The Utilization of the Clinical Practice Guideline: Neck Pain in

The Utilization of the Clinical Practice Guideline: Neck Pain in Diagnosis and Treatment of a Patient with Neck Pain: A Case Report A case report submitted for the degree of Doctor of Physical Therapy at Carroll University Waukesha, WI Courtney Wagner, SPT Spring 2009

The Utilization of the Clinical Practice Guideline: Neck Pain in Diagnosis and Treatment of a Patient with Neck Pain: A Case Report Courtney Wagner, SPT

Abstract Title: The Utilization of the Clinical Practice Guideline: Neck Pain in Diagnosis and Treatment of a Patient with Neck Pain Background and purpose: In order to better utilize best evidence the Orthopedic Section of the American Physical Therapy Association (ATPA) had released clinical practice guidelines (CPG) for management of patients with musculoskeletal pathologies. However there has been little research looking at the ability of a clinician to utilize these guidelines within practice. The purpose of this case report is to describe the ability of a clinician to utilize the CPG for neck pain in management and treatment of a patient with neck pain within an outpatient orthopedic clinic. Case description: A 54 yearold male presented with C4 radiculopathy of his right arm which was causing onset of sharp pain with movement. Scores on the Neck Disability Index (NDI) demonstrated limitations due to pain and were affecting the patient's ability to sleep and causing headaches throughout the day. The patient was seen for 9 visits over a 4-week period. Patient was diagnosed and treated based on the recommendations in the CPG. The NDI, neck range of motion, onset of pain and cervical flexion strength were all used as outcome measures. Outcomes: The patient s score on the NDI showed significant clinical improvements between visits 2 and 9. At discharge patient was no longer experiencing any onsets of pain and had increases in neck ROM and increased neck flexor endurance. Discussion: This case report demonstrated the potential usefulness of utilizing a CPG to categorize the patient s signs and symptoms in order to establish an appropriate treatment intervention and plan of care. This CPG allowed for complete management of a patient. Further consideration of additional interventions and prescription is needed. However, the CPG is useful tool for students and new clinicians who have yet to develop a practice pattern of their own and for all clinicians to maintain evidenced based practice. Key Words: Clinical Practice Guideline, Neck Pain, Cervical radiculopathy, Neck Disability Index, Patient Specific Functional Scale 2

Introduction The Orthopaedic Section of the American Physical Therapy Association has developed clinical practice guidelines (CPG) for the management of patients with musculoskeletal pathologies. These guidelines are based on the best available evidence and grading of recommendations are based on level of evidence articles and the number of articles reporting similar results ( see figures 1 & 2). 1 These guidelines were created for use as a reference for the Orthopaedic physical therapy management of patients with musculoskeletal pathologies. These guidelines cover management of a patient giving recommendations in the following categories: examination, diagnosis, prognosis and treatment interventions. A CPG for neck pain was released in September of 2008. The CPG is of relevance to clinicians practicing in an orthopaedic environment due to the increased number of patients experiencing neck pain. Approximately 25% of patients seen in an outpatient orthopaedic environment report complaints of neck pain. 2 Twenty to seventy percent of individuals will experience some type of neck pain in their lives. 1 Management of neck pain includes conservative methods of exercises, stretching, postural changes and traction before surgical interventions are performed. Carroll et al. 3 determined that 50% of patients with neck pain will experience pain up to one year later. Within the past decade there has been an increase in the number of studies looking at interventions for neck pain. However, current research is limited to only one area of patient care and does not include complete management from initial examination to discharge of a patient. This proposed CPG integrates all current research into the best evidence based management of patients with neck pain. The CPG was released as a recommendation for therapists; however 3

there is currently lack of documentation of therapists' utilization of CPG s and its usefulness with management of patients. The purpose of this case report is to describe the ability of a clinician to utilize the CPG for neck pain in the management and treatment of a patient with neck pain within an outpatient orthopaedic clinic. Case Description HISTORY The patient is a 56- year old male and full time Information Technology operator, who was referred to physical therapy by his primary care physician with the medical diagnosis of upper extremity paresthesia. He stated he had first felt the pain while driving three weeks ago and experienced a shooting pain into his right shoulder. The patient stated his pain had continued intermittently, however he was unable to trigger a specific position or activity which evokes his pain. He stated he had tightness through the right side of his neck and pain would shoot into his right upper extremity (UE). The patient received and took a seven day steroid pack he stated the pain is continued throughout the day. The patient s Magnetic Resonance Imaging (MRI) results showed a suspected C3-C4 disc herniation and arthritis at the same level. The patient s electromyography (EMG) results confirmed a C3-C4 disc herniation. The patient stated that he was not currently limited in everyday activities, however with onset of pain he stretched his neck and arm and had a relief of pain. The patient stated his pain lasted for no longer than five minutes at a time, but it shot down into his arm and was very painful when it occurred. Based on this patient's description of symptoms and positive MRI findings, the source of his pain was 4

