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Application of a Diagnosis-Based Clinical Decision Guide in Patients with Neck Pain By Frank M. Methods: Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of NP patients examined by one of three examiners trained in the application of the DBCDG. Neck pain (NP), along with related disorders such as cervical radiculopathy and headache, is very common. A diagnosis-based clinical decision Guide (DBCDG) has been proposed for the purpose of guiding clinicians in the application of the biopsychosocial model in patients with NP.
In the majority of cases it is not possible to know with absolute certainty what the pain generating tissue is. With this question the clinician seeks to identify factors that serve to perpetuate the ongoing pain and suffering experience.
In seeking an answer to the first question of diagnosis, standard history and examination procedures were used. Patients also completed the BDQ [15] and the Numerical Rating Scale for pain intensity (NRS) [16]. Data regarding the second and third questions of diagnosis are provided in tables 2 and 3, respectively. Identifying specific diagnostic characteristics in patients with NP upon which treatment decisions can be made has been established as a research priority [3]. Future studies are planned that will investigate correlations and patterns among the diagnostic components and investigate the reliability and efficacy of this approach in patients with NP.
Treatment?based classification approach to neck pain - Physiopedia, universal access to physiotherapy knowledge. Renew Your Subscription and List Your Practice for Free!Chronic pain sufferers are using our pain specialist directory to find pain specialists in your area. Location and intensity of the pain: The use of a body pain diagram may be helpful to understand the pain distribution and characteristics, and may be helpful in directing further evaluation. Practical Pain Management is sent without charge 10 times per year to pain management clinicians in the US. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, oculomotor dysfunction, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as interexaminer reliability, validity and efficacy of treatment based on the DBCDG. This has been referred to in previous publications as a diagnosis-based clinical decision rule. This effort began with observational cohort studies in defined populations that documented the clinical outcomes of patients with cervical radiculopathy [10], lumbar spine stenosis [11], pregnancy-related lumbopelvic pain [12] and lumbar radiculopathy secondary to disc herniation [13].
Gastrointestinal and anterior neck disorders are included in addition to such “red flag” disorders as fracture, infection and malignancy. However there is evidence that characteristics of the pain generating tissue can be reliably identified [17-24] and that treatment decisions can be made based on these characteristics [10, 24]. The combined answers to the three questions of diagnosis are formulated into a working diagnosis (figure 1) from which a management strategy is derived (figure 2). Segmental pain provocation signs, detected via segmental palpation as described by Jull, et al [19, 28].
Central pain hypersensitivity (CPH), detected through observation of pain behavior in response to stimuli as well as through cervical nonorganic signs [50]. Multimodal management of mechanical neck pain using a treatment based classification system.

This article reviews the anatomy, common causes, as well as practical approaches to the management of neck pain.By Gerard A. A forward head and rounded shoulder posture are common in patients presenting with myofascial neck pain. The prevalence of neck pain in the world population: a systematic critical review of the literature. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: executive summary. 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. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Rehabilitation of neck-shoulder pain in women industrial workers: a randomized trial comparing isometric shoulder endurance training with isometric shoulder strength training. Efficacy of lidocaine patch 5% in the treatment of focal peripheral neuropathic pain syndromes: a randomized, double-blind, placebo-controlled study. Effectiveness and safety of topical capsaicin cream in the treatment of chronic soft tissue pain. Efficacy of pregabalin in neuropathic pain evaluated in a 12-week, randomised, double-blind, multicentre, placebo-controlled trial of flexible- and fixed-dose regimens. Controlled-release oxycodone relieves neuropathic pain: a randomized controlled trial in painful diabetic neuropathy. Long-term results of cervical epidural steroid injection with and without morphine in chronic cervical radicular pain. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain: a randomized, controlled trial.
Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults.
Radiofrequency denervation for neck and back pain: a systematic review of randomized controlled trials.
Long-term effect of pulsed radiofrequency on chronic cervical radicular pain refractory to repeated transforaminal epidural steroid injections.
A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based guide in applying the biopsychosocial model of care.
Centralization signs were found in 27%, segmental pain provocation signs were found in 69% and radicular signs were found in 19%. In many cases, the working diagnosis is multifactorial, leading to a multi-modal management strategy. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. Impairment of the motor control system has been theorized to lead to perpetuation of pain and disability as a result of ongoing microtrauma to the tissues of the spine [38-40]. This is commonly associated with pain that occurs after cervical trauma in patients who experience delayed recovery [42-44].
This was based on the findings of Fishbain, et al [51] who reviewed the literature on nonorganic signs in patients with low back pain and found that these signs, in addition to predicting poor functional abilities and poor outcome to treatment, were associated with greater pain levels and that the majority of these signs can be explained on the basis of pain intensity.

Several guidelines on the management of neck pain have been published.3-6 However, there remains no definitive consensus on this topic. The recent Bone and Joint Decade Neck Pain Task Force identified the need for research that examines the clinical criteria for diagnosis as well as the best forms of treatment for patients with NP and related disorders [3]. It is influenced by the existing disparate literature on the diagnosis and management of patients with spinal pain [9]. Future studies will require identifying specific subgroups of patients that have certain multifactorial diagnoses according to the answers to the three questions of diagnosis.
The presence of segmental pain provocation signs was based on the examiner perceiving increased resistance to this pressure relative to other segments and the patient reporting reproduction of the NP [19, 28].
Trigger points can occur in latent form in individuals without pain and as such it is considered important to not only identify the presence of a trigger point but to determine whether it is diagnostically relevant in any given patient [33]. Intensity of chronic pain is thought to reflect central nervous system processes (termed here central pain hypersensitivity) in addition to peripheral processes [52].
In addition, two questions from the Coping Strategies Questionnaire [64] which have previously been found to be predictive of changes in disability in LBP patients [65] were used to measure patients’ perception of their control over the pain. Although acute neck pain generally resolves with conservative treatment, an algorithmic approach should be applied to ensure a full assessment of this complaint.
Additionally, cervical disc herniations can occur with a sudden load with the neck in either flexion or extension. Also recognized by the Neck Pain Task Force is the importance of applying a patient-focused approach that considers the biopsychosocial nature of NP [4, 5]. Given the fact that there is a variety of potential factors that can contribute to the experience of NP, there could potentially be a large number of different diagnoses, making subgrouping difficult. Also considered a centralization sign would be a progressive decrease in pain intensity even if movement of the pain to the center was not perceived.
In cases in which there was a discrepancy between the amount of resistance perceived by the examiner and reproduction of pain perceived by the patient, pain reproduction was given priority.
Thus, these signs were only recorded if the clinician felt they were diagnostically relevant to the patient’s NP. This was a 77-year-old man with recent onset neck pain and temporal headache and marked tenderness over the temporal artery who was referred for blood tests to rule out temporal arteritis.
However, clinical experience seems to suggest that there are enough commonalities among NP patients that the actual number of different diagnostic factors is small enough to make subgrouping possible. Symptoms Isolated to the Neck -referred pain may be presentNeck Pain with Radiating Pain[3]1. The standardized outcome measurement instruments were those tools used in the normal course of patient care at the facility at which the study was conducted to measure improvement in pain and perceived disability. These instruments were the Bournemouth Disability Questionnaire (BDQ) [14, 15] and Numerical Rating Scale [16] for pain intensity.

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