7 Colo. Code Regs. § 1101-3-17-08-7
Introduction. Active therapies are therapeutic exercises and/or activities that intend to restore flexibility, strength, endurance, function, and range of motion (ROM) and to alleviate discomfort. Given the anatomic proximity, active therapies for cervical conditions may also incorporate the shoulder. They require intrinsic motivation by the patient to complete a specific exercise or task. The following active therapies are common treatments:
* activities of daily living (ADLs) therapy,
* functional activities therapy,
* functional electrical stimulation or neuromuscular electrical stimulation (NMES),
* neuromuscular re-education,
* pilates,
* tai chi,
* therapeutic exercise,
* yoga,
* work conditioning, and
* work simulation.
Active therapies also include developing functional goal-setting, maintaining or returning to usual activities and exercise in a graded fashion, and providing patient education and key recovery messages. Active therapies may coincide with pain neuroscience education. Pain neuroscience education involves educating patients about the biological and physiological processes involved in their pain experience and, importantly, deemphasizing the issues associated with anatomical structures, pain generators, and tissue damage.
Individual patients may benefit from additional education approaches. Education may include, but is not limited to: a favorable prognosis for recovery, the importance of continuing daily activities, promotion of self-efficacy, problem-solving, engagement of support systems, and relaxation techniques.
Contraindications / Side Effects and Adverse Events.
Relative Contraindications to Active Therapies.
* Motor, sensory, or reflex abnormalities are relative contraindications to the use of the McKenzie
Method of Mechanical Diagnosis and Therapy.
* Pulmonary or cardiac conditions limiting participation are relative contraindications to active therapy.
Side Effects and Adverse Events Related to Active Therapies.
* Exercise therapy may result in transient neck, shoulder, or thoracic muscle soreness. This side effect, within reasonable limits, should not deter continued active therapy.
Recommendations.
Core Requirements.
Recommendation 47. Active interventions, including therapeutic exercise and/or functional treatment, are recommended in the treatment of neck pain (table 9).
Recommendation 48. Medical clearance is required prior to participation in active therapies if a patient has any of the following:
* angina/dyspnea on exertion or at rest,
* paroxysmal nocturnal dyspnea and/or orthopnea,
* syncope or presyncope,
* arrhythmia or palpitations, or
* cardiac murmur (see Contraindications to Active Therapies).
Recommendation 49. Patients in active therapy must:
* demonstrate functional progress that is documented through validated sequential functional assessment measures,
* return to work with decreased restrictions, and/or
* have improvement in clinical measures (e.g., strength, ROM, and ADLs)
If there is no documented evidence of functional progress after 6 treatments, the therapy will be discontinued and the patient must be referred back to their treating provider for further evaluation. Each patient is limited to a maximum of 4 discrete active therapy trials without documented functional progress (Appendix Functional Screens).
Recommendation 50. A patient is allowed up to 6 active therapy visits to advance their active home exercise program. These visits are contingent on documented demonstration of previously instructed exercises, performance of their home program at the recommended frequency, and progress in their exercise program.
Recommendation 51. Adjunct passive therapy can occur concurrently with active therapy and the frequency of passive therapies will decrease over time. See the Passive Therapies section.
Recommendation 52. Durations of care beyond those listed as "time to produce effect" and "maximum" are warranted in certain circumstances when treatment to date has resulted in measurable and clinically meaningful functional improvement. These circumstances include:
* re-injury;
* interrupted continuity of care;
* after surgery, particularly after multiple surgeries;
* injuries (e.g., fracture); or
* comorbidities.
Recommendation 53. Functional electrical stimulation or NMES home units require prior authorization, documenting medical justification for home use.
Time Frames.
Time Frames for Active Therapies | |||
Time to produce effect | Frequency | Optimum duration | Maximum duration |
6 treatments | up to 4 times per week | 6 weeks | 8 weeks |
Evidence Tables.