determined to be cervical in nature. Therefore, he was considered a good candidate for this study and initial examination was performed using the framework proposed in the CPG. EXAMINATION Observation of the patient, in a sitting posture, demonstrated bilateral protracted scapulae with his right greater as compared to the left. The patient also exhibited a forward head positioning with a decrease in cervical lordosis and lateral flexion to his left side in sitting. Increased muscle tone was apparent with palpation in his bilateral upper trapezius and pectoralis minor and major.the patient had increase tone in his right levator scapulae, suboccipital and scalenes upon palpation. He reported increased tenderness with palpation of his pectoralis muscles. Cervical range of motion (ROM) was measured in a seated position using a standard long-arm goiniometer. Left cervical rotation was 73 degrees and right cervical rotation was found to be 58 degrees. Lateral flexion was within normal limits bilaterally and did not evoke patient's symptoms. Repeated motions testing brought on the patient's symptoms with repeated flexion. The patient was able to centralize his pain with cervical retractions. Myotome testing was performed bilaterally for C4- T1 levels and no deficits were found. Light touch was examined along dermatomal distribution C4- T1 and was intact bilaterally. Distraction of the cervical spine in supine demonstrated a decrease in the patient's neck symptoms. Upper limb tension test was performed in supine and the patient experienced tightness and tingling into his right upper extremity, however this position did not reproduce the patient's right UE symptoms. Spurling's compression test resulted in onset of pain into the patient s right UE. See table 1 for description of special tests. 5

During the first treatment session following his initial examination, the patient s thoracic and cervical segmental mobility were assessed. Thoracic mobility was assessed by applying an posterior to anterior force with the patient in prone with findings of decreased mobility from T2- T8. Cervical segmental mobility was assessed in supine and he was found to have decreased right lateral flexion of segments C3- C5. Neck flexor muscle endurance test was performed during session two in a supine hook-lying position, with chin retracted and maintained in an isometric position, the patient was instructed to lift his head one inch off the table and hold. Patient was able to hold the position for two seconds secondary to onset of right shoulder pain. The Neck Disability Index (NDI) and Patient Specific Functional Scale (PSFS) were assessed as outcome measures to determine patient's level of disability and as a means to determine overall progression. These outcome measures were assessed on the second and ninth visits. APPLICATION OF THE CLINICAL PRACTICE GUIDELINE (CPG) The recommendations proposed by the clinical practice guideline for neck pain were used in aid to classify our patient into a specific diagnosis and organize our examination along with implementation of specific outcome measures. Interventions were chosen based on the recommendations of best evidence by the CPG and by specific impairments found within the examination and throughout the overall care of our patient. Interventions, positioning and dosage were determined by researching the cited literature within the CPG. 6

DIAGNOSIS Using the clinical practice guideline (CPG), four diagnosis categories were given with specific special tests and patient characteristics to classify them within a specific diagnosis. The four impairment-based categories of neck pain with impairments of body function include: Neck pain with mobility deficits, neck pain with headaches, neck pain with movement coordination impairments and neck pain with radiating pain. 1 The patient's report of symptoms and examination findings the patient was placed in the ICD diagnosis of spondylosis with radiculopathy or cervical disc disorder with radiculopathy. This was based on the patient's description of his symptoms of a radicular pain along C4 dermatome, decreased pain with distraction, decreased cervical rotation towards involved side and the ability to reduce upper extremity symptoms with cervical retractions. PROGNOSIS Previous studies have shown active treatment approaches to have an increased benefit as compared to more passive approaches. Cervical radiculopathy prognosis can vary based on the severity of symptoms. A study looking at predictors of short- term outcomes of patients experiencing cervical radiculopathy found four predictors (age less than 54 years, dominant arm not affected, looking down does no worsen symptoms and multimodal therapy treatment for 50% of sessions) that would determine a high likelihood ratio of the patient achieving a quick recovery. 4 Given his age and symptoms, the patient in this report was placed in the category of a likelihood of a longer recovery time. Based on clinical experience and current research it was determined patient would require four to six weeks of therapy with two to three sessions per week to decrease his symptoms and achieve his goal of becoming pain free. 7

