pain with radiating
radicular pain.
• Because of the detrimental effects of prolonged use, collars
B pain, clinicians should provide mechanical inter-
mittent cervical traction, combined with other in-
should be restricted to a limited time in the acute phase terventions such as stretching and strengthening exercise
only, and only in individuals who do not obtain relief from plus cervical and thoracic mobilization/manipulation.
other treatments.
• Available adherence strategies (eg, McLean et al136) for Clinicians should provide education and counseling
adoption and maintenance of home exercise should be in-
tegrated to maximize clinical benefit over the long term.
B to encourage participation in occupational and ex-
ercise activities.
Limitations to This CPG

1. The estimates of the prevalence of neck pain vary so wide- the diagnostic process and intervention delivery. In ad-
ly, with respect to definitions and associated estimates, dition, intervention specifics (eg, position, dosage) are
that reporting the actual prevalence is likely impossible. frequently poorly described, further complicating com-
parison between and among studies. The clinician may
2. Reviews of musculoskeletal clinical research frequently have to return to the original articles in an attempt to
draw somewhat vague conclusions that are only partially determine evidence-based dosage.
helpful to clinical practice. This makes the development
of absolute or firm recommendations or guidelines dif- 7. The guideline recommends interventions predominantly
ficult at this point in time. for their effect on pain, and thus the reader may be under
the impression that the authors have ignored other com-
3. Health care research does not account well for the dy- mon symptoms associated with neck disorders, such as
namic or individualized nature of the less well-defined di- light-headedness and poor balance/dizziness (which are
agnoses, such as those afflicting patients with neck pain, common symptoms in persons with whiplash and even
the solutions to those problems, or the ongoing doubt as- cervicogenic headache).
sociated with whether a solution to any given problem has
been reached after the implementation of treatment. 8. The guideline discusses the major problem of the recur-
rent nature of neck pain and the transition to chronicity.
4. The comparable sign, a highly adaptable patient response Recommendations are based on higher-level evidence
to a specific clinical test, appears to not be present in the that considered relief of an episode of pain.
scientific literature. This may complicate attempts to in-
corporate scientific findings into clinical practice. 9. The guideline does not review a large body of research on
neuromuscular and sensorimotor impairments in neck
5. Health care research attempts to classify and quantify the pain disorders. In many cases, the available evidence did
scientific aspects of patient care but cannot sufficiently not meet our threshold for inclusion.
capture the intuitive, responsive process so frequently
associated with both the evaluation and management 10. The guideline positions itself within the ICF but does
processes. This, to a certain extent, will of course limit not consider the biopsychosocial context informing
the applicability of CPGs in certain scenarios. assessment, prognostic, and theranostic strategies on
a patient-by-patient basis. In time and with more re-
6. Comparison across scientific papers is problematic search, it is anticipated that this information will com-
when discrepencies exist in experience and mastery of bine, if not refine, using strict inclusion criteria.
Competing Interests, Disclosures, and Author Contributions
The guideline development group members declared rela- for assessment. Partial funding was provided to the CPG
tionships and developed a conflict management plan that development team for travel and expenses for CPG training
included submitting a Conflict of Interest form to the and development; the content of this guideline was not in-
Orthopaedic Section, APTA, Inc. Articles that were authored fluenced by this funding. The CPG development team main-
by a group member were assigned to an alternate member tained editorial independence.
AFFILIATIONS AND CONTACTS

AUTHORS Eric Robertson, PT, DPT The Ohio State University Sacramento, CA
Peter R. Blanpied, PT, PhD Clinical Assistant Professor Columbus, OH torburn@yahoo.com
Professor Physical Therapy Department john.dewitt@osumc.edu
Physical Therapy Department University of Texas-El Paso GUIDELINES EDITORS
University of Rhode Island El Paso, TX Amanda Ferland, DPT Christine M. McDonough, PT, PhD
Kinston, RI ekrdpt@gmail.com Clinical Faculty ICF-Based Clinical Practice
blanpied@uri.edu Intech Rehabilitation Group/Division Guidelines Editor
REVIEWERS of Biokinesiology and Physical Orthopaedic Section, APTA, Inc
Anita R. Gross, PT, MSc Roy Altman, MD Therapy La Crosse, WI
Associate Clinical Professor Professor of Medicine Orthopaedic Physical Therapy and
Rehabilitation Sciences Division of Rheumatology and Residency Adjunct Clinical Assistant Professor
McMaster University Immunology University of Southern California Department of Orthopaedic
Hamilton, Ontario, Canada David Geffen School of Medicine Los Angeles, CA Surgery
grossa@mcmaster.ca University of California at Los Angeles and Geisel School of Medicine at
Los Angeles, CA Spine Rehabilitation Fellowship Dartmouth
James M. Elliott, PT, PhD journals@royaltman.com Beijing, China Dartmouth-Hitchcock Medical
Associate Professor AmandaFerland@incarehab.com Center
Department of Physical Therapy and Paul Beattie, PT, PhD Lebanon, NH
Human Movement Sciences Clinical Professor Timothy Flynn, PT, PhD and
Feinberg School of Medicine Doctoral Program in Physical Therapy Professor Research Assistant Professor
Northwestern University Department of Exercise Science School of Physical Therapy Health and Disability Research
Chicago, IL Arnold School of Public Health South College Institute
j-elliott@northwestern.edu University of South Carolina Knoxville, TN Boston University School of
Columbia, SC tflynn1@southcollegetn.edu Public Health

Laurie Lee Devaney, PT, MSc pbeattie@gwm.sc.edu Boston, MA
Clinical Instructor Sandra Kaplan, PT, PhD cmm@bu.edu
Physical Therapy Program Eugene R. Boeglin, DPT Clinical Practice Guidelines
Department of Kinesiology Principal Coordinator Joseph J. Godges, DPT, MA
University of Connecticut Milton Orthopaedic & Sports Physical Academy of Pediatric Therapy, ICF-Based Clinical Practice
Storrs, CT Therapy, PC APTA, Inc Guidelines Editor
laurie.devaney@uconn.edu Milton, MA and Orthopaedic Section, APTA, Inc
erboeglin@verizon.net Professor La Crosse, WI
Derek Clewley, DPT Doctoral Programs in Physical and
Assistant Professor John Childs, PT, PhD, MBA Therapy Adjunct Associate Professor
Division of Physical Therapy Associate Professor and Director of Rutgers University Clinical Physical Therapy
Duke University Research Newark, NJ Division of Biokinesiology and
Durham, NC School of Physical Therapy kaplansa@shp.rutgers.edu Physical Therapy

derek.clewley@duke.edu South College Herman Ostrow School of Dentistry
Knoxville, TN David Killoran, PhD University of Southern California
David M. Walton, PT, PhD jchilds@southcollegetn.edu Patient/Consumer Representative Los Angeles, CA
Associate Professor for the ICF-Based Clinical Practice godges@pt.usc.edu
School of Physical Therapy Joshua Cleland, PT, PhD Guidelines
University of Western Ontario Professor Orthopaedic Section, APTA, Inc Guy. G. Simoneau, PT, PhD, FAPTA
London, Ontario, Canada Doctor of Physical Therapy Program La Crosse, WI ICF-Based Clinical Practice
dwalton5@uwo.ca Franklin Pierce University and Guidelines Editor
Manchester, NH Professor Emeritus Orthopaedic Section, APTA, Inc
Cheryl Sparks, PT, PhD clelandj@franklinpierce.edu Loyola Marymount University La Crosse, WI
Director Los Angeles, CA and
Rehabilitation Center of John Dewitt, DPT david.killoran@lmu.edu Professor
Expertise Director Department of Physical Therapy
OSF HealthCare Physical Therapy Sports and Leslie Torburn, DPT Marquette University
Peoria, IL Orthopaedic Residencies and Principal and Consultant Milwaukee, WI
Cheryl.L.Sparks@osfhealthcare.org Fellowships Silhouette Consulting, Inc guy.simoneau@marquette.edu
ACKNOWLEDGMENTS: The authors wish to acknowledge and graciously thank P. Lina Santaguida and the members of the International
Collaboration on Neck Pain (ICON) for their assistance and sharing their work. In addition, the authors wish to thank Christine
McDonough and Joseph Godges for their valuable guidance and assistance in editing drafts.
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APPENDIX A
SEARCH STRATEGIES neuralgia* OR ‘cervicobrachial neuritis’ OR cervicobrachial

Below is an example EMBASE search strategy for articles neuralgia* OR neck pain* OR neck injur* OR brachial plexus
related to the Physical Agents section of Interventions. neuropath* OR ‘brachial plexus neuritis’ OR monoradicul*
OR monoradicl* OR torticollis OR ‘thoracic outlet syndrome’
Modalities =#1 OR ‘cervical dystonia’ OR (headache* AND cervic*)
‘combined modality therapy’/de OR ‘electrostimulation
therapy’/exp OR ‘electrostimulation’/de OR ‘traction thera- disc problems =#5
py’/exp OR ‘phototherapy’/exp OR ‘physiotherapy’/exp OR ‘vertebra dislocation’/exp OR ‘intervertebral disk disease’/exp
‘rehabilitation’/exp OR ‘ultrasound therapy’/exp OR ‘laser’/ OR ((‘intervertebral disk’/exp OR disks OR disk OR discs OR
de OR ‘cryotherapy’/exp OR ‘cryoanesthesia’/de OR ‘ice’/de disc) AND (herniat* OR slipped OR prolapse* OR displace*
OR ‘acupuncture’/exp OR Modalit* OR ‘electric stimulation’ OR degenerat* OR bulge OR bulged OR bulging))
OR ‘electrical stimulation’ OR electrotherapy OR tens OR
‘transcutaneous electric nerve stimulation’ OR electroacu- diseases =#6
puncture OR acupuncture OR needling OR heat OR cold OR ‘radiculopathy’/exp OR ‘temporomandibular joint disorder’/
traction OR laser OR lasers OR rehabilitation OR ‘physical de OR ‘myofascial pain’/de OR ‘musculoskeletal disease’/exp
therapy’ OR ultrasound OR ultrasonic OR cryotherapy OR OR ‘neuritis’/exp OR radiculopath* OR radiculitis OR tem-
hyperthermia OR ‘vapocoolant spray’ OR cryoanesthesia OR poromandibular OR (myofascial NEAR/3 pain*) OR (tho-
ice OR faradic OR traction OR iontophoresis OR phonopho- racic outlet syndrome*) OR ‘spinal osteophytosis’ OR neuritis
resis OR phototherapy OR hydrotherapy OR ‘light therapy’ OR spondylosis OR splondylitis OR spondylolisthesis OR