Table 9. Evidence Summary: Active Therapies |
Active therapies may provide functional benefit and symptomatic relief in patients with neck pain. No evidence demonstrates that 1 form of active therapy is superior to any other, and the selection of an active therapy may be guided by local availability and the patient's preference and capability. Patients with barriers to functional recovery may benefit from the incorporation of pain education into therapeutic exercise. |
Table 10. Evidence Table: Exercise and Neck Pain | ||
Summary: For patients with subacute and chronic neck pain, exercise provides symptomatic relief as compared to control interventions. For patients with neck pain, participation in active therapy in combination with passive therapy (e.g., manipulation, mobilization, stretching, muscle energy) results in reduced pain and disability as compared to either treatment alone, education alone, or other minimal intervention. | ||
Good evidence | Evidence statement | Design |
Adding exercise in combination with other interventions such as: 1) manipulation alone, or 2) manipulation and mobilization, or 3) mobilization, muscle energy, and stretching, is more effective than manipulation alone, mobilization alone, exercise alone, and other minimal intervention or education alone in reducing neck pain and disability. | Systematic review | |
In people with chronic neck pain, exercise with or without manipulation results in decreased pain and disability compared to home exercise and advice at 12 weeks but not 52 weeks. The percentage of patients with 2.5% decrease in pain at 1 year was 51% with manipulation and exercise, 57% with exercise only, and 41% with home exercise and advice. It is not clear that the expense is worth the outcome long-term. | RCT | |
A 12-week physiotherapist-led neck-specific exercise program (with or without a behavioral approach) consisting of 2 physiotherapy sessions weekly in addition to home-exercise of increasing intensity in terms of duration (or repetitions) was found to be more effective in reducing pain and disability than "prescription of physical activity." The effect was sustained up to 6 months in both groups as well. | RCT | |
For patients with subacute to chronic mechanical neck disorders, a combination of scapulothoracic and upper extremity strength training decreased pain intensity compared to control interventions. The programs ranged from 2 minutes to 2 hours per session, sessions ranged from 3 times/week to 6 times/week, and the programs lasted up to 20 weeks. All programs included specific forms of scapulothoracic and upper extremity strength training. | Systematic review | |
For patients with chronic mechanical neck disorders a program consisting of repeated active cervical rotations, strength and flexibility exercises had a beneficial effect on reducing pain intensity. The specific programs ranged from 3 to 6 months (the shorter-length program included a 3 month-self-directed follow-up), 18 to 24 sessions, and duration of sessions was 45 to 90 minutes. Exercise was monitored by a qualified physiotherapist. | Systematic review | |
For patients with chronic mechanical neck disorders, a combination of cervico-scapulothoracic strengthening and stretching exercises improved function at the intermediate term follow-up (defined as 3 months up to, but not including, 1 year). The specific programs ranged from 6 weeks to 11 weeks, the sessions ranged from 1 to 2 times/week, and the duration of sessions ranged from 20 minutes to 45 minutes. | Systematic review | |
In the setting of symptomatic cervical radiculopathy from herniated discs and/or osteophytes at 1 or 2 levels, it is reasonable to initiate a program of structured physical therapy before any surgical decisions are made, since many patients will experience significant improvement in pain and function. However, a program of anterior cervical discectomy and fusion (ACDF) plus structured physical therapy is likely to be superior to physical therapy alone, and the improvements appear to continue for at least 5 to 8 years. | RCT | |
In a population of female office workers with "constant chronic neck pain and disability" and symptoms lasting greater than 6 months, a home exercise program consisting of either muscle endurance training (i.e., 3 sets of 20 reps, 3 times a week for 12 months) or muscle strength training (i.e., 1 set of 15 reps, 3 times a week for 12 months) was found to be effective in improving function in the short-term. | Systematic review | |
Some evidence | Evidence statement | Design |
An exercise program that includes resistance training of the cervical and scapulothoracic muscles, combined with stretching of the same muscles, is likely to be beneficial for mechanical neck pain. | Meta analysis | |
General fitness exercises and upper extremity exercises are unlikely by themselves to be beneficial for mechanical neck pain. | Meta analysis | |
In patients with chronic mechanical neck pain, stabilization exercises with or without connective tissue massage are equally effective for reducing pain, anxiety and physical health while increasing the quality of life. | RCT | |
A 3-week program of twice weekly home neck exercises with manual physical therapy that includes joint mobilization, muscle energy, and stretching, reduces neck pain and disability compared with a minimal intervention for patients with chronic neck pain at 6 weeks follow-up, but it did not persist at 1 year follow-up. | RCT | |