INTERVENTION The patient was seen for nine visits over a four week period. The patient was not seen for a week between the third and fourth treatment sessions due to a work conflict. Interventions were chosen based on the patient s diagnosis and impairments and the level of recommendations of the CPG. The patient was initially educated on cervical radiculopathy and the goals that would be achieved in therapy. During session two he was educated on proper ergonomics and positioning while programming computers at work. Based on the CPG a level A recommendation was given for education of the prognosis and expected outcomes from therapy for neck pain after a whiplash injury (CPG). 1 While our patient did not experience a whiplash injury it was deemed that patient education would be appropriate. Initial evaluation was followed by passive neck retractions in supine, passive bilateral upper trapezius stretch and passive cervical distraction. A home exercise program (HEP) including: cervical retractions, standing bilateral pectoralis stretch and standing scapular retraction were issued was performed on days the patient did not attend therapy. Stretching based on the CPG is considered a grade C based on evidence, however due to the patient's increased tightness, it was determined that stretching out of a forward shoulder posture along with posterior scapular strengthening would improve overall posture and head position. Improper alignment of the cervical spine and scapulae are commonly considered sources of pain and a change in positioning of either can change the overall biomechanics and alter tension of cervicoscapular musculature. 5 During the second visit, the patient was instructed to perform chin tucks to strengthen his deep cervical flexors. In a randomized clinical trial Ylinene et al. 6 looked at the effectiveness of 8

strengthening versus endurance training of deep neck flexor in reducing pain and disability after 1 year. It was found both groups achieved long term benefits when deep neck flexor activation was addressed. With the patient in supine an air filled pressure sensor was used to monitor changes in cervical lordosis. The sensor was placed suboccipitally behind the neck and inflated to 20 mmhg to fill the space between the table and the patient's neck. The patient was instructed to perform a nod and created a double chin and hold the position for 5 seconds. Patient was given immediate feedback by the pressure sensor. The patient performed a total of 25 repetitions before fatigue set in. Fatigue was determined by the patient's inability to maintain a certain level of increase in pressure above 20mmHg. During the second session intermittent mechanical cervical traction was administered. This traction was administered due to patient's relief of symptoms with manual distraction. The patient also demonstrated 3/5 predictors for benefit from cervical traction: peripheralization into upper extremity (C4-C7), age greater than or equal to 55 and a positive neck distraction test. 3 out of 5 is shown to have a positive likelihood ratio of 4.81. 7 Intermittent traction was administered for 15 minutes with a 30 second traction period and 10 seconds of rest. A pull of 12 pounds was administered on initial evaluation and increased per session based on patient tolerance. The patient was told the pull provided should be a tolerable stretch. Traction was performed during session 2-8. Cervical joint mobilizations were performed to levels C3-C5 due to decreased mobility into right lateral flexion with passive intervertebral range of motion. Review of current literature demonstrates mobilization and or manipulation when used with exercise are effective for Stabilizer Pressure Biofeedback Unit, Chattanooga Group, 2733 Kanasita Dr. Hixson, TN 37343 9

improving function and eliminating symptoms as compared to exercise alone. 8 Grade IV mobilizations were performed with 1-2 oscillations per second for a total 30 seconds and four repetitions. Mobilizations were done in a direction to facilitate right lateral flexion. Cervical mobilizations were performed on sessions 3-8. Thoracic spine manipulations were performed in a prone position with hand placement on either side of the spinous processes. A posterior anterior force was applied once thoracic segments reached end range. Patients who receive thoracic manipulations experience improvements in pain, cervical range of motion and overall functional disability. 2 Manipulations were performed on patients second through fifth visit and on the eight visit. Thoracic manipulations were performed when necessary based on lack of mobility through the upper thoracic spine. The patient received stretches to his right scalenes, upper trapezius, levator scapulae and bilateral pectoralis as needed. An exercise routine included deep neck flexor strengthening, pectoralis stretch and scapulohumeral muscle stabilization and strengthening: which included a low row exercise, side lying external rotation and scapular retraction. A randomized clinical trial looking at spinal manipulation along with dynamic neck exercises and strengthening exercises of the neck and upper back were found to have better immediate and long term effects (2 years). 9 Table 2 shows the exercises performed with parameters on each visit. Outcomes The patient no longer had complaints of shooting pain into his right shoulder after session four. Cervical ROM, NDI scores and neck flexor strength were assessed at initial evaluation and discharge. 10

