Neck pain is a common health problem that affects approximately 70% of individuals at some time in their lives. International epidemiological data suggest that a point prevalence of between 10% and 40% of the population will experience neck in any 1 year. It is often considered that the course of neck pain is favorable, with the majority of people showing full recovery; however, recent data suggest that this may not be the case. The course of neck pain is marked by periods of recurrence and exacerbation, with most people not reporting full symptom resolution following a whiplash injury. These data provide a challenge to all clinicians and researchers involved in the management of cervical spine pain to develop improved preventative and management approaches. A first step in this process would be to gain a deeper understanding of the processes underlying various neck pain conditions.

J Orthop Sports Phys Ther 2009;39(5):309-311. doi:10.2519/jospt.2009.0113

KEY WORDS: cervical spine, neck pain

SYNOPSIS: There is irrefutable evidence of an association between mechanical neck pain (MNP) and dysfunction of the muscles of the cervical spine. A myriad of impairments have been demonstrated that include changes in the physical structure (cross-sectional area, fatty infiltration, fiber type), as well as changes in behavior (timing and activation level), of the cervical muscles. Such changes suggest an impaired capacity of the cervical muscles to generate, sustain, and maintain precision of the required levels of torque needed for optimal function. In the context of physical support, these changes potentially have deleterious consequences for the cervical region, which relies heavily on its muscles for mechanical stability. While interventions focused on the retraining of cervical muscle function have shown favorable responses in alleviating MNP, the development of best practice strategies for the assessment and management of cervical muscle dysfunction is still a work in progress. One obstacle in researching the efficacy of cervical muscle training is that, as yet, we do not possess the capacity to optimally measure and classify those patients most likely to respond to different methods of training that would enrich clinical practice. While gains in this area are emerging, the ability of a clinician to best identify the need and implement the most appropriate method of training cervical muscle function is still largely dependent on a comprehensive examination of the patient that considers all aspects of the patient's disorder and functional requirements. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther 2009;39(5):324-333, Epub 15 December 2008. doi:10.2519/jospt.2009.2872

KEY WORDS: mechanical neck pain, rehabilitation, therapeutic exercise

SYNOPSIS: For clinicians, systematic reviews can enhance incorporation into practice of the large volumes of information emerging from research on effectiveness and risks. But we believe that these reviews are most useful with simplified tools to facilitate translation of this knowledge into practice. We provide a "Neck Care Tool Kit" that gives a diagrammatic approach to prioritizing intervention. The evidence from a series of 11 systematic reviews by the Cervical Overview Group is depicted in decision flow-charts and tables to enhance clinical interpretation of the overview findings. On simple visual inspection of symbols in a table, the reader can establish where there is evidence of benefit or no benefit, the strength of the recommendation, and if these data represent short- or long-term findings. Where possible, we guide clinicians to dosage of specific treatment methods. There is no consensus as to which outcome measures to prioritize among the large number in use. This clinical commentary guides clinicians to view the evidence in enough detail to integrate it into their clinical practice environment. We conclude by delineating research gaps and proposing future research directions. LEVEL OF EVIDENCE: Therapy, level 5.

Note: Appendix is online-only and is included in this downloadable PDF. 

J Orthop Sports Phys Ther 2009;39(5):351-363, Epub 24 October 2008. doi:10.2519/jospt.2009.2831

KEY WORDS: cervical spine, exercise, guidelines, systematic reviews

SYNOPSIS: This clinical commentary provides evidence-based information regarding adverse cerebrovascular events in the context of manual therapy assessment and management of the cervical spine. Its aim is to facilitate clinical decision making during diagnosis and treatment of patients presenting to the therapist with cervicocranial pain. Rather than focusing on a traditional view of premanipulative testing as the cornerstone for decision making, we present information concerning the clinical presentation of specific vascular conditions. Additionally, we discuss the assessment and management of musculoskeletal pain in the presence of risk factors for cerebrovascular accident. It is proposed that vascular "red flag" presentations mimic neuromusculoskeletal cervicocranial syndromes. Invariably, the 2 conditions coexist. This reasoning presupposes that some patients who have poor clinical outcomes, or a serious adverse response to treatment, may be those who actually present with undiagnosed vascular pathology. We use 2 case reports to demonstrate how incorporating vascular knowledge into clinical reasoning processes may influence clinical decision making. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther 2009;39(5):378-387, Epub 24 February 2009. doi:10.2519/jospt.2009.2926

KEY WORDS: carotid artery, cervical spine, neck, vertebral artery

STUDY DESIGN: Systematic review of clinical measurement. OBJECTIVE: To find and synthesize evidence on the psychometric properties and usefulness of the neck disability index (NDI). BACKGROUND: The NDI is the most commonly used outcome measure for neck pain, and a synthesis of knowledge should provide a deeper understanding of its use and limitations. METHODS AND MEASURES: Using a standard search strategy (1966 to September 2008) and 4 databases (Medline, CINAHL, Embase, and PsychInfo), a structured search was conducted and supplemented by web and hand searching. In total, 37 published primary studies, 3 reviews, and 1 in-press paper were analyzed. Pairs of raters conducted data extraction and critical appraisal using structured tools. Ranking of quality and descriptive synthesis were performed. RESULTS: Horizon estimation suggested the potential for 1 missed paper. The agreement between raters on quality assessments was high(kappa = 0.82). Half of the studies reached a quality level greater than 70%. Failures to report clear psychometric objectives/hypotheses or to rationalize the sample size were the most common design flaws. Studies often focused on less clinically applicable properties, like construct validity or group reliability, than transferable data, like known group differences or absolute reliability (standard error of measurement [SEM] or minimum detectable change [MDC]). Most studies suggest that the NDI has acceptable reliability, although intraclass correlation coefficients (ICCs) range from 0.50 to 0.98. Longer test intervals and the definition of stable can influence reliability estimates. A number of high-quality published (Korean, Dutch, Spanish, French, Brazilian Portuguese) and commercially supported translations are available. The NDI is considered a 1-dimensional measure that can be interpreted as an interval scale. Some studies question these assumptions. The MDC is around 5/50 for uncomplicated neck pain and up to 10/50 for cervical radiculopathy. The reported clinically important difference (CID) is inconsistent across different studies ranging from 5/50 to 19/50. The NDI is strongly correlated (>0.70) to a number of similar indices and moderately related to both physical and mental aspects of general health. CONCLUSION: The NDI has sufficient support and usefulness to retain its current status as the most commonly used self-report measure for neck pain. More studies of CID in different clinical populations and the relationship to subjective/work/function categories are required.

Note: Appendix B is online-only and is included in this downloadable PDF.

J Orthop Sports Phys Ther 2009;39(5):400-417. doi:10.2519/jospt.2009.2930

KEY WORDS: cervical spine, outcome measure, reliability, validity

A selection of important abstracts of articles published in other journals.

J Orthop Sports Phys Ther 2009;39(5):419-426.