In the setting of nonspecific acute or subacute neck pain that limits daily activities but is unaccompanied by radicular signs, weakness, or numbness in the arm, 3 treatment options include spinal manipulative therapy, prescription or nonprescription medication, and home exercise with advice. 12 weeks of spinal manipulative therapy is likely to be marginally more beneficial than medication, but is not more beneficial than home exercise with advice consisting of 2 hours of instruction by a physical therapist, focused on simple self-mobilization exercise of the neck and shoulder joints done 6 to 8 times per day. | RCT | |
A combination of exercise and spinal manipulation is more effective than manipulation alone in relieving chronic neck pain, and these advantages remain for more than 1 year after the end of treatment. | RCT | |
Multimodal care consisting of a 3-week program of twice weekly exercise with manual therapy with joint mobilization, muscle energy techniques, and home strengthening and ROM exercises, reduces neck pain and disability compared with a minimal intervention consisting of postural advice, ROM exercise, subtherapeutic ultrasound, and continuation of prescribed medication. | Systematic review | |
A program of 2 sessions of thoracic thrust manipulation followed by a cervical exercise program is more effective than a cervical exercise program alone. | Systematic review | |
Mobilization, manipulation, and exercise does not provide greater long-term pain relief when compared to exercise alone. | Systematic review | |
In patients with tension-type musculoskeletal neck pain with no neurological deficits, both individually applied physical therapy and a 7-week group course teaching relaxation and body awareness activities lead to improvements in pain and function after 20 weeks. However, the benefits are likely to be greater in patients who receive the group instruction in relaxation and body awareness exercises. A brief course in this intervention is needed for the physical therapists who will implement the intervention at their clinics. | Systematic review | |
Table 11. Evidence Table: The McKenzie Method and Neck Pain | ||
Some evidence | Evidence statement | Design |
The McKenzie approach provides similar outcomes in improving pain, disability, and ability to carry out work activities in comparison with cognitive behavioral therapy (CBT). | RCT | |
Table 12. Evidence Table: Pilates and Tai Chi in Neck Pain | ||
Good evidence | Evidence statement | Design |
Pilates exercise shows statistically and clinically significant reductions in pain and statistically significant improvements in function in the short-term (maximum follow up 15 weeks) compared with usual care, no exercise, education, or physical activity for the treatment of patients with chronic low back pain. | Systematic review | |
Some evidence | Evidence statement | Design |
12 weeks of Tai Chi is more effective than no treatment to improve pain, disability, quality of life, and postural control in subjects with chronic nonspecific neck pain. | RCT | |
Table 13. Evidence Table: Craniosacral Therapy and Neck Pain | ||
Some evidence | Evidence statement | Design |
Craniosacral therapy for chronic nonspecific neck pain, performed by a physical therapist trained in the technique, is superior to sham treatment in reducing neck pain intensity at 8 weeks and probably at 20 weeks. | RCT | |
Table 14. Evidence Table: Active Therapies with Education for Neck Pain | ||
Some evidence | Evidence statement | Design |
Among patients with persistent grade I-II whiplash-associated disorders, the addition of a 10-week standardized progressive goal attainment program to a functional restoration physical therapy (2.5 hours/day, 3 times/week for 10 weeks or until return to work) improves the rate at which patients return to work. | Systematic review | |
A 2-day course focusing on the biopsychosocial model with an emphasis on the goals of returning to usual activities and fitness is as effective in reducing disability as 6 sessions of manual therapy sessions provided by physiotherapists and more limited patient education. | RCT | |
Table 15. Evidence Table: Pain Neuroscience Education | ||
Summary: For patients with chronic musculoskeletal pain, including neck pain, active therapy with pain neuroscience education reduces pain and increases function as compared to active therapy alone. | ||
Good evidence | Evidence statement | Design |
Pain neuroscience education combined with a physical intervention is more effective in reducing pain, improving disability, and reducing healthcare utilization compared with either usual care, exercise, other education, or another control group for the treatment of patients with chronic musculoskeletal pain. | Systematic review | |
Some evidence | Evidence statement | Design |
The difference between the pain-education and control group for patients with chronic neck or low back pain reaches clinical relevance for both physical and mental-health domains in the 36-item Short Form Health Survey (SF-36 scale) and persists at 12 months. | RCT | |
Introduction. Psychological therapeutic and diagnostic interventions have selected use in acute pain problems and more widespread use in sub-acute and chronic pain populations. Psychosocial interventions include psychotherapeutic treatments for mental health conditions, as well behavioral medicine treatments. Therapeutic psychological interventions include, but are not limited to, individual counseling and group therapy. Treatment can occur within an individualized model, a multi-disciplinary model, or a structured pain management program.
