If you have neck pain, check out this presentation of how physical therapy can help you avoid surgery and drugs.

1. Neck Pain with/without Headache Evidence validates that PTs can help your patients…. WITHOUT NARCOTICS OR SURGERY!

2. Problem: Neck Pain with/without Headache Neck pain, without symptoms or signs of serious medical or psychological conditions, associated with motion limitations in the cervical and upper thoracic regions, headaches, and referred or radiating pain into an upper extremity (Childs et al, 2008)

4. Specific Exercise for the Upper Quarter

5. Intermittent Cervical Traction

6. Patient Education and Counseling

7. Intervention: Manual Therapy Thrust and non-thrust techniques at the Thoracic and Cervical Spine1-7 1. Cleland et al. Phys Ther. 2007;87(4):431-440. 2. Gonzalez-Iglesias et al. J Orthop Sports Phys Ther. 2009;39(1):20-27. 3. Cleland et al. Phys Ther. 2010;90(9):1239-1250. 4. Lau et al. Man Ther. 2011;16:141-147. 5. Walker et al. Spine. 2008;33(22):2371-2378. 6. Jull et al. Spine. 2002;27(17):1835-1843. 7.Childs et al. J Orthop Sports Phys Ther. 2008;38(9):A1-A34 8. Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC. www.evidenceinmotion.com, all rights reserved .

8. Intervention: Manual Therapy Cervical Spine Mobilization with Upper Limb Neurodynamics Positioning1, 2 1. Cleland JA et al. J Orthop Sports Phys Ther. 2005. 2. Childs et al. J Orthop Sports Phys Ther. 2008.

9. Intervention: Specific Exercise Deep Neck Flexor Retraining and Endurance1, 2 1. Jull et al. Spine. 2002. 2. Childs et al. J Orthop Sports Phys Ther. 2008. 3. Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC. www.evidenceinmotion.com, all rights reserved .

10. Intervention: Specific Exercise Scapular Stabilizer Strengthening1,2 1. Jull et al. Spine. 2002. 2. Childs et al. J Orthop Sports Phys Ther. 2008. 3.Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC. www.evidenceinmotion.com, all rights reserved .

11. Intervention: Specific Exercise Stretching as indicated1,2 1. Jull et al. Spine. 2002. 2. Childs et al. J Orthop Sports Phys Ther. 2008. 3. Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC. www.evidenceinmotion.com, all rights reserved .

12. Evidence - Manual Therapy + Exercise A. Manual therapy & exercise - indicated for patients with neck pain, +/- headache, & +/- arm pain. B. Mobilization and/or manipulation and exercise is more effective than either alone. (Level 1 evidence, systematic review, Gross et al. Spine. 2004) NNT = 2 with Manual Therapy and Exercise to achieve one additional successful outcome than would have occurred with an alternative treatment approach

15. Evidence: Manual Therapy + ExerciseHoving et al, Ann Intern Med, 2002 A. RCT – Man Ther (no thrust, 6 visits) vs Ex/Stretch (12 visits) vs Meds/Advice (1 visit, more optional) B. Outcomes @ 7 week follow-up 1. Patient Perceived Recovery (defined a priori) Man Ther 68%; Ex/Stretching 51%; Meds/Advice 36% 2. Pain - Manual Therapy > Ex/Stretch > Meds/Advice C. Other Noteworthy Items 1. Man Ther & Ex/Stretching took less analgesics 2. Man Ther - missed less work 3. NNT with Manual Therapy is 3

18. Tenderness with palpation in at least one of the upper 3 cervical segments

20. Patients :less additional care sought, reduction in headache duration, neck pain, headache intensity, & frequency, reduction on medication intake (93% decrease in MT with Ex,100% decrease in Ex/MT only)

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

23. Evidence: Traction A. Mechanical traction for the cervical spine involves a tractive force applied to the neck via a mechanical system - Intermittent or Continuous B. Indications: radicularsxs,  sx with distraction test, fit CPR by Raney et al C. Systematic review, mod evidence of benefit for intermittent traction for acute @ chronic neck pain (Level 1 Evidence) (Graham, J Rehabil Med. 2006.)

24. Evidence: Traction CPR Raney et al, Eur Spine J, 2009 A. Developed CPR to determine who would respond to traction 68 patients/30 positive outcomes included in analysis B. 5 variable CPR identified Age >55 Positive shoulder abduction test Positive ULTT A Symptom peripheralization with central posterior–anterior motion testing at lower cervical (C4–7) spine Positive neck distraction test C. 3/5 variables present= +LR of 4.8 D. 4/5 variables present= +LR of 11.7 and post-test probability of 90.2% of having improvement

26. Yellow Flags - Psychosocial factors that indicate risk for chronicity, potential work loss

27. Pain Neurophysiology Education in presence of yellow flags2

28. Multidisciplinary Approach: Referral to appropriate discipline (psychologist, vocational specialist, pharmaceutical) as indicated by presence of yellow flags1,3 1. Childs et al. J Orthop Sports Phys Ther. 2008. 2. Nijs et al. Man Ther. 2011. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21632273 3. Sterling M. Man Ther. 2009.

29. Evidence: Patient Education and Counseling RCT for patients with whiplash Encouragement to exercise/move vs collar Exercise/move advice -  outcomes/  pain vs collar (Crawford 2004) B. RCT for patients with whiplash Early PT/education vs collar PT/education -  long term outcomes vs collar (Rosenfeld 2003))

32. Bronfort G, Evans R, Nelson B, et al. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine. 2001;26(7):788-799.

33. Childs JD, Cleland JA, Elliott JM, et al. Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9):A1-A34.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

52. Walker MJ, Boyles RE, Young BA, et al. The effectiveness of manual physical therapy and exercise for mechanical neck pain. Spine. 2008;22:2371-2378.

53. Wright A, Mayer T, Gatchel R. Outcomes of disabling cervical spine disorders in compensation injuries: a prospective comparison to tertiary rehabilitation response for chronic lumbar disorders. Spine. 1999; 24:178–183.