Neck Pain Best Practice: Treatment-Based Classification

Neck pain, one of the most common musculoskeletal complaints, affects between 22% and 77% of individuals in their lifetime.1 While this pain is typically self-limiting and resolves with time, 30% of patients reporting neck pain ultimately develop chronic symptoms of greater than six months in duration.2 Between 37%3 and 44%4 of those who experience neck pain will also report lingering symptoms for at least 12 months. Unfortunately, even after successful treatment, there is a reported recurrence rate of 50-85% within the first one to five years following resolution of symptoms.5

Neck pain is multi-factorial in nature with patients reporting varying symptoms depending on pathology, psychosocial influences, fear-avoidance, and age. These complex clinical presentations require an individualized treatment plan based on each patient’s specific impairments and symptoms.

Steps to Classification

The goal of classification is to determine the treatment approach most likely to yield the best clinical outcome for an individual patient. Classification can also determine the patient’s appropriateness for physical therapy. Similar to the treatment-based classification model proposed by Delitto et al for low back pain, Childs et al developed a system for cervical spine disorders:

Is Physical Therapy Appropriate?

The first step in this classification scheme determines the patient’s need for physical therapy. This stage involves screening for ‘red flags’ (cervical myelopathy, cancer, ligamentous instability, fracture, and vascular compromise) as well as non-musculoskeletal causes of neck pain (i.e. cardiac event).

This preliminary stage is integral in ruling out significant pathology that needs further radiological imaging and/or surgical intervention prior to beginning a course of physical therapy. During this stage, two specific clinical prediction rules (CPR) can aid in making the best clinical judgment: Cervical Myelopathy and Canadian C-Spine Rule.

Is the Patient Ready for Treatment?

After clearing your patient from the presence of serious pathology, the patient’s psychosocial profile should be screened for any ‘yellow flags’ that may alter your treatment approach (catastrophizing, high fear-avoidance beliefs, etc.). These patients may benefit from a graded exercise, graduated exposure, and/or a pain science education in addition to the treatment-based classification system groupings.

What’s the Correct Treatment Category?

The final stage of this classification determines the correct treatment category for the patient. The classification system for neck pain can be broken into five distinct categories:


The mobility group receives cervical and/or thoracic manipulative and mobilization interventions along with cervical exercises (active range of motion, deep cervical flexors, etc.). Identifying these patients can be improved by implementing the CPR for cervical manipulation and the CPR for thoracic manipulation in addition to the criteria proposed by Childs et al.


Those in the centralization group should receive interventions to centralize their symptoms. We can do so through the use of their specific directional preference via repeated movements, or through the use of manual/mechanical cervical traction. The CPR developed by Raney et al. can also aid in identifying individuals who will benefit from cervical traction.8

Exercise & Conditioning

Patients who will benefit from general conditioning and exercise typically display lower pain/disability scores. While their duration of symptoms is longer, they usually benefit from targeted strengthening and endurance interventions that improve muscular imbalances and/or deficits.

Pain Control

The pain control grouping consists of non-aggravating manual techniques, therapeutic modalities, and activity modification. The patient should be progressed to a more active classification category as soon as tolerated.


The headache group is treated with upper extremity strengthening and manual therapy techniques directed at the cervical and thoracic spine (manipulation, sub-occipital release, etc.).

Change Classification with the Patient

As stated in Chad Cook, PT, PhD, MBA, FAAOMPT’s MedBridge course, “Manual Therapy for the Cervical Spine: An Evidence-Based Approach”, the classification process is ongoing because a patient’s presentation changes with time and treatment. Ongoing reassessment is required to determine the most appropriate sub-group and subsequent intervention at any point during the patient’s course of treatment.

Supported by Evidence

Evidence supports the effectiveness of this classification system. In 2007, Fritz et al performed a preliminary investigation into the utility of this particular treatment approach.9 Baseline patient characteristics and evaluations were performed on 274 patients and subjects were split into two groups:

  • 113 of these patients received matched interventions
  • 161 patients received unmatched interventions

Patients receiving matched interventions showed greater changes in both Neck Disability Index (NDI) scores and pain rating scores compared to their unmatched counterparts. 72.5% of patients in the matched group achieved the minimal detectable change in NDI, whereas those in the unmatched group only achieved this feat in 53.8% of patients. Along with this outcome data, the authors found a kappa value of 0.95 for classification determination and 0.96 for the treatment matching decision, both of which are in very strong agreement.

Heintz and Hegedus also published a case report of a patient presenting with mechanical neck pain who was successfully treated with the aforementioned treatment-based classification system.10 Over this patient’s 6-week treatment (38 days):

  • Pain was reduced from 4-10/10 to 0/10 with only a complaint of stiffness at end-range
  • NDI score decreased from 52% (severe disability) to 6% (no disability).

This is only one patient, but it does add evidence to the effectiveness of this particular treatment approach.

While the research regarding this treatment approach is in its infancy, the available evidence gives preliminary support to its effectiveness in treating patients presenting with mechanical neck pain.

  1. Childs J, Cleland J, Elliott 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. doi:10.2519/jospt.2008.0303
  2. Bovim G, Schrader H, Sand T. Neck Pain in the General Population. Spine (Phila Pa 1976). 1994 Jun 15;19(12):1307-9.
  3. Cote P, Cassidy JD, Carroll LJ, Kristman V, The Annual Incidence and Course of Neck Pain in the General Population: a Population-Based Cohort Study. Pain. 2004 Dec;112(3):267-73.
  4. Hogg-Johnson S, van der Velde G, Carroll LJ, et al., The Burden and Determinants of Neck Pain in the General Population, Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders, Eur Spine J (2008) 17 (Suppl 1): S39-S51 DOI 10.1007/s00586-008-624-y
  5. Haldeman S, Carroll L, Cassidy JD, et al., The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated DisordersEur Spine J (2008) 17 (Suppl 1): S5-S7 DOI 10.1007/s00586-008-0619-8
  6. Delitto A, Erhard RE, Bowling RW, A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment.Phys Ther. 1995 Jun;75(6):470-85; discussion 485-9.
  7. Childs JD, Fritz JM, Piva SR, Whitman JM, Proposal of a Classification System for Patients with Neck Pain. J Orthop Sports Phys Ther. 2004 Nov;34(11):686-96; discussion 697-700.
  8. 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 Mar;18(3):382-91. doi: 10.1007/s00586-008-0859-7. Epub 2009 Jan 14.
  9. Fritz JM, Brennan GP, Preliminary Examination of a Proposed Treatment-Based Classification System for Patients Receiving Physical Therapy Interventions for Neck PainPhys Ther. 2007 May;87(5):513-24. Epub 2007 Mar 20.
  10. Hegedus E, M Heintz, Multimodal Management of Mechanical Neck Pain Using a Treatment Based Classification System. The Journal of Manipulative Therapy. 17(4): 217-224.