These interventions may similarly benefit patients without psychiatric conditions but who may need to make major life changes in order to cope with pain or adjust to disability. Health behavior assessment and intervention services are used to identify and address the psychological, behavioral, emotional, cognitive, and interpersonal factors important to the assessment, treatment, or management of physical health problems.
The following commonly used terminology appears in the context of addressing behavioral and psychological interventions:
* biofeedback training, including:
o electromyogram,
o skin temperature,
o respiration feedback,
o respiratory sinus arrhythmia,
o heart rate variability,
o electrodermal response, and
o electroencephalograph,
* cognitive behavioral therapy (CBT);
* mindfulness-based stress reduction;
* progressive relaxation;
* relaxation therapy; and
* sleep hygiene training.
CBT is a psychological therapy that integrates theories of cognition and learning with treatment techniques derived from cognitive therapy and behavior therapy. It assumes that cognitive, emotional, and behavioral variables are functionally interrelated. Treatment is aimed at identifying and modifying the patient's unproductive thought processes and behaviors through cognitive restructuring and behavioral techniques to achieve change. Variations of CBT methods can be used to treat a variety of conditions, including chronic pain, depression, anxiety, phobias, and post-traumatic stress disorder. For patients with multiple diagnoses, more than 1 type of CBT might be needed. A "manualized" approach to CBT follows a specific protocol in a manual. See the Chronic Pain Disorder Medical Treatment Guidelines (MTGs) for additional information on psychological evaluation.
Contraindications / Complications / Side Effects and Adverse Events.
Absolute and Relative Contraindications to Behavioral and Psychological Interventions.
* Contraindications include active suicidality, homicidality, active psychosis, or major untreated psychological comorbidity.
* Relative contraindication includes a lack of patient engagement despite interventions targeting initial resistance.
* Relative contraindications to CBT include literacy below the 6th grade level, lack of English language proficiency, and cognitive impairment.
Side Effects and Adverse Events Related to Behavioral and Psychological Interventions.
* Side effects and adverse events include emotional discomfort, cognitive dissonance, irritability, interpersonal difficulties, or temporary increase in stress.
Recommendations.
Core Requirements.
Recommendation 54. Formal psychological or psychosocial evaluation is recommended as a component of the biopsychosocial approach to patient recovery from physical injury and should attempt to identify both primary psychological risk factors (e.g., psychosis and active suicidality) and secondary psychological risk factors (e.g., moderate depression and job dissatisfaction) (table 16). The evaluation should distinguish between pre-existing, aggravated, and/or purely causative psychological conditions.
Recommendation 55. Comprehensive psychological evaluation must be performed by a psychologist with PhD, PsyD, or EdD credentials or a physician with psychiatric MD/DO credentials.
Recommendation 56. Psychometric testing, distinct from screening psychological questionnaires, must be administered by a psychologist with a PhD, PsyD, or EdD or a health professional working under the supervision of a doctorate level psychologist. A physician with appropriate training may also administer such testing, but interpretation of the tests should be done by a properly credentialed mental health professional.
Recommendation 57. Evaluation for psychiatric medication is permitted if there is an established diagnosis consistent with the standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). See the Medications section.
Recommendation 58. An initial assessment, ongoing assessment, and treatment plan with measurable and clinically meaningful behavioral goals, time frames, and specific planned interventions are required before initiating psychological/psychiatric interventions. Ongoing requirements include:
* a biweekly status report during initial, more frequent treatment and monthly thereafter, documenting progress toward functional recovery;
* a discussion of the psychosocial issues affecting the patient's ability to participate in treatment; and
* addressing pertinent issues such as pre-existing, aggravated, and/or causative issues, as well as realistic functional prognosis.
* Recommendation 59. The following is recommended when obtaining a psychological evaluation:
* a full release from the patient prior to evaluation acknowledging that information that may go to the employer, and
* exclusion of sensitive health information not directly related to the work-related conditions in reports sent to the insurer is essential.
CBT Requirements.
