Cervical: Treatment-based classification approach
Extensive research has allowed physical therapists to identify which patients will benefit from each type of treatment. It is important to understand that more than 1 single intervention will be necessary during the treatment process, however, the primary focus of treatment should be directed at one of these strategies. Click on each treatment to see the key examination findings which are used to determine the most effective form of treatment.
  • Recent onset of symptoms
  • No radicular or referred symptoms in the upper quarter
  • Restricted range of motion with side-to-side rotation or discrepancy in lateral flexion range of motion, or both
  • No signs of nerve root compression or peripheralization of symptoms in the upper quarter with cervical range of motion
If these findings are present, treatment should include:
  • Cervical and thoracic spine mobilization/manipulation
  • Active range of motion exercises
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  • Radicular or referred symptoms in the upper quarter
  • Peripheralization or centralization of symptoms with range of motion, or both
  • Signs of nerve root compression present
  • May have pathoanatomic diagnosis of cervical radiculopathy
If these findings are present, treatment should include:
  • Mechanical or manual cervical traction
  • Repeated movements to centralize symptoms
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Conditioning and increased exercise tolerance
  • Lower pain and disability scores
  • Longer duration of symptoms
  • No signs of nerve root compression
  • No peripheralization or centralization during range of motion
If these findings are present, treatment should include:
  • Strengthening and endurance exercises for the muscles of the neck and upper quarter
  • Aerobic conditioning exercises
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Pain control
  • High pain and disability scores
  • Very recent onset of symptoms
  • Symptoms precipitated by trauma
  • Referred or radiating symptoms extending into the upper quarter
  • Poor tolerance for examination or most interventions
If these findings are present, treatment should include:
  • Gentle active range of motion within pain tolerance
  • Range-of-motion exercises for adjacent regions
  • Physical modalities as needed
  • Activity modification to control pain
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Reduce headache
  • Unilateral headache with onset preceded by neck pain
  • Headache pain triggered by neck movement or positions
  • Headache pain elicited by pressure on posterior neck
If these findings are present, treatment should include:
  • Cervical spine mobilization/manipulation
  • Strengthening of neck and upper quarter muscles
  • Postural education
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Childs JD, Fritz JM, Piva SR, Whitman JM. Proposal of a classification system for patients with neck pain. J Orthop Sports Phys Ther. 2004;34:686-696.

Independent Study Course 13.3, Physical Therapy for the Cervical Spine and Temporomandibular Joint. LaCrosse, Wis. Copyright 2003, Orthopaedic Section, APTA, Inc.

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Donelson R, Silva G, Murphy K. Centralization phenomenon. Its usefulness in evaluating and treating referred pain. Spine. 1990;15:211-213.

Nilsson N. A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther. 1995;18:435-440.

Sterling M. A proposed new classification system for whiplash associated disorders: implications for assessment and management. Man Ther. 2004;9:60-70.

Antonaci F, Fredriksen TA, Sjaastad O. Cervicogenic headache: clinical presentation, diagnostic criteria, and differential diagnosis. Curr Pain Headache Rep. 2001;5:387-392.
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