The NDI contains ten questions, seven related to activities of daily living, two to pain and one to concentration. Each item is scored on a zero to five scale. The final score is expressed as a percentage. The NDI has shown moderate test-retest reliability (ICC=.68) 10. A study by Cleland et al. 11 found that a minimal clinical significant change on the NDI was 5 points (10 percentage points). The NDI score for the patient in this report decreased from seven points to one point at discharge. This 12% change based on the criteria demonstrates a clinically significant change. The Patient Specific Functional Scale (PSFS) is an outcome measure used to assess patient improvements with their specific functional limitations. The patient is asked to determine what three functional tasks in which they are limited and have the most impact on their activities of daily living. Patients then use a 10 point Likert Scale to determine the level of impairment. The three scores are then averaged. 1 The test retest reliability in patients with cervical radiculopathy was.82 and minimal detectible change in that population was 2.1 points. 1 The PSFS was also assessed at the initial evaluation. Our patient had difficulty completing this based on his inability to isolate specific limitations due to his pain. The PSFS was completed with prompting by the therapist to assist, due to patient s inability to answer questions and determine their functional limitations. Therefore it was deemed to be an inaccurate assessment of the patient's limitations. At discharge the patient s total active cervical rotation was 79 degrees (73 at initial) with left rotation and 72 with right rotation (58 at initial).the patient increased his deep neck flexor endurance and was able to hold a cervical chin tuck and lift for 18 seconds (2 seconds at initial evaluation). The patient continued to have increased thoracic kyphosis and a left laterally flexed head positioning at discharge with no improvement seen session to session with his cervical passive intervertebral ROM. 11

Discussion The purpose of this case report was to describe the ability to utilize a CPG for neck pain in a clinical setting. Currently there is a lack of literature demonstrating clinical use of a CPG. The CPG is meant to be a reference for clinicians. The model provides users with useful references that allow them to develop and implement a plan of care. The process used in this report facilitated an organized examination and treatment approach with the patient. This process may have been a factor in the elimination of the cervical radiculopathy symptoms. It should be determined if utilization of this CPG is effective for diagnosis and treatment of the other three diagnoses proposed by the CPG and the ICF. A useful aspect of this CPG was the suggested outcome measures. Various studies have validated the effectiveness of the NDI and PSFS. Self report questionnaires allow for an integration of the patients perspective of pain with certain activities. These measures therefore demonstrate improvements to both patients and insurance companies. However, the use of these two outcome measures may not be appropriate for all patients. In this case study the patient was unable to express functional limitations. Therefore in order to complete the PSFS suggestions and input was required of the therapist, which may have lead to a bias in scoring and would not give accurate outcomes. Westway et al. 12 looked at the validation of the PSFS in persons with neck dysfunction and found a high correlation coefficient (.80) with the NDI. Therefore due to the high correlation it may not be necessary to require completion of both measures. Suggestions of a variety of effective interventions are given in this CPG for neck pain. One concern may be that these may not all be appropriate when implemented. For example, a B level recommendation based on the evidence was issued for nerve mobilization 1. However the 12

patient's symptoms were not reproduced with the upper extremity tension test therefore it was determined that nerve gliding would not be of increased benefit to our patient. Using clinical knowledge along with proposed interventions allows a proper development of a plan of care based on the patient's physical therapy diagnosis and impairments. A limitation of this CPG is the vague recommendations about interventions. General statements within the guideline citing the literature lacked positioning and procedural directions on the implementation of the recommended exercises. Therefore, with interventions of interest research was performed to obtain the cited literature. This is a concern of those who are limited on time and resources to obtain this information and therefore would be unable to utilize this as a quick reference to aid in the development of their plan of care. While the proposed interventions may be vague as seen in this CPG, it is a useful guideline that directs a clinician to an area or certain type of treatment that may be appropriate for their patient. Giving direction will help in development of an appropriate plan of care for the patient and allows the use of the therapist s clinical decision making skills. This is because based on the patient s presentation and impairments the therapist needs to determine which treatments and parameters are appropriate in management of their patient. Another area that could be addressed within the CPG is the relationship between scapular weakness and positioning and its impact it can play in neck pain. In this case report the patient had protracted scapulae with impairments in rotator cuff strength and increase activity to levator scapulae and upper trapezius muscles. This may have played a role in the patient s compensation and movement patterns that may have contributed to his onset of neck pain. 13

This CPG gives an overall reference source that allows a new clinician or student a good baseline protocol for plan of care that could be beneficial to the patient and result in functional improvements. Additional patients should be treated with utilization of the CPG to determine its overall effectiveness with different patient populations who have complaints of neck pain. This case report demonstrated an ability to utilize a CPG to categorize the patient s signs and symptoms in order to establish appropriate treatment interventions and plan of care. This CPG allowed for complete management of a patient. Further consideration of additional interventions and exercise prescription is needed. However, the CPG is useful tool for students and new clinicians who have yet to develop a practice pattern of their own. It is a beneficial tool that aids all clinicians in the ability to maintain up to date on current research and continue to practice evidence-based therapy. 14