Recommendation 60. CBT is recommended for cervical spine pain patients who catastrophize, cope ineffectively with pain, or avoid activity out of fear of re-injury (table 17).
Recommendation 61. A full psychological evaluation is required before CBT can be initiated.
Recommendation 62. A CBT provider must be a:
* psychologist with PhD, PsyD, or EdD credentials;
* psychiatric MD/DO; or
* licensed mental health or licensed health care provider with training in CBT or certified as a CBT therapist with experience in treating chronic pain disorders who works in consultation with a psychologist with a PhD, PsyD, EdD, or psychiatric MD/DO.
Recommendation 63. A manualized approach to CBT is strongly recommended if being performed by a non-mental health professional, with appropriate supervision by a psychologist with a PhD, PsyD, EdD, or psychiatric MD/DO provider.
Recommendation 64. Candidates for CBT will have all of the following characteristics:
* adequate literacy level to complete homework used to teach inductive rational thinking,
* adequate cognitive and education abilities to meet the requirements of a CBT protocol, and
* otherwise stable social circumstances.
The selection of CBT methods should be based on the individual's literacy level, English proficiency, and cognitive capabilities, as assessed by the behavioral health provider. Individuals who are not candidates for CBT may benefit from other behavioral and psychological approaches.
Biofeedback Requirements.
Recommendation 65. Biofeedback as an adjunct to psychological therapy is recommended for patients who meet 1 of the following indications:
* musculoskeletal injury, in which muscle dysfunction or other physiological indicators of excessive prolonged stress response affects and/or delays recovery;
* a need for training to improve self-management of pain, anxiety, panic, anger or emotional distress, opioid withdrawal, insomnia, sleep disturbance, and/or other central and autonomic nervous system imbalances; and/or
* motivation to learn and practice biofeedback and self-regulation techniques (table 18).
Recommendation 66. If biofeedback treatment is indicated, it must be done in conjunction with the patient's other psychosocial or medical interventions.
Recommendation 67. Psychologists or psychiatrists who provide psycho-physiological therapy, which integrates biofeedback with psychotherapy, must be either Biofeedback Certification International Alliance (BCIA) certified or practicing within the scope of their training.
Non-licensed health care providers of biofeedback for chronic pain patients must be BCIA certified and shall have their biofeedback treatment plan approved by the authorized treating psychologist or psychiatrist.
Biofeedback can also be provided by health care providers who follow a set treatment and educational protocol. Such treatment may utilize standardized material, relaxation recordings, or app-based interventions. App-based interventions must meet the criteria in Rule 18.
Substance Use Disorder Requirements.
Recommendation 68. Patients with substance use disorder, high-dose opioid use, or use of other drugs of abuse may require inpatient and/or outpatient chemical dependency treatment programs before or in conjunction with other interdisciplinary rehabilitation. See the Chronic Pain Disorder Medical Treatment Guidelines (MTGs).
Time Frames.
Time Frames for Behavioral and Psychological Interventions | |||
Time to produce effect (sessions) | Frequency (sessions/week) | Maximum duration | |
Group CBT | up to 8 (2-hours) | up to 2 | 16 sessions |
Individual CBT | up to 8 (1-hour) | up to 2 | 16 sessions |
Biofeedback | up to 4 sessions | up to 2 | 12 sessions [UPSILON] |
Relaxation | up to 4 sessions | up to 2 | 12 sessions [UPSILON] |
Other psychological interventions | up to 8 | up to 2* | 6 months [DOUBLE DAGGER] |
[UPSILON] Treatment beyond 12 sessions must be documented with respect to need, expectation, and ability to facilitate positive symptomatic and functional gains. * For the first 2 weeks of treatment, excluding hospitalization, if required; decreasing to weekly in the 2nd month of treatment and then 2-4 times per month (with the exception of exacerbations, which may require increased frequency of visits). [DOUBLE DAGGER] Longer supervised psychological/psychiatric treatment may be required, especially if there are ongoing medical procedures or complications. If counseling beyond 6 months is indicated, the management of psychosocial risks or functional progress must be documented. | |||
Evidence Tables.