OR diathermy OR ultraviolet OR infrared OR ((trigger* OR spondylolysis OR arthritis OR osteoarthritis OR spondylar-
dry) and needl*) thritis OR fibromyalgia OR sprain* OR strain*
neck anatomy =#2 disease rehab =#7

‘neck’/exp OR ‘cervical plexus’/de OR ‘cervical spine’/de OR ‘radiculopathy’/exp/dm_rh OR ‘temporomandibular joint
‘atlantoaxial joint’/de OR ‘atlantooccipital joint’/de OR ‘spi- disorder’/dm_rh OR ‘myofascial pain’/dm_rh OR ‘musculo-
nal root’/de OR ‘brachial plexus’/de OR ‘atlas’/de OR ‘axis’/ skeletal disease’/exp/dm_rh OR ‘neuritis’/exp/dm_rh
de OR ‘thoracic spine’/de OR (brachial NEAR/3 plexus) OR
neck OR (thoracic NEAR/3 spine) OR (thoracic NEAR/3 neck pain rehab =#8
outlet) OR (thoracic NEAR/3 vertebra*) OR trapezius OR ‘atlantoaxial dislocation’/dm_rh OR ‘neck pain’/dm_rh OR

odontoid* OR occip* OR atlant* OR ((cervical OR cervico*) ‘brachial plexus neuropathy’/dm_rh OR ‘neck injury’/exp/
NOT (‘gynecologic disease’/exp OR ‘uterus’/exp OR uterus dm_rh OR ‘thorax outlet syndrome’/dm_rh OR ‘torticollis’/
OR cervix)) dm_rh
pain =#3 Systematic Review Filter =#9

‘pain’/exp OR pain* OR ache* OR sore* OR stiff * OR dis- ‘meta analysis’/de OR ‘meta analysis (topic)’/de OR ‘system-
comfort OR injur* OR neuropath* OR neuralgia* OR atic review’/de OR ‘systematic review (topic)’/de OR Meta
neurodynia* analy* OR metaanaly* OR meta analy* OR Systematic re-
view* OR systematic overview* OR Cochrane OR embase
neck pain =#4 OR psyclit OR psychlit OR psycinfo OR psychinfo OR cinahl
‘atlantoaxial dislocation’/de OR ‘neck pain’/de OR ‘brachial OR cinhal OR science citation index OR bids OR cancerlit
plexus neuropathy’/de OR ‘neck injury’/exp OR ‘thorax outlet OR ‘web of science’ OR Reference list* OR bibliograph* OR
syndrome’/de OR ‘torticollis’/de OR ‘cervical pain’ OR neck- hand search* OR ‘relevant journals’ OR manual search* OR
ache* OR neck ache* OR whiplash OR cervicodynia* OR cer- ((‘selection criteria’ OR data NEAR/3 extract*) AND (review
vicalgia* OR brachialgia* OR ‘brachial neuritis’ OR brachial OR reviews))
APPENDIX A
Embase Session Results

Number Query Results, n
1 ‘combined modality therapy’/de OR ‘electrostimulation therapy’/exp OR ‘electrostimulation’/de OR ‘traction 1647419
therapy’/exp OR ‘phototherapy’/exp OR ‘physiotherapy’/exp OR ‘rehabilitation’/exp OR ‘ultrasound therapy’/exp
OR ‘laser’/de OR ‘cryotherapy’/exp OR ‘cryoanesthesia’/de OR ‘ice’/de OR ‘acupuncture’/exp OR modalit* OR
‘electric stimulation’ OR ‘electrical stimulation’ OR electrotherapy OR tens OR ‘transcutaneous electric nerve
stimulation’ OR electroacupuncture OR acupuncture OR needling OR heat OR cold OR laser OR lasers OR reha-
bilitation OR ‘physical therapy’ OR ultrasound OR ultrasonic OR cryotherapy OR hyperthermia OR ‘vapocoolant
spray’ OR cryoanesthesia OR ice OR faradic OR traction OR iontophoresis OR phonophoresis OR phototherapy OR
hydrotherapy OR ‘light therapy’ OR diathermy OR ultraviolet OR infrared OR (trigger* OR dry AND needl*) AND
[english]/lim AND ([embase]/lim OR [embase classic]/lim)
2 ‘neck’/exp OR ‘cervical plexus’/de OR ‘cervical spine’/de OR ‘atlantoaxial joint’/de OR ‘atlantooccipital joint’/de 1467424
OR ‘spinal root’/de OR ‘brachial plexus’/de OR ‘atlas’/de OR ‘axis’/de OR ‘thoracic spine’/de OR brachial NEAR/3
plexus OR neck OR thoracic NEAR/3 spine OR thoracic NEAR/3 outlet OR thoracic NEAR/3 vertebra* OR trape-
zius OR odontoid* OR occip* OR atlant* OR (cervical OR cervico* NOT (‘gynecologic disease’/exp OR ‘uterus’/exp
OR uterus OR cervix))
3 ‘pain’/exp OR pain* OR ache* OR sore* OR stiff* OR discomfort OR injur* OR neuropath* OR neuralgia* OR 3295582
neurodynia*
4 ‘atlantoaxial dislocation’/de OR ‘neck pain’/de OR ‘brachial plexus neuropathy’/de OR ‘neck injury’/exp OR ‘thorax 22970
outlet syndrome’/de OR ‘torticollis’/de OR ‘cervical pain’ OR neckache* OR neck AND ache* OR whiplash OR cer-
vicodynia* OR cervicalgia* OR brachialgia* OR ‘brachial neuritis’ OR brachial AND neuralgia* OR ‘cervicobrachial
neuritis’ OR cervicobrachial AND neuralgia* OR neck AND pain* OR neck AND injur* OR brachial AND plexus
AND neuropath* OR ‘brachial plexus neuritis’ OR monoradicul* OR monoradicl* OR torticollis OR ‘thoracic outlet
syndrome’ OR ‘cervical dystonia’ OR (headache* AND cervic*)
5 ‘vertebra dislocation’/exp OR ‘intervertebral disk disease’/exp OR (‘intervertebral disk’/exp OR disks OR disk 46463
OR discs OR disc AND (herniat* OR slipped OR prolapse* OR displace* OR degenerat* OR bulge OR bulged OR
bulging))
6 ‘radiculopathy’/exp OR ‘temporomandibular joint disorder’/de OR ‘myofascial pain’/de OR ‘musculoskeletal dis- 2801790
ease’/exp OR ‘neuritis’/exp OR radiculopath* OR radiculitis OR temporomandibular OR myofascial NEAR/3 pain*
OR (thoracic AND outlet AND syndrome*) OR ‘spinal osteophytosis’ OR neuritis OR spondylosis OR splondylitis
OR spondylolisthesis OR spondylolysis OR arthritis OR osteoarthritis OR spondylarthritis OR fibromyalgia OR

sprain* OR strain*
7 ‘radiculopathy’/exp/dm_rh OR ‘temporomandibular joint disorder’/dm_rh OR ‘myofascial pain’/dm_rh OR 20066
‘musculoskeletal disease’/exp/dm_rh OR ‘neuritis’/exp/dm_rh
8 ‘atlantoaxial dislocation’/dm_rh OR ‘neck pain’/dm_rh OR ‘brachial plexus neuropathy’/dm_rh OR ‘neck injury’/ 644
exp/dm_rh OR ‘thorax outlet syndrome’/dm_rh OR ‘torticollis’/dm_rh
9 ‘meta analysis’/de OR ‘meta analysis (topic)’/de OR ‘systematic review’/de OR ‘systematic review (topic)’/de OR 75731
meta AND analy* OR metaanaly* OR meta AND analy* OR systematic AND review* OR systematic AND overview*
OR cochrane OR embase OR psyclit OR psychlit OR psycinfo OR psychinfo OR cinahl OR cinhal OR science AND
citation AND index OR bids OR cancerlit OR ‘web of science’ OR reference AND list* OR bibliograph* OR hand
AND search* OR ‘relevant journals’ OR manual AND search* OR (‘selection criteria’ OR data NEAR/3 extract*
AND (review OR reviews))
10 #1 AND #2 AND #3 71583
11 #1 AND #4 4332
12 #1 AND #2 AND #5 1956
13 #1 AND #2 AND #6 31349
14 #2 AND #7 2689
15 #8 OR #10 OR #11 OR #12 OR #13 OR #14 83564
16 #9 AND #15 979
17 #16 AND [english]/lim AND ([embase]/lim OR [embase classic]/lim) 957
18 #17 AND (2010:py OR 2011:py OR 2012:py OR 2013:py OR 2014:py) 500
APPENDIX A
Below is an example Medline-OVID search for articles relat- 46. (thoracic adj3 vertebrae).mp.
ed to Interventions. We only used articles published between 47. neck.mp.
January 2007 and August 2016. 48. (thoracic adj3 spine).mp.
49. (thoracic adj3 outlet).mp.
1. Neck Pain/ 50. trapezius.mp.
2. exp Brachial Plexus Neuropathies/ 51. cervical.mp.
3. exp neck injuries/ or exp whiplash injuries/ 52. cervico*.mp.
4. cervical pain.mp. 53. 51 or 52
5. neckache.mp. 54. exp genital diseases, female/
6. whiplash.mp. 55. genital disease*.mp.
7. cervicodynia.mp. 56. exp *Uterus/
8. cervicalgia.mp. 57. 54 or 55 or 56
9. brachialgia.mp. 58. 53 not 57
10. brachial neuritis.mp. 59. 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or
11. brachial neuralgia.mp. 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or
12. neck pain.mp. 47 or 48 or 49 or 50 or 58
13. neck injur*.mp. 60. exp pain/
14. brachial plexus neuropath*.mp. 61. exp injuries/
15. brachial plexus neuritis.mp. 62. pain.mp.

16. thoracic outlet syndrome/ or cervical rib syndrome/ 63. ache.mp.
17. Torticollis/ 64. sore.mp.
18. exp brachial plexus neuropathies/ or exp brachial 65. stiff.mp.
plexus neuritis/ 66. discomfort.mp.
19. cervico brachial neuralgia.ti,ab. 67. injur*.mp.
20. cervicobrachial neuralgia.ti,ab. 68. neuropath*.mp.
21. (monoradicul* or monoradicl*).tw. 69. or/60-68
22. or/1-21 70. 59 and 69
23. exp headache/ and cervic*.tw. 71. Radiculopathy/
24. exp genital diseases, female/ 72. exp temporomandibular joint disorders/ or exp tem-
25. genital disease*.mp. poromandibular joint dysfunction syndrome/
26. or/24-25 73. myofascial pain syndromes/
27. 23 not 26 74. exp “Sprains and Strains”/
28. 22 or 27 75. exp Spinal Osteophytosis/
29. neck/ 76. exp Neuritis/
30. neck muscles/ 77. Polyradiculopathy/
31. exp cervical plexus/ 78. exp Arthritis/
32. exp cervical vertebrae/ 79. Fibromyalgia/
33. atlanto-axial joint/ 80. spondylitis/ or discitis/
34. atlanto-occipital joint/ 81. spondylosis/ or spondylolysis/ or spondylolisthesis/
35. Cervical Atlas/ 82. radiculopathy.mp.
36. spinal nerve roots/ 83. radiculitis.mp.
37. exp brachial plexus/ 84. temporomandibular.mp.
38. (odontoid* or cervical or occip* or atlant*).tw. 85. myofascial pain syndrome*.mp.
39. axis/ or odontoid process/ 86. thoracic outlet syndrome*.mp.
40. Thoracic Vertebrae/ 87. spinal osteophytosis.mp.
41. cervical vertebrae.mp. 88. neuritis.mp.
42. cervical plexus.mp. 89. spondylosis.mp.
43. cervical spine.mp. 90. spondylitis.mp.
44. (neck adj3 muscles).mp. 91. spondylolisthesis.mp.
45. (brachial adj3 plexus).mp. 92. or/71-91
APPENDIX A
93. 59 and 92 141. Torticollis/rh

94. exp neck/ 142. exp brachial plexus neuropathies/rh or exp brachial
95. exp cervical vertebrae/ plexus neuritis/rh
96. Thoracic Vertebrae/ 143. 137 or 138 or 139 or 140 or 141 or 142
97. neck.mp. 144. Radiculopathy/rh
98. (thoracic adj3 vertebrae).mp. 145. exp temporomandibular joint disorders/rh or exp
99. cervical.mp. temporomandibular joint dysfunction syndrome/rh
100. cervico*.mp. 146. myofascial pain syndromes/rh
101. 99 or 100 147. exp “Sprains and Strains”/rh
102. exp genital diseases, female/ 148. exp Spinal Osteophytosis/rh
103. genital disease*.mp. 149. exp Neuritis/rh
104. exp *Uterus/ 150. Polyradiculopathy/rh
105. or/102-104 151. exp Arthritis/rh
106. 101 not 105 152. Fibromyalgia/rh
107. (thoracic adj3 spine).mp. 153. spondylitis/rh or discitis/rh
108. cervical spine.mp. 154. spondylosis/rh or spondylolysis/rh or spondylolisthesis/
109. 94 or 95 or 96 or 97 or 98 or 106 or 107 or 108 rh
110. Intervertebral Disk/ 155. or/144-154
111. (disc or discs).mp. 156. 59 and 155

112. (disk or disks).mp. 157. exp Combined Modality Therapy/
113. 110 or 111 or 112 158. Exercise/
114. 109 and 113 159. Physical Exertion/
115. herniat*.mp. 160. exp Exercise Therapy/
116. slipped.mp. 161. exp Electric Stimulation Therapy/
117. prolapse*.mp. 162. Transcutaneous Electric Nerve Stimulation/
118. displace*.mp. 163. pulsed electro magnetic field.mp.
119. degenerat*.mp. 164. pulsed electromagnetic field.tw.
120. (bulge or bulged or bulging).mp. 165. Electromagnetic Fields/
121. 115 or 116 or 117 or 118 or 119 or 120 166. Magnetic Field Therapy/
122. 114 and 121 167. Electric Stimulation/
123. intervertebral disk degeneration/ or intervertebral 168. exp Orthotic Devices/
disk displacement/ 169. kinesiotaping.tw.
124. intervertebral disk displacement.mp. 170. taping.tw.
125. intervertebral disc displacement.mp. 171. oral splints.tw.
126. intervertebral disk degeneration.mp. 172. Occlusal Splints/
127. intervertebral disc degeneration.mp. 173. pillow?.tw.
128. 123 or 124 or 125 or 126 or 127 174. collar?.tw.
129. 109 and 128 175. Traction/
130. 28 or 70 or 93 or 122 or 129 176. traction.tw.
131. animals/ not (animals/ and humans/) 177. exp Laser Therapy/
132. 130 not 131 178. laser therapy.tw.
133. exp *neoplasms/ 179. exp Rehabilitation/
134. exp *wounds, penetrating/ 180. Ultrasonic Therapy/
135. 133 or 134 181. exp Phototherapy/
136. 132 not 135 182. Lasers/
137. Neck Pain/rh [Rehabilitation] 183. exp Physical Therapy Modalities/
138. exp Brachial Plexus Neuropathies/rh 184. repetitive magnetic stimulation.tw.
139. exp neck injuries/rh or exp whiplash injuries/rh 185. exp Cryotherapy/
140. thoracic outlet syndrome/rh or cervical rib 186. Hydrotherapy/
syndrome/rh 187. exp Hyperthermia, Induced/
APPENDIX A
188. vapocoolant spray.mp. 215. exp meta-analysis as topic/

189. Cryoanesthesia/ 216. (meta analy* or metaanaly* or met analy* or
190. Ice/ metanaly*).tw.
191. postur* correction.mp. 217. review literature as topic/
192. Feldenkrais.mp. 218. (collaborative research or collaborative review* or
193. (alexander adj (technique or method)).tw. collaborative overview*).tw.
194. Relaxation Therapy/ 219. (integrative research or integrative review* or inter-
195. Biofeedback, Psychology/ grative overview*).tw.
196. faradic stimulation.mp. 220. (quantitative adj3 (research or review* or overview*)).tw.
197. or/157-196 221. (research integration or research overview*).tw.
198. 136 and 197 222. (systematic* adj3 (review* or overview*)).tw.
199. 143 or 156 or 198 223. (methodologic* adj3 (review* or overview*)).tw.
200. animals/ not (animals/ and humans/) 224. exp technology assessment biomedical/
201. 199 not 200 225. (hta or thas or technology assessment*).tw.
202. guidelines as topic/ 226. ((hand adj2 search*) or (manual* adj search*)).tw.
203. practice guidelines as topic/ 227. ((electronic adj database*) or (bibliographic* adj da-
204. guideline.pt. tabase*)).tw.
205. practice guideline.pt. 228. ((data adj2 abstract*) or (data adj2 extract*)).tw.
206. (guideline? or guidance or recommendations).ti. 229. (analys* adj3 (pool or pooled or pooling)).tw.
207. consensus.ti. 230. mantel haenszel.tw.
208. or/202-207 231. (cohrane or pubmed or pub med or medline or em-
209. 201 and 208 base or psycinfo or psyclit or psychinfo or psychlit or
210. 136 and 208 cinahl or science citation indes).ab.
211. 209 or 210 232. or/214-231
212. limit 211 to yr=”2006 -Current” 233. 201 and 232
213. limit 211 to yr=”1902 - 2005” 234. limit 233 to yr=”2006 -Current”
214. meta-analysis/ 235. limit 233 to yr=”1902 - 2005”
Below is an example MEDLINE-OVID search for articles 16. thoracic outlet syndrome/ or cervical rib syndrome/
related to Manual Therapy. We only used articles published 17. Torticollis/
between January 2007 and August 2016. Last update: April 18. exp brachial plexus neuropathies/ or exp brachial
21, 2012. plexus neuritis/
19. cervico brachial neuralgia.ti,ab.
1. Neck Pain/ 20. cervicobrachial neuralgia.ti,ab.
2. exp Brachial Plexus Neuropathies/ 21. (monoradicul* or monoradicl*).tw.
3. exp neck injuries/ or exp whiplash injuries/ 22. or/1-21
4. cervical pain.mp. 23. exp headache/ and cervic*.tw.
5. neckache.mp. 24. exp genital diseases, female/
6. whiplash.mp. 25. genital disease*.mp.
7. cervicodynia.mp. 26. or/24-25
8. cervicalgia.mp. 27. 23 not 26
9. brachialgia.mp. 28. 22 or 27
10. brachial neuritis.mp. 29. neck/
11. brachial neuralgia.mp. 30. neck muscles/
12. neck pain.mp. 31. exp cervical plexus/
13. neck injur*.mp. 32. exp cervical vertebrae/
14. brachial plexus neuropath*.mp. 33. atlanto-axial joint/
15. brachial plexus neuritis.mp. 34. atlanto-occipital joint/
APPENDIX A
35. Cervical Atlas/ 82. radiculopathy.mp.

36. spinal nerve roots/ 83. radiculitis.mp.
37. exp brachial plexus/ 84. temporomandibular.mp.
38. (odontoid* or cervical or occip* or atlant*).tw. 85. myofascial pain syndrome*.mp.
39. axis/ or odontoid process/ 86. thoracic outlet syndrome*.mp.
40. Thoracic Vertebrae/ 87. spinal osteophytosis.mp.
41. cervical vertebrae.mp. 88. neuritis.mp.
42. cervical plexus.mp. 89. spondylosis.mp.
43. cervical spine.mp. 90. spondylitis.mp.
44. (neck adj3 muscles).mp. 91. spondylolisthesis.mp.
45. (brachial adj3 plexus).mp. 92. or/71-91
46. (thoracic adj3 vertebrae).mp. 93. 59 and 92
47. neck.mp. 94. exp neck/
48. (thoracic adj3 spine).mp. 95. exp cervical vertebrae/
49. (thoracic adj3 outlet).mp. 96. Thoracic Vertebrae/
50. trapezius.mp. 97. neck.mp.
51. cervical.mp. 98. (thoracic adj3 vertebrae).mp.
52. cervico*.mp. 99. cervical.mp.
53. 51 or 52 100. cervico*.mp.

54. exp genital diseases, female/ 101. 99 or 100
55. genital disease*.mp. 102. exp genital diseases, female/
56. exp *Uterus/ 103. genital disease*.mp.
57. 54 or 55 or 56 104. exp *Uterus/
58. 53 not 57 105. or/102-104
59. 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 106. 101 not 105
38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 107. (thoracic adj3 spine).mp.
47 or 48 or 49 or 50 or 58 108. cervical spine.mp.
60. exp pain/ 109. 94 or 95 or 96 or 97 or 98 or 106 or 107 or 108
61. exp injuries/ 110. Intervertebral Disk/

62. pain.mp. 111. (disc or discs).mp.
63. ache.mp. 112. (disk or disks).mp.
64. sore.mp. 113. 110 or 111 or 112
65. stiff.mp. 114. 109 and 113
66. discomfort.mp. 115. herniat*.mp.
67. injur*.mp. 116. slipped.mp.
68. neuropath*.mp. 117. prolapse*.mp.
69. or/60-68 118. displace*.mp.
70. 59 and 69 119. degenerat*.mp.
71. Radiculopathy/ 120. (bulge or bulged or bulging).mp.
72. exp temporomandibular joint disorders/ or exp tem- 121. 115 or 116 or 117 or 118 or 119 or 120
poromandibular joint dysfunction syndrome/ 122. 114 and 121
73. myofascial pain syndromes/ 123. intervertebral disk degeneration/ or intervertebral
74. exp “Sprains and Strains”/ disk displacement/
75. exp Spinal Osteophytosis/ 124. intervertebral disk displacement.mp.
76. exp Neuritis/ 125. intervertebral disc displacement.mp.
77. Polyradiculopathy/ 126. intervertebral disk degeneration.mp.
78. exp Arthritis/ 127. intervertebral disc degeneration.mp.
79. Fibromyalgia/ 128. 123 or 124 or 125 or 126 or 127
80. spondylitis/ or discitis/ 129. 109 and 128
81. spondylosis/ or spondylolysis/ or spondylolisthesis/ 130. 28 or 70 or 93 or 122 or 129
APPENDIX A
131. animals/ not (animals/ and humans/) 173. muscle energy technique*.tw.
132. 130 not 131 174. trigger point.tw.
133. exp *neoplasms/ 175. proprioceptive Neuromuscular Facilitation*.tw.
134. exp *wounds, penetrating/ 176. cyriax friction.tw.
135. 133 or 134 177. (lomilomi or lomi-lomi or trager).tw.
136. 132 not 135 178. aston patterning.tw.
137. Neck Pain/rh, th [Rehabilitation, Therapy] 179. (strain adj counterstrain).tw.
138. exp Brachial Plexus Neuropathies/rh, th 180. (craniosacral therap* or cranio-sacral therap*).tw.
139. exp neck injuries/rh, th or exp whiplash injuries/rh, th 181. (amma or ammo or effleuurage or petrissage or
140. thoracic outlet syndrome/rh, th or cervical rib syn- hacking or tapotment).tw.
drome/rh, th 182. Complementary Therapies/
141. Torticollis/rh, th 183. ((complement* or alternat* or osteopthic*) adj
142. exp brachial plexus neuropathies/rh, th or exp bra- (therap* or medicine)).tw.
chial plexus neuritis/rh, th 184. (Tui Na or Tuina).tw.
143. or/137-142 185. or/157-184
144. Radiculopathy/rh, th 186. 136 and 185
145. exp temporomandibular joint disorders/rh, th or exp 187. 143 or 156 or 186
temporomandibular joint dysfunction syndrome/rh, 188. animals/ not (animals/ and humans/)
th 189. 187 not 188

146. myofascial pain syndromes/rh, th 190. exp randomized controlled trials as topic/
147. exp “Sprains and Strains”/rh, th 191. randomized controlled trial.pt.
148. exp Spinal Osteophytosis/rh, th 192. controlled clinical trial.pt.
149. exp Neuritis/rh, th 193. (random* or sham or placebo*).tw.
150. Polyradiculopathy/rh, th 194. placebos/
151. exp Arthritis/rh, th 195. random allocation/
152. Fibromyalgia/rh, th 196. single blind method/
153. spondylitis/rh, th or discitis/rh, th 197. double blind method/
154. spondylosis/rh, th or spondylolysis/rh, th or spondy- 198. ((singl* or doubl* or trebl* or tripl*) adj25 (blind* or
lolisthesis/rh, th dumm* or mask*)).ti,ab.

155. or/144-154 199. (rct or rcts).tw.
156. 59 and 155 200. (control* adj2 (study or studies or trial*)).tw.
157. acupuncture/ or chiropractic/ 201. or/190-200
158. exp Musculoskeletal Manipulations/ 202. 189 and 201
159. massage.tw. 203. limit 202 to yr=”2006 -Current”
160. mobili?ation.tw. 204. limit 202 to yr=”1902 -Current”
161. Acupuncture Therapy/ 205. limit 202 to yr=”1902 -2005”
162. (acupuncture or acu-puncture or needling or acu- 206. guidelines as topic/
pressure or mox?bustion).tw. 207. practice guidelines as topic/
163. ((neck or spine or spinal or cervical or chiropractic* 208. guideline.pt.
or musculoskeletal* or musculo-skeletal*) adj3 (ad- 209. practice guideline.pt.
just* or manipulat* or mobiliz* or mobilis*)).tw. 210. (guideline? or guidance or recommendations).ti.
164. (manual adj therap*).tw. 211. consensus.ti.
165. (manipulati* adj (therap* or medicine)).tw. 212. or/206-211
166. (massag* or reflexolog* or rolfing or zone therap*).tw. 213. 189 and 212
167. Nimmo.mp. 214. limit 213 to yr=”2006 -Current”
168. exp Vibration/tu [Therapeutic Use] 215. limit 213 to yr=”1902 -2005”
169. (vibration adj5 (therap* or treatment*)).tw. 216. meta-analysis/
170. (Chih Ya or Shiatsu or Shiatzu or Zhi Ya).tw. 217. exp meta-analysis as topic/
171. (flexion adj2 distraction*).tw. 218. (meta analy* or metaanaly* or met analy* or
172. (myofascial adj3 (release or therap*)).tw. metanaly*).tw.
APPENDIX A
219. review literature as topic/ 234. or/216-233

220. (collaborative research or collaborative review* or 235. 189 and 234
collaborative overview*).tw. 236. limit 235 to yr=”2006 -Current”
221. (integrative research or integrative review* or 237. limit 235 to yr=”1902 -2005”
intergrative overview*).tw. 238. (ae or to or po or co).fs.
222. (quantitative adj3 (research or review* or 239. (safe or safety or unsafe).tw.
overview*)).tw. 240. (side effect* or side event*).tw.
223. (research integration or research overview*).tw. 241. ((adverse or undesirable or harm* or injurious or
224. (systematic* adj3 (review* or overview*)).tw. serious or toxic) adj3 (effect* or event* or reaction*
225. (methodologic* adj3 (review* or overview*)).tw. or incident* or outcome*)).tw.
226. exp technology assessment biomedical/ 242. (abnormalit* or toxicit* or complication* or
227. (hta or thas or technology assessment*).tw. consequence* or noxious or tolerabilit*).tw.
228. ((hand adj2 search*) or (manual* adj search*)).tw. 243. or/238-242
229. ((electronic adj database*) or (bibliographic* adj 244. 189 and 243
database*)).tw. 245. limit 244 to yr=”2006 -Current”
230. ((data adj2 abstract*) or (data adj2 extract*)).tw. 246. limit 244 to yr=”1902 -2005”
231. (analys* adj3 (pool or pooled or pooling)).tw. 247. limit 202 to ed=20100701-20120321
232. mantel haenszel.tw. 248. limit 213 to ed=20100701-20120321
233. (cohrane or pubmed or pub med or medline or em- 249. limit 235 to ed=20100701-20120321
base or psycinfo or psyclit or psychinfo or psychlit 250. limit 245 to ed=20100701-20120321
or cinahl or science citation indes).ab.
APPENDIX B
SEARCH DATES AND RESULTS

August 25, 2016
Database Platform Years Covered Date Conducted Results, n
MEDLINE OVID 2014-August 2016 8-25-16 835
CINAHL EBSCO 2014-August 2016 8-25-16 40
Web of Science Web of Knowledge 2014-August 2016 8-25-16 …
Cochrane Wiley 2014-August 2016 8-25-16 27
Embase 2014-August 2016 8-25-16 161
Total 1063
With duplicates removed 177
April 25, 2014: Neck Pain Modalities

MEDLINE OVID 2010-2014 4-21-14 153
CINAHL EBSCO 2010-2014 4-21-14 92
Web of Science Web of Knowledge 2010-2014 4-21-14 235

Cochrane Wiley 2010-2014 4-21-14 57
Embase 2010-2014 4-25-14 500
Total 1037
May 29, 2015: Update Through November 2014

MEDLINE OVID 2014 5-29-15 31

CINAHL EBSCO 2014 5-29-15 11
Web of Science Web of Knowledge 2014 5-29-15 52
Cochrane Wiley 2014 5-29-15 13
Embase 2014 5-29-15 47
Total 154
September 29, 2014: Education*

MEDLINE OVID 2010-current 9-29-14 34
CINAHL EBSCO 2010-current 9-29-14 15
Web of Science Web of Knowledge 2010-current 9-29-14 33
Cochrane Wiley 2010-current 9-29-14 10
Embase 2010-current 9-29-14 26
Total 118
*Some Overlap With ICON, Whose Search Went From 2000 to 2010.
APPENDIX B
September 29, 2014: Cervical Orthoses*

MEDLINE OVID 2010-current 9-29-14 43
CINAHL EBSCO 2010-current 9-29-14 17
Web of Science Web of Knowledge 2010-current 9-29-14 46
Cochrane Wiley 2010-current 9-29-14 10
Embase 2010-current 9-29-14 32
Total 148
*Some Overlap With ICON, Whose Search Went From 2000 to 2010.
APPENDIX C
CRITERIA FOR INCLUSION AND EXCLUSION OF - manual therapy

STUDIES OF INTERVENTIONS - exercise
- multimodal physical therapy treatments
Systematic reviews and meta-analyses published in peer-reviewed - patient education
journals were reviewed. - physical agents
Exclusions: experimental and quasi-experimental trials, cohort, case • heat and cold
series, and cross-sectional studies, meeting abstracts, press releas- • electrotherapeutic modalities
es, theses, nonsystematic review articles, case reports, and articles • laser
that could not be retrieved in English. • inserted needle techniques (reviews clearly identified as
dry needling)
Inclusion Criteria • traction
• screening / differential diagnosis • ultrasound
OR • orthoses (neck braces)
• diagnosis / classification
OR Exclusion Criteria
• patient reported outcome measures related to neck pain. Articles reporting on the following were excluded:
OR • primarily infants, children, or adolescents (<18 years old)
• measurement properties of physical impairments, or of activity • postsurgical neck pain
limitation/participation restriction using data from a sample of • cervical vertebral fracture
patients with neck pain • nonmusculoskeletal neck pain:

AND - visceral or vascular referral
• adults (≥18 years old) - integumentary
AND • topics outside the scope of physical therapist practice
• interventions within the scope of physical therapist practice for (eg, surgery)
neck pain, including: • pharmacological interventions
APPENDIX D
FLOW DIAGRAM OF ARTICLES LEADING TO INTERVENTION RECOMMENDATIONS

Identification
Records identified through Gray literature and additional Update search, n = 1457 Update search 2, n = 1063
database searching, records identified from
n = 10059 other sources, n = 234
Records after duplicates removed, n = 3874

Screening
Records screened, n = 3874 Title and abstract exclusion, n = 3126
Full-text articles excluded, n = 513

• Incorrect publication type, n = 121
Full-text articles assessed for eligibility, n = 748
• No/incorrect intervention, n = 241
Eligibility
• Incorrect population, n = 76
• Unable to obtain PDF, n = 3
• Unable to translate, n = 3
Articles used in intervention recommendations (some articles • Other, n = 69
contributed to more than 1 category), n = 72
Articles used in other Sections, n = 163

Included
Manual therapy, Exercise, n = 43 Education, n = 7 Physical agents, Other, n = 4

n = 38 n = 15
APPENDIX E
ARTICLES INCLUDED IN RECOMMENDATIONS Disorders. J Occup Environ Med. 2010;52:424-427. https://doi.

BY TOPIC org/10.1097/JOM.0b013e3181d44f3b
Holmstrom EB, Lindell J, Moritz U. Low back and neck/shoulder pain
IMPAIRMENT/FUNCTION-BASED DIAGNOSIS in construction workers: occupational workload and psychosocial
Prevalence risk factors. Part 2: Relationship to neck and shoulder pain. Spine
Andersson HI. The epidemiology of chronic pain in a Swedish (Phila Pa 1976). 1992;17:672-677.
rural area. Qual Life Res. 1994;3 suppl 1:S19-S26. https://doi. Hoving JL, Gross AR, Gasner D, et al. A critical appraisal of review
org/10.1007/BF00433371 articles on the effectiveness of conservative treatment for neck
Borghouts JA, Koes BW, Bouter LM. The clinical course and prognos- pain. Spine (Phila Pa 1976). 2001;26:196-205.
tic factors of non-specific neck pain: a systematic review. Pain. Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck
1998;77:1-13. https://doi.org/10.1016/S0304-3959(98)00058-X pain. Best Pract Res Clin Rheumatol. 2010;24:783-792. https://
Borghouts JA, Koes BW, Vondeling H, Bouter LM. Cost-of-illness of doi.org/10.1016/j.berh.2011.01.019
neck pain in The Netherlands in 1996. Pain. 1999;80:629-636. Jacobsson L, Lindgarde F, Manthorpe R. The commonest rheumatic
https://doi.org/10.1016/S0304-3959(98)00268-1 complaints of over six weeks’ duration in a twelve-month period
in a defined Swedish population. Prevalences and relationships.
Bot SD, van der Waal JM, Terwee CB, et al. Incidence and prevalence
Scand J Rheumatol. 1989;18:353-360.
of complaints of the neck and upper extremity in general prac-
tice. Ann Rheum Dis. 2005;64:118-123. https://doi.org/10.1136/ Jette DU, Jette AM. Physical therapy and health outcomes in patients
ard.2003.019349 with spinal impairments. Phys Ther. 1996;76:930-941; discussion
942-945.
Bovim G, Schrader H, Sand T. Neck pain in the general population.
Spine (Phila Pa 1976). 1994;19:1307-1309. Jette AM, Smith K, Haley SM, Davis KD. Physical therapy episodes of
care for patients with low back pain. Phys Ther. 1994;74:101-110;
Brattberg G, Thorslund M, Wikman A. The prevalence of pain
discussion 110-115.
in a general population. The results of a postal survey in
a county of Sweden. Pain. 1989;37:215-222. https://doi. Linton SJ, Ryberg M. Do epidemiological results replicate? The preva-
org/10.1016/0304-3959(89)90133-4 lence and health-economic consequences of neck and back pain
in the general population. Eur J Pain. 2000;4:347-354. https://doi.
Côté P, Cassidy JD, Carroll L. The factors associated with neck pain org/10.1053/eujp.2000.0190
and its related disability in the Saskatchewan population. Spine
(Phila Pa 1976). 2000;25:1109-1117. Mäkela M, Heliövaara M, Sievers K, Impivaara O, Knekt P, Aromaa
A. Prevalence, determinants, and consequences of chronic neck
Côté P, Cassidy JD, Carroll L. The Saskatchewan Health and Back
pain in Finland. Am J Epidemiol. 1991;134:1356-1367. https://doi.

Pain Survey. The prevalence of neck pain and related disability in org/10.1093/oxfordjournals.aje.a116038
Saskatchewan adults. Spine (Phila Pa 1976). 1998;23:1689-1698.
March L, Smith EU, Hoy DG, et al. Burden of disability due to mus-
Côté P, Cassidy JD, Carroll LJ, Kristman V. The annual incidence and culoskeletal (MSK) disorders. Best Pract Res Clin Rheumatol.
course of neck pain in the general population: a population-based 2014;28:353-366. https://doi.org/10.1016/j.berh.2014.08.002
cohort study. Pain. 2004;112:267-273. https://doi.org/10.1016/j.
Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years
pain.2004.09.004
(DALYs) for 291 diseases and injuries in 21 regions, 1990-2010:
Croft PR, Lewis M, Papageorgiou AC, et al. Risk factors for neck pain: a systematic analysis for the Global Burden of Disease Study
a longitudinal study in the general population. Pain. 2001;93:317- 2010. Lancet. 2012;380:2197-2223. https://doi.org/10.1016/
325. https://doi.org/10.1016/S0304-3959(01)00334-7 S0140-6736(12)61689-4
Di Fabio RP, Boissonnault W. Physical therapy and health-related Murray CJ, Barber RM, Foreman KJ, et al. Global, regional, and
outcomes for patients with common orthopaedic diagnoses. J Or- national disability-adjusted life years (DALYs) for 306 dis-
thop Sports Phys Ther. 1998;27:219-230. https://doi.org/10.2519/ eases and injuries and healthy life expectancy (HALE) for 188
jospt.1998.27.3.219 countries, 1990-2013: quantifying the epidemiological transi-
Elnaggar IM, Nordin M, Sheikhzadeh A, Parnianpour M, Kahanovitz N. tion. Lancet. 2015;386:2145-2191. https://doi.org/10.1016/
Effects of spinal flexion and extension exercises on low-back pain S0140-6736(15)61340-X
and spinal mobility in chronic mechanical low-back pain patients. Nygren A, Berglund A, von Koch M. Neck-and-shoulder pain, an
Spine (Phila Pa 1976). 1991;16:967-972. increasing problem. Strategies for using insurance material to fol-
Goode AP, Freburger J, Carey T. Prevalence, practice patterns, and low trends. Scand J Rehabil Med Suppl. 1995;32:107-112.
evidence for chronic neck pain. Arthritis Care Res (Hoboken). Palmer KT, Walker-Bone K, Griffin MJ, et al. Prevalence and occupa-
2010;62:1594-1601. https://doi.org/10.1002/acr.20270 tional associations of neck pain in the British population. Scand J
Haldeman S, Carroll L, Cassidy JD. Findings from the Bone and Joint Work Environ Health. 2001;27:49-56.
Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Pransky G, Benjamin K, Hill-Fotouhi C, et al. Outcomes
APPENDIX E
in work-related upper extremity and low back in- (Phila Pa 1976). 2008;33:S83-S92. https://doi.org/10.1097/
juries: results of a retrospective study. Am J Ind BRS.0b013e3181643eb8
Med. 2000;37:400-409. https://doi.org/10.1002/ Casey PP, Feyer AM, Cameron ID. Course of recovery for whip-
(SICI)1097-0274(200004)37:4<400::AID-AJIM10>3.0.CO;2-C lash associated disorders in a compensation setting. Injury.
Rempel DM, Harrison RJ, Barnhart S. Work-related cumulative trau- 2015;46:2118-2129. https://doi.org/10.1016/j.injury.2015.08.038
ma disorders of the upper extremity. JAMA. 1992;267:838-842. Daenen L, Nijs J, Raadsen B, Roussel N, Cras P, Dankaerts W. Cervi-
https://doi.org/10.1001/jama.1992.03480060084035 cal motor dysfunction and its predictive value for long-term
Takala EP, Viikari-Juntura E, Tynkkynen EM. Does group gymnastics recovery in patients with acute whiplash-associated disorders: a
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O’Riordan C, Clifford A, Van De Ven P, Nelson J. Chronic neck pain
1540. https://doi.org/10.1016/j.spinee.2014.03.039
and exercise interventions: frequency, intensity, time, and type
principle. Arch Phys Med Rehabil. 2014;95:770-783. https://doi.
org/10.1016/j.apmr.2013.11.015 Neck Pain With Headache
Parreira PC, Costa LC, Hespanhol Junior LC, Lopes AD, Costa LO. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of
Current evidence does not support the use of Kinesio Taping in manual therapies: the UK evidence report. Chiropr Osteopat.
clinical practice: a systematic review. J Physiother. 2014;60:31-39. 2010;18:3. https://doi.org/10.1186/1746-1340-18-3
https://doi.org/10.1016/j.jphys.2013.12.008 Brønfort G, Nilsson N, Haas M, et al. Non-invasive physical treat-
APPENDIX E
ments for chronic/recurrent headache. Cochrane Database https://doi.org/10.1016/j.math.2010.02.007

Syst Rev. 2004:CD001878. https://doi.org/10.1002/14651858. Racicki S, Gerwin S, DiClaudio S, Reinmann S, Donaldson M.
CD001878.pub2 Conservative physical therapy management for the treatment
Carlesso LC, MacDermid JC, Santaguida PL, Thabane L. Determining of cervicogenic headache: a systematic review. J Man Manip
adverse events in patients with neck pain receiving orthopaedic Ther. 2013;21:113-124. https://doi.org/10.1179/204261861
manual physiotherapy: a pilot and feasibility study. Physiother 2Y.0000000025
Can. 2013;65:255-265. https://doi.org/10.3138/ptc.2012-28 Reid SA, Rivett DA. Manual therapy treatment of cervicogenic dizzi-
Chaibi A, Russell MB. Manual therapies for cervicogenic headache: a ness: a systematic review. Man Ther. 2005;10:4-13. https://doi.
systematic review. J Headache Pain. 2012;13:351-359. https://doi. org/10.1016/j.math.2004.03.006
org/10.1007/s10194-012-0436-7 Varatharajan S, Ferguson B, Chrobak K, et al. Are non-invasive inter-
Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Pareja ventions effective for the management of headaches associated
JA. Spinal manipulative therapy in the management of cervi- with neck pain? An update of the Bone and Joint Decade Task
cogenic headache. Headache. 2005;45:1260-1263. https://doi. Force on Neck Pain and Its Associated Disorders by the Ontario
org/10.1111/j.1526-4610.2005.00253_1.x Protocol for Traffic Injury Management (OPTIMa) Collabora-
Furlan AD, Malmivaara A, Chou R, et al. 2015 updated method tion. Eur Spine J. 2016;25:1971-1999. https://doi.org/10.1007/
guideline for systematic reviews in the Cochrane Back and Neck s00586-016-4376-9
Group. Spine (Phila Pa 1976). 2015;40:1660-1673. https://doi. Zronek M, Sanker H, Newcomb J, Donaldson M. The influence
org/10.1097/BRS.0000000000001061 of home exercise programs for patients with non-specific or
Gross A, Kay TM, Paquin JP, et al. Exercises for mechanical neck dis- specific neck pain: a systematic review of the literature. J Man
orders. Cochrane Database Syst Rev. 2015;1:CD004250. https:// Manip Ther. 2016;24:62-73. https://doi.org/10.1179/204261861
doi.org/10.1002/14651858.CD004250.pub5 3Y.0000000047
Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation
for neck pain contrasted against an inactive control or another Neck Pain With Radiating Pain
active treatment. Cochrane Database Syst Rev. 2015:CD004249. Boyles R, Toy P, Mellon J, Jr., Hayes M, Hammer B. Effectiveness of
https://doi.org/10.1002/14651858.CD004249.pub4 manual physical therapy in the treatment of cervical radiculopa-
Gross AR, Goldsmith C, Hoving JL, et al. Conservative management thy: a systematic review. J Man Manip Ther. 2011;19:135-142.
of mechanical neck disorders: a systematic review. J Rheumatol. https://doi.org/10.1179/2042618611Y.0000000011
2007;34:1083-1102. Furlan AD, Malmivaara A, Chou R, et al. 2015 updated method
guideline for systematic reviews in the Cochrane Back and Neck
Gross AR, Kaplan F, Huang S, et al. Psychological care, patient

education, orthotics, ergonomics and prevention strategies Group. Spine (Phila Pa 1976). 2015;40:1660-1673. https://doi.
for neck pain: an systematic overview update as part of the org/10.1097/BRS.0000000000001061
ICON project. Open Orthop J. 2013;7:530-561. https://doi. Graham N, Gross AR, Carlesso LC, et al. An ICON over-
org/10.2174/1874325001307010530 view on physical modalities for neck pain and associ-
Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck ated disorders. Open Orthop J. 2013;7:440-460. https://doi.
pain: noninvasive interventions: results of the Bone and Joint org/10.2174/1874325001307010440
Decade 2000-2010 Task Force on Neck Pain and Its Associated Gross A, Kay TM, Paquin JP, et al. Exercises for mechanical neck dis-
Disorders. Spine (Phila Pa 1976). 2008;33:S123-S152. https://doi. orders. Cochrane Database Syst Rev. 2015;1:CD004250. https://
org/10.1097/BRS.0b013e3181644b1d doi.org/10.1002/14651858.CD004250.pub5
Kay TM, Gross A, Goldsmith CH, et al. Exercises for mechanical neck Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation
disorders. Cochrane Database Syst Rev. 2012:CD004250. https:// for neck pain contrasted against an inactive control or another
doi.org/10.1002/14651858.CD004250.pub4 active treatment. Cochrane Database Syst Rev. 2015:CD004249.
McLean SM, Burton M, Bradley L, Littlewood C. Interventions for https://doi.org/10.1002/14651858.CD004249.pub4
enhancing adherence with physiotherapy: a systematic re- Gross AR, Goldsmith C, Hoving JL, et al. Conservative management
view. Man Ther. 2010;15:514-521. https://doi.org/10.1016/j. of mechanical neck disorders: a systematic review. J Rheumatol.
math.2010.05.012 2007;34:1083-1102.
Macaulay J, Cameron M, Vaughan B. The effectiveness of Gross AR, Kaplan F, Huang S, et al. Psychological care, patient
manual therapy for neck pain: a systematic review of the education, orthotics, ergonomics and prevention strategies
literature. Phys Ther Rev. 2007;12:261-267. https://doi. for neck pain: an systematic overview update as part of the
org/10.1179/108331907X223038 ICON project. Open Orthop J. 2013;7:530-561. https://doi.
Miller J, Gross A, D’Sylva J, et al. Manual therapy and exercise for org/10.2174/1874325001307010530
neck pain: a systematic review. Man Ther. 2010;15:334-354. Kadhim-Saleh A, Maganti H, Ghert M, Singh S, Farrokhyar F. Is low-
APPENDIX E
level laser therapy in relieving neck pain effective? Systematic for Traffic Injury Management (OPTIMa) Collaboration. Spine J.
review and meta-analysis. Rheumatol Int. 2013;33:2493-2501. 2016;16:1503-1523. https://doi.org/10.1016/j.spinee.2014.02.014
https://doi.org/10.1007/s00296-013-2742-z Thoomes EJ, Scholten-Peeters W, Koes B, Falla D, Verhagen AP. The
Kay TM, Gross A, Goldsmith CH, et al. Exercises for mechanical neck effectiveness of conservative treatment for patients with cervical
disorders. Cochrane Database Syst Rev. 2012:CD004250. https:// radiculopathy: a systematic review. Clin J Pain. 2013;29:1073-
doi.org/10.1002/14651858.CD004250.pub4 1086. https://doi.org/10.1097/AJP.0b013e31828441fb
McLean SM, Burton M, Bradley L, Littlewood C. Interventions for Varatharajan S, Côté P, Shearer HM, et al. Are work disability preven-
enhancing adherence with physiotherapy: a systematic re- tion interventions effective for the management of neck pain or
view. Man Ther. 2010;15:514-521. https://doi.org/10.1016/j. upper extremity disorders? A systematic review by the Ontario
math.2010.05.012 Protocol for Traffic Injury Management (OPTIMa) Collaboration.
J Occup Rehabil. 2014;24:692-708. https://doi.org/10.1007/
Rhee JM, Shamji MF, Erwin WM, et al. Nonoperative management of s10926-014-9501-1
cervical myelopathy: a systematic review. Spine (Phila Pa 1976).
Zhu L, Wei X, Wang S. Does cervical spine manipulation reduce pain
2013;38:S55-S67. https://doi.org/10.1097/BRS.0b013e3182a7f41d
in people with degenerative cervical radiculopathy? A system-
Salt E, Wright C, Kelly S, Dean A. A systematic literature review atic review of the evidence, and a meta-analysis. Clin Rehabil.
on the effectiveness of non-invasive therapy for cervicobra- 2016;30:145-155. https://doi.org/10.1177/0269215515570382
chial pain. Man Ther. 2011;16:53-65. https://doi.org/10.1016/j.
Zronek M, Sanker H, Newcomb J, Donaldson M. The influence
math.2010.09.005 of home exercise programs for patients with non-specific or
Southerst D, Nordin MC, Côté P, et al. Is exercise effective for the specific neck pain: a systematic review of the literature. J Man
management of neck pain and associated disorders or whiplash- Manip Ther. 2016;24:62-73. https://doi.org/10.1179/204261861
associated disorders? A systematic review by the Ontario Protocol 3Y.0000000047
APPENDIX F
PROCEDURES FOR ASSIGNING LEVELS OF EVIDENCE using the GRADE system and methods described in the text. Sources
• Levels of evidence were assigned based on the study design, the receiving a rating of very low were not used in this guideline.
quality of the study, and the quality of the primary sources (if the - GRADE system77
study is a systematic review or meta-analysis), using the Levels of • Study starts with a “high” rating
Evidence table (TABLE 1). • Downgrade at least 1 level for violations of
• Quality of systematic reviews (or review of reviews) was assessed - Risk of bias
- Precision
using a critical appraisal tool (AMSTAR, or the closely related SIGN
- Directness
II), and the review was assigned 1 of 4 overall quality ratings based
- publication bias
on the critical appraisal results:
• Results in 4 levels of quality of evidence
- High, AMSTAR or SIGN score of 8 or better
- High
- Acceptable, AMSTAR or SIGN score of 6 or 7 - moderate
- Low, AMSTAR or SIGN score of 4 or 5 - Low
- Very low, AMSTAR or SIGN score of less than 4 (Reviews scored - very low
very low were not used in this revision) - PEDro system (http://abiebr.com/set/1-introduction-and-
• Quality of primary sources was calibrated to a 4-level scale. If the methodology/determining-levels-evidence)
quality of the primary sources were not available in the systematic • High, score of 9 or better
review, or if the quality appraisal tool was unique or not familiar • moderate, score of 6 to 8
to the guideline authors, or if the quality ratings differed between • Low, score of 4 or 5
reviews, the primary source was graded by the guideline authors • Very low, score of 3 or lower
APPENDIX G
AMSTAR SCORES*
Study 1 2 3 4 5 6 7 8 9 10 11 Quality†
Included articles
Bertozzi et al10 Y Y Y Y N Y Y Y Y Y N High
Boyles et al 17
Y Y Y N Y Y Y Y NA N N Acceptable
Brønfort et al20 Y Y Y Y Y Y Y Y NA N N High
Bronfort et al 19
Y N Y N N N Y Y NA N N Low
Brown et al21 Y Y Y Y N Y Y Y NA N Y High
Cagnie et al22 Y Y Y Y N Y Y Y N N Y High
Chaibi and Russell 28
Y N N N N Y Y Y NA NA N Low
Clar et al30 Y Y Y N N Y Y Y NA N N Acceptable
Conlin et al 33
Y N Y N N Y Y Y Y N N Acceptable
Coronado et al36 Y N N N N Y Y Y NA N N Low
Cross et al 41
Y Y Y N N Y Y Y NA N N Acceptable
Damgaard et al44 Y Y Y Y Y Y Y Y N N Y High
Drescher et al49 Y Y Y Y N Y Y Y NA N N Acceptable
Fernández-de-las-Peñas Y N Y N N Y Y Y NA N N Low
et al59
Ferreira et al60 Y Y Y Y N N N NA NA N N Low
Furlan et al64 Y Y Y Y N Y Y Y Y N N High
Graham et al 68
Y Y Y Y Y Y Y Y Y Y Y High
Gross et al75 Y Y Y Y N Y Y Y Y N N High
Gross et al 73
Y Y Y Y Y Y Y Y Y N N High
Gross et al70 Y Y Y Y Y Y Y Y Y Y Y High
Gross et al74 Y Y Y Y N Y Y Y Y Y Y High
Gross et al 76
Gross et al71 Y Y Y Y Y Y Y Y Y Y N High
Gross et al 72
Y Y Y Y Y Y Y Y Y Y N High
Haines et al79 Y Y Y Y Y Y Y Y Y N N High
Holly et al 87
Y N Y N N Y Y Y NA N N Low
Horn et al89 Y Y Y Y N Y Y Y NA N N Acceptable
Huisman et al92 Y N Y N Y Y Y Y NA N N Acceptable
Hurwitz et al 93
Y N N Y N Y Y Y NA N N Low
Kabisch103 Y N Y N N Y Y Y Y N N Acceptable
Kadhim-Saleh et al 104
Y Y Y Y N Y Y Y Y Y N High
Kay et al108 Y Y Y Y Y Y Y Y Y N N High
Kay et al109 Y Y Y Y Y Y Y Y Y N N High
Kelly et al 112
Y Y Y Y N Y Y Y NA N N Acceptable
Kietrys et al113 Y Y Y Y N Y Y Y Y N Y High
Kroeling et al 118
Y Y Y Y Y Y Y Y Y N Y High
Leaver et al119 Y Y Y N N Y Y Y Y N N Acceptable
Lee et al 120
Y Y Y Y Y Y Y Y NA N N High
Liu et al124 Y Y Y Y N Y y Y Y Y N High
Macaulay et al125 Y N Y N N Y Y Y NA N N Low
APPENDIX G
AMSTAR SCORES* (CONTINUED)

Study 1 2 3 4 5 6 7 8 9 10 11 Quality†
MacDermid et al 127
McCaskey et al134 Y N Y Y N Y Y Y NA Y Y High
McLean et al 136
Y Y Y Y N Y Y Y NA N N Acceptable
Meeus et al138 Y Y Y Y Y Y Y Y Y Y N High
Miller et al140 Y Y Y Y N Y Y Y Y N N High
Monticone et al 141
Y Y Y Y N N Y Y Y N N Acceptable
Nunes and Moita152 Y Y Y Y N Y Y Y Y N Y High
Ong and Claydon 156
Y Y Y Y N Y Y Y Y Y Y High
O’Riordan et al157 Y N Y N N Y Y N NA N N Low
Parreira et al161 Y Y Y Y N Y Y Y Y Y N High
Racicki et al 163
Y N Y N Y Y Y N NA N N Low
Reid and Rivett167 Y N Y N N Y Y Y NA N N Low
Rhee et al 169
Y Y Y Y N Y Y Y Y N N High
Rubio-Ochoa et al176 Y Y Y Y N Y Y Y NA N N Acceptable
Salt et al178 Y Y Y Y N Y Y Y Y N N High

Schellingerhout et al 180
Schellingerhout et al181 Y Y Y N N Y Y Y NA N N Moderate
Scholten-Peeters et al 182
Y Y Y Y N Y Y Y Y Y N High
Shaw et al186 Y Y Y N N Y Y Y NA N N Acceptable
Snodgrass et al189 Y Y Y Y N Y Y Y NA Y Y High
Southerst et al 190
Y Y Y N N Y Y N NA N N Low
Stanton et al192 Y Y Y Y N Y Y Y Y Y Y High
Sutton et al 200
Takasaki and May202 Y Y Y Y N Y Y Y Y N Y High

Teasell et al203 Y N Y N N Y Y Y NA N N Low
Teasell et al 204
Y N Y N N Y Y Y NA N N Low
Teasell et al205 Y N Y N N Y Y Y NA N N Low
Thoomes et al 208
Y Y Y Y N Y Y Y Y N N High
Vanti et al216 Y Y Y Y Y Y Y Y Y N N High
van Trijffel et al217 Y Y N Y N Y Y Y NA N N Acceptable
Varatharajan et al 219
Varatharajan et al220 Y Y Y Y Y Y Y Y Y Y N High
Verhagen et al 223
Y Y Y N Y Y Y Y Y N N High
Verhagen et al221 Y Y Y N Y Y Y Y Y N N High
Vernon et al226 Y N Y N N Y Y Y NA N N Low
Vincent et al 229
Y N Nr N N Y Y Y NA N N Low
Walser et al231 Y N Y Y N Y Y Y Y N N Acceptable
Williams et al238 Y N Y N N N Y Y NA N Y Low
Wong et al 240
Y Y Y Y Y Y Y Y NA N N High
Young et al244 Y N Y Y N Y Y Y NA N N Acceptable
Yu et al245
Zhu et al246 Y N Y Y N Y Y Y Y N Y High
APPENDIX G
AMSTAR SCORES* (CONTINUED)

Study 1 2 3 4 5 6 7 8 9 10 11 Quality†
Zronek et al 247
Y Y Y Y Y Y Y Y N N N High
Excluded articles
Ainpradub et al Y N Y Y N Y Y Y Y Y Y High
Ambrosio et al Y N Y Y N Y Y Y Y Y N High
Bervoets et al Y Y Y Y N Y Y Y Y N Y High
Clay et al Y Y Y Y N y Y Y Y Y Y High
Ernst et al Y Y Y Y N Y Y Y N N N Acceptable
Ernst et al Y N Y N N Y N N N N N Very low
Fernández-de-las-Peñas Y N Y N N Y Y N NA N N Low
et al
France et al Y Y Y Y N Y Y Y NA Y Y High
Franke et al Y Y Y Y Y Y Y Y Y N Y High
Furlan et al Y Y Y Y N Y Y Y Y N N High
Garcia et al Y N Y Y N Y N N NA N Y Low
Hug et al Y N Y Y Y Y N N N N N Low
Jang et al Y Y N Y N Y Y Y Y Y Y High
Kim et al Y Y Y Y N Y Y N NA N Y Acceptable
Kroeling et al Y Y Y Y Y Y Y Y N Y N High
Lee et al N N N Y N N Y Y N N N Very low
Lu et al Y Y Y Y N Y Y Y Y N N High
MacPherson et al Y N Y N N Y N N Y N N Low
Mao et al N N N N N N N N N N N Very low
Misailidou et al Y N Y N N N N N NA N N Very low
Moon et al Y Y Y Y N Y Y Y NA Y Y High
Murphy et al Y Y Y N N N N N NA N N Very low
Rodine et al Y N N N N Y N NA NA N N Very low
Ruston et al Y Y Y Y N Y Y Y Y N Y High
Schroeder et al N N N N N Y N N N N Y Very low
Sihawong et al Y Y N N Y Y Y Y NA N N Acceptable
Trinh et al Y Y Y Y Y Y Y Y Y Y Y High
Vernon et al Y N N N N Y N N NA N N Very low
Wanderley et al Y Y Y Y N Y Y Y NA N N Acceptable
Yuan et al Y N Y N N Y Y Y Y Y N Acceptable
Wei et al Y Y Y Y N Y Y Y NA N Y High
Wiangkham et al Y Y Y Y N y y Y Y N N High
Zarghooni et al Y N N N N N N N NA N N Very low
Abbreviations: N, no; NA, not applicable; Y, yes.
*Yes/no. Items: 1, the study addresses a clearly defined research question; 2, at least two people should select studies and extract data; 3, a comprehensive litera-
ture search is carried out; 4, the authors clearly state if or how they limited their review by publication type; 5, the included and excluded studies are listed; 6,
the characteristics of the included studies are provided; 7, the scientific quality of the included studies is assessed and documented; 8, yhe scientific quality of
the included studies was assessed appropriately; 9, appropriate methods are used to combine the individual study findings; 10, the likelihood of publication
bias is assessed; 11, conflicts of interest are declared.
†
Quality rating: 8 or higher, high; 6 or 7, acceptable; 5 or 4, low; 3 or below, very low.
APPENDIX H
IMAGING CONDITIONS FOR SUSPECTED SPINE TRAUMA FROM THE AMERICAN COLLEGE
OF RADIOLOGY APPROPRIATENESS CRITERIA
Any high-risk factor?

• Age ≥65 y, or
• Dangerous mechanism
(A), or
• Upper extremity
paresthesia
No
Yes
Any low-risk factor allowing
range-of-motion
assessment?
• Simple rear-end motor
vehicle collision (B), or No
• Sitting position in external Imaging (D)
rotation, or
• Ambulatory at any
time, or
• Delayed-onset neck pain

(C) , or
• Absence of midline
cervical spine tenderness
No
Yes
Able to rotate neck 45° left

and right?
Yes
No imaging (D)
(A) Dangerous Mechanism = Fall from ≥3 ft/5 stairs, axial load, MVC at >60 mph or rollover or ejection, motorized recreational vehicle acci-
dent, bicycle collision.
(B) Simple Rear-End MVC excludes pushed into on-coming traffic, hit by bus or large truck, rollover, hit by high speed vehicle
(C) Delayed onset neck pain = No immediate onset after trauma
(D) At time of derivation, radiograph was chosen imaging. Now, American College of Radiology recommends computed tomography, if positive
on criteria.
Reproduced from Elliott JM, Dayanidhi S, Hazle C, et al. Advancements in imaging technology: do they (or will they) equate to advancements in
our knowledge of recovery in whiplash? J Orthop Sports Phys Ther. 2016;46:862-873. https://doi.org/10.2519/jospt.2016.6735
Sensitivity, Specificity, and Negative Predictive Values of the Canadian Cervical Spine Rules and the NEXUS Low-Risk Criteria for 162 Cases of
“Clinically Important” Injury in 7438 Patients32,85,160,196,197
APPENDIX H
Canadian Cervical Spine Rule NEXUS Low-Risk Criteria
Decision Rule Yes No Yes No

Positive 161 3995 147 4599
Negative 1 3281 15 2677
Sensitivity, %* 99.4 (96, 100) 90.7 (85, 94)
Specificity, %* 45.1 (44, 46) 36.8 (36, 88)
Negative predictive value, % 100.0 99.4
Abbreivation: NEXUS, National Emergency X-Radiography Utilization Study.
*Values in parentheses are 95% confidence interval.
Interests that were disclosed include financial interests and secondary interests (eg, personal, academic, political).
Author Competing Interests Disclosures

Peter Blanpied None known None known
Anita Gross ICON - International Collaboration on Neck - I am a lead and None known
reviewer within this body of work.
COG - Cervical Overview Group contributing to a series of

systematic reviews for Neck Pain in Cochrane Collaboration - I
am the coordinator and reviewer on primary systematic reviews
on this topic.
James Elliott JOSPT - Board of Directors - Advisory Member Partial ownership/investment interest
JOSPT - International Editorial Board in Pain ID, LLC (a medical-consulting
Spine - Advisory Board Member start-up).
Musculoskeletal Science and Practice (formerly Manual Therapy)
- International Advisory Board
NIHR01HD079076 - NICHD/NCMRR
Laurie Devaney None known None known

Derek Clewley None known None known
David Walton ICON - International Consensus on Neck Pain, Prognosis section Owner/Operator - David Walton Rehabilita-
lead reviewer tion Education, Consulting and Research
Journal of Musculoskeletal Science and Practice (formerly
Manual Therapy) - Associate Editor
JOSPT - International Editor
International Association for the Study of Pain - Education
Special Interest Group Secretary
Cheryl Sparks None known None known
Eric Robertson None known None known
Peter Blanpied coordinated the Neck Pain CPG Revision, secured limited funding, coordinated and collated searches and search results, organized
retrieval of papers, screened and appraised papers, extracted data from papers, analyzed and interpreted data, provided a methodological, clinical,
and end-user perspective, and wrote the revision.
Anita Gross coordinated and collated searches and search results, organized retrieval of papers, screened and appraised papers, extracted
data from papers, analyzed and interpreted data, provided a methodological, clinical, and end-user perspective, and wrote the revision.
James Elliott screened and appraised papers, extracted data from papers, analyzed and interpreted data, provided a methodological, clinical,
APPENDIX H
Laurie Devaney screened and appraised papers, extracted data from papers, analyzed and interpreted data, provided a methodological, clinical,
Derek Clewley screened and appraised papers, extracted data from papers, analyzed and interpreted data, provided a methodological, clinical,
David Walton screened and appraised papers, extracted data from papers, analyzed and interpreted data, provided a methodological, clinical,
Cheryl Sparks screened and appraised papers, extracted data from papers, analyzed and interpreted data, provided a methodological, clinical,
Eric Robertson screened and appraised papers, extracted data from papers, analyzed and interpreted data, provided a methodological, clinical,

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Clinical Practice Guidelines

J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302

AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS. . . . . . . A44

PATHOANATOMICAL FEATURES/DIFFERENTIAL DIAGNOSIS • Neck pain with headaches (cervicogenic headache)

and to monitor changes relative to pain, function, disability, and psycho-

DIAGNOSIS/CLASSIFICATION B Clinicians should provide the following:

Summary of Recommendations* (continued)

B Clinicians should provide cervical manipulation and

• TENS Clinicians should provide education and counseling to

List of Abbreviations (continued)

The purposes of these clinical guidelines are to: STATEMENT OF INTENT

Cochrane Library, Web of Science, CINAHL, ProQuest Dis-

brated into high, acceptable, low, and very low categories.

Pathoanatomic/Risk/ Diagnosis/ Prevalence of

Pathoanatomic/Risk/ Diagnosis/ Prevalence of

the higher-quality trials tend to favor a

Beneficial Effect Neutral Effect Harmful Effect

Grade Strength of Evidence Basis of Strength Assignment

and M99.01 Segmental and somatic dysfunction.241

Planned Strategies and Tools to Support the Dissemination

a synthesis of the recent literature with the corresponding

Construct Recommended Tool

ing capacity (control over work) had a small but significant

PATHOANATOMICAL FEATURES/ The 2012 IFOMPT “International Framework for Examina-

neurologic deficits. Congenital narrowing of the spinal canal

2017 Recommendation ultrasonography, CT, and MRI, in patients without neuro-

There remains uncertainty about whether changes in the 2017 Recommendation

Fillingim et al61 recommended assessing 4 compo-

episode of care. of 0.94 and specificity of 1.00.176

A high-quality review by Stanton et al192 examined

dard goniometer, and the inclinometer to be the most

(MDC90) of 4.7° to 7°.82 for classifying pain.

distressed groups. lowing categories:

Evaluation/Intervention Component 1: medical screening

Figure continues on page A23.

Evaluation/Intervention Component 3: determination of condition stage (acute/subacute/chronic)

Evaluation/Intervention Component 4: intervention strategies for patients with neck pain

upper extremity stretching, prolonged recovery trajectory manipulation

Identified were 43 systematic reviews investigating physical

Young et al244 techniques:

Table continues on page A28.

Southerst et al190 and intermediate term109,190

Table continues on page A29.

Table continues on page A30.

Stage/Level Study Evidence Statement

Stage/Level Study Evidence Statement

Stage/Level Study Evidence Statement

Table continues on page A31.

comes in patients with chronic myofascial pain syndrome

Table continues on page A32.

and chronic neck pain with mobility deficits. proach of:

Stage/Level Study Evidence Statement

Stage/Level Study Evidence Statement

Table continues on page A35.

Multimodal: Exercise and Manual Therapy

Stage/Level Study Evidence Statement

Table continues on page A36.

Stage/Level Study Evidence Statement

Subacute No update evidence identified