References 1. Childs JD, Cleland JA, Elliot JM, Teyhen DS, Wainner RS, Whitman Jm, Sopky BJ, Godges JJ, Flynn TW. Neck Pain: Clinical Practice Guideline Linket 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. 2. Gonzalez-Iglesisa J, Fernandez-De-Las-Penas C, Cleland JA, Gutierrez-Vega M. Thoracic Spine Manipulation for the management of patients with neck pain: a randomized clinical trial. J Orthop Sports Phys Ther.2009; 39(1):20-27. 3. Carroll LJ, Hogg-Johnson S, Cote Pierre et al. Course and Prognostic Factors for Neck Pain in Workers. Spine. 2008; 33(48):S93-S100. 4. Cleland JA, Fritz JM, Whitman JM, Health R. Predictors of short-term outcome in people with a clilnical diagnosis of cervical radiculopathy. Phys Ther. 2007;87(12):1619-1632. 5. Andrade GH, Azevedo DC, Lorentz IG, Neto RS, Pinho VS, Goncalves RT, Mcdonnell MK, Van Dillen LR. Influence of Scapular Position on Cervical Rotation Range of Motion. J Orthop Sports Phys Ther. 2008; 38(11): 668-673. 6. Ylinen J, Takala E, Nykanen M et al. Active Neck Muscle Training in the Treatment of Chronic Neck Pain in Women: A Randomized Controlled Trial. JAMA. 2003; 289(19):2509-2516. 7. Raney NH, Petersen EJ, Smith TA, Cowan JE, Renderio DG, Deyle GD, Childs JD. Development of a clinical prediction rult to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009;18:382-391. 8. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G, and Cervical Overview group. A Cochrane Review of Manipulative and Mobilization for Mechanical Neck Disorders. Spine. 2004; 14:1541-1548. 9. 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. 10. Tamayo A. The Use of a Clinical Prediction Rule to Diagnosis and Treatment Based Classification System for the Treatment of a Cervical Radiculopathy Patient: A Case Report. J Orthop Sports Phys Ther.2009; 21(1):24-30. 11. Cleland JA, Fritz JM, Whitman JM, Palmer JA. The Reliability and Construct Validity of the Neck Disability Index and Patient Specific Functional Scale in Patients with Cervical Radiculopathy. Spine. 2006; 31(5):598-602. 12. Westway MD, Stratford PW, Binkley JM. The Patient-Specific Functional Scale : validation of its Use in Persons with Neck Dysfunction. J Orthop Sports Phys Ther.1998; 27(5):331-338. 15

Figure 1: Levels of Evidence 1 Level of evidence for each article was graded using the Center for Evidence-Based Medicine, Oxford, United Kingdom and can be seen in the figure above. 16

Figure 2: Grades of Recommendation 1 The overall strength of evidence was determined by reviewers using this adapted system seen in the Figure above 17

Table 1. Special Tests Description 1 Special Test Description of Test Results Spuling's Test A Upper Limb Tension Test Distraction Test Neck Flexor Muscle Endurance Test Patient placed in a side bent position to the side of symptoms along with a compression force through the spine Patient in a supine position, sequentially the patient in placed in the following directions: Scapular depression, shoulder abduction of 90, shoulder lateral rotation, elbow extension, forearm supination wrist and finger extension and contralateral lateral flexion Patient in a supine position, tester grasps under the chin and occiput and provides a gradual distraction force until reduction of symptoms occurs (or 14 kg). Patient position in a hook lying position is instructed to perform a chin tuck and lift head off table 1 inch off the table. Testing is completed once the patient's head drops into the therapist or a loss of chin folds is seen Positive Negative Positive 2 Seconds 18

Table 2. Interventions Visit2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Visit 8 Visit 9 Chin Tuck: Deep neck flexors 25x 3'' 30 x 3'' 30x 5'' 3x12x5'' 3x12x5'' 3x10x10'' 3x10x10'' 20x2x10'' Pectoralis stretch 30x30'' 3x30'' 3' 3' 5' 5' 5' Cervical Retraction X30 reps X30 X30 X30 X30 Neck flexion X3 X10 2x10 3x10 3x8 3x10 Low Row Green X25 Green X25 Green X25 Black X25 S/L ER 3x8 3x10 #1 3x8 #1 3x8 #2 3x8 Seated Thoracic Extension X10 X15 X15 X15 X20 19