Table 16. Evidence Table: Psychological Assessments and Outcomes | ||
Summary: Psychological testing identifies patients most likely to benefit from surgery. | ||
Good evidence | Evidence statement | Design |
Psychometric testing can predict medical treatment outcomes. | Cohort study | |
Interdisciplinary programs that include screening for psychological issues, identification of fear-avoidance beliefs and treatment barriers, and establishment of individual functional and work goals will improve function and decrease disability. | RCT | |
Some evidence | Evidence statement | Design |
Psychological and medical risk factor assessment prior to surgery can identify patients unlikely to benefit from surgery. | Cohort study | |
Table 17. Evidence Table: CBT | ||
Summary: CBT may reduce pain, disability, sick leave, health care utilization, and insomnia for patients with chronic pain. | ||
Good evidence | Evidence statement | Design |
CBT may reduce pain and disability in patients with chronic pain, but the magnitude of the benefit is uncertain. | Meta analysis | |
CBT, but not behavioral therapy, shows weak to small effects in reducing pain, and small effects on improving disability, mood, and catastrophizing in the treatment of patients with chronic pain. | Meta analysis | |
A stepped care program is more effective than usual care in veterans with chronic musculoskeletal pain. The stepped care program consisted of 12 weeks during which nurse case managers took a medication use history and adjusted medication dosage and scheduling through telephone contacts with patients every other week, followed by a 12-week step in which cognitive behavioral treatment was administered by 45 minute individual sessions by telephone every other week. Disability and pain interference with daily activity with stepped care were both superior to usual care in which patients were given printed handouts and were followed for all care by their primary treating physicians. | Meta analysis | |
Some evidence | A 6-week program of cognitive-behavioral group intervention with or without physical therapy can reduce sick leave, health care utilization, and the risk for developing long-term sick leave disability (> 15 days) in workers with nonspecific low back or neck pain compared with simple verbal instruction by a physician. | RCT |
CBT provided in seven 2-hour small group sessions can reduce the severity of insomnia in chronic pain patients. | RCT | |
The McKenzie approach provides similar outcomes in improving pain, disability, and ability to carry out work activities in comparison with CBT. | RCT | |
The benefits of CBT continue to be present 3 or more years after the initial intervention, although the differences between CBT and the control group are likely to become narrower with extended follow-up. | RCT | |
Behavioral modification, such as patient education and group or individual counseling with CBT, can be effective in reversing the effects of insomnia. | RCT | |
Table 18. Evidence Table: Biofeedback and Relaxation Training | ||
Summary: Both biofeedback and relaxation therapy may reduce pain and disability for patients with chronic low back pain. While the literature in this table discusses chronic low back pain, there is presumed physiologic similarity for chronic neck pain. | ||
Good evidence | Evidence statement | Design |
Biofeedback or relaxation therapy is equal in effect to CBT for chronic low back pain. | Meta analysis | |
Self-regulatory interventions, such as biofeedback and relaxation training, may be equally effective. | Meta analysis | |
Some evidence | Evidence statement | Design |
Progressive relaxation was the only psychological therapy associated with improvement in function as well as pain intensity compared to wait-list control in chronic low back pain. | Systematic review | |
Introduction. Passive therapies include treatments that do not require a patient's energy expenditure. They are most helpful early in treatment, and they are directed at controlling symptoms and improving the rate of healing soft tissue injuries. They can be used adjunctively with active therapies to help control swelling, pain, and inflammation. The following passive therapies are common treatments: treatments:
* acupuncture,
* acupuncture with electrical stimulation,
* iontophoresis,
* joint mobilization,
* low level laser,
* manipulation,
* manual treatment,
* manual traction,
* massage,
* mechanical or motorized traction,
* phonophoresis,
* soft tissue mobilization,
* short-wave diathermy,
* superficial heat and cold therapy,
* trigger point dry needling,
* ultrasound, and
* unattended electrical stimulation (e.g., transcutaneous electrical nerve stimulation [TENS]).
Contraindications / Complications / Side Effects and Adverse Events.
Absolute and Relative Contraindications to Passive Therapies.
* High velocity / low amplitude manipulation is contraindicated in those with joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthritis, signs of progresssive neurologic deficits, myelopathy, vertebrobasilar insufficiency, or carotid artery disease.
* Relative contraindications to manipulation include spinal stenosis, spondylosis, and disc herniation.
* Manual traction is contraindicated in those with tumor, infection, fracture, or fracture dislocation.
* Non-oscillating inversion traction methods are contraindicated in patