Classification of Neck Pain

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Introduction

Classification provides a general framework for identifying subgroups of patients based on the primary goal of treatment, with the ultimate aim of matching indivuals to specific interventions from which they are most likely to benefit[1]. Diagnostic algorithms and classification may be beneficial to clinical decision making and allows clinicians to easily identify the correct intervention strategy and predict a patient’s prognosis.

Evidence for the conservative management of neck pain in primary care does not support any particular approach and it remains unclear as to what the most effective method of treatment in terms of costs, time and resolution. As a result there has been a shift from the pathoanatomical model of diagnosis towards the development of prognostic tests that can separate a heterogeneous population into treatment-oriented subgroups that will inform patient management and be cost effective[2][3]. This form of classification provides a general framework for identifying subgroups of patients based on the primary goal of treatment, with the ultimate aim of matching individuals to specific interventions from which they are most likely to benefit[2][4].

Classification Types

Neurological or non-specific

Once diagnostic triage has taken place and the individual has been cleared of serious spinal pathology neck pain is often refer simply classified as having neurological involvement or being non-specific (sometimes referred to as mechanical) neck pain. However, 50% of individuals have mixed pain[5], probably due to the fact that radicular (neurological) pain is usually caused by degenerative conditions that predispose a person to nociceptive (non-specific) pain, which makes for an unclear classification system.

Clinical condition

This is a medical model that is signs and symptoms based[5] i.e. what condition does the individual have, such as cervical osteoarthritis, cervicogenic headache etc.

Pathoanatomical

Another medical model but structurally based[5] i.e. which structure is dysfunctional, such as facet joint, intervertebral disc, myofascial. Specific pathoanatomic source cannot be identified in most patients with neck pain[6][4][7] and existing classification systems designed to identify pathoanatomic mechanisms have largely failed[1]. The pathoanatomical model has proven limited for the correlation between diagnosis and clinical decisions regarding treatment management plans because different diagnoses often exhibit similar symptoms[8].

Response to movement (centralisation)

Symptom response based i.e. how does movement change symptoms, such as with repeated movements and the centralisation phenomenon. Werneke et al[9] suggested categorisation by changes in pain location to mechanical assessment and treatment allowed identification of patients with improved treatment outcomes and facilitated planning of conservative treatment of patients with acute spinal pain syndromes. However, limited inference can be taken from this study as the choice of interventions was left to the discretion of the therapists and not explicitly linked to the classification[1], and pooled data for all participants was reported of which only 23% had neck pain[10].

Treatment based

Proposed Childs et al[2] and supported by Fritz and Brennan[11], the system was based on the goals of treatment and the interventions used to achieve these goals, rather than an attempt to classify patients by pathology or symptom distribution. It was updated in 2008 as part of the APTA Orthopedic section ICF Guidelines with the four current classification categories including: neck pain with mobility deficits, neck pain with radiating pain (radicular), neck pain with movement coordination impairments (WAD), and neck pain with headache (cervicogenic). 

Summary

Therapists should be aware of the different classification systems that exist. Appropriate use of these systems can guide specific assessment and treatment selection. There has been a shift from the pathoanatomical model of diagnosis towards a more cost effective model that separates a heterogeneous population into treatment-oriented subgroups with matched treatment interventions. This type of classification is likely to be most helpful for therapists as it is based on signs and symptoms that match interventions to the subgroup of individuals most likely to benefit from them[1]. The treatment based classification is a widely used system that has been proven to be effective for managing individuals with neck pain[4].

References

  1. 1.0 1.1 1.2 1.3 Childs MJ, Fritz JM, Piva SR, Whitman JM. Proposal of a classification system for patients with neck pain. Journal of Orthopaedic & Sports Physical Therapy. 2004 Nov;34(11):686-700.
  2. 2.0 2.1 2.2 Childs MJ, Fritz JM, Piva SR, Whitman JM. Proposal of a classification system for patients with neck pain.Journal of Orthopaedic & Sports Physical Therapy. 2004 Nov;34(11):686-700.
  3. Childs J, Cleland J, Elliott J, Deydre T, Wainner R, Whitman J, et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9):A1-A34
  4. 4.0 4.1 4.2 Fritz, J. M., & Brennan, G. P. (2007). Preliminary Examination of a Proposed Treatment-Based Classification System for Patients Receiving Physical Therapy Interventions for Neck Pain. Physical Therapy, 87(5), 513-524.
  5. 5.0 5.1 5.2 Steven P Cohen and W Michael Hooten. Advances in the diagnosis and management of neck pain. BMJ 2017;358:j3221
  6. Borghouts JA, Koes BW, Bouter LM. The clinical course and prognostic factors of non-specific neck pain: a systematic review. Pain. 1998;77:1-13
  7. Hush JM, Maher CG, Refshauge KM. Risk factors for neck pain in office workers: A prospective study. BMC Musculoskelet Disord. 2006;7:81
  8. Wang, W. T. J., Olson, S. L., Campbell, A. H. M., Hanten, W. P., & Gleeson, P. B. (2003). Effectiveness of Physical Therapy for Patients with Neck Pain: An Individualized Approach Using a Clinical Decision-Making Algorithm. American Journal of Physical Medicine & Rehabilitation, 82(3), 203-218.
  9. Werneke, M., Hart, D., & Cook, D. (1999). A Descriptive Study of the Centralization Phenomenon: A Prospective Analysis. Spine, 24(7), 676-683.
  10. Hing W. Differential Diagnosis and Classification of Neck Pain. WCPT Congress, 2015.
  11. Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther. 2007;87(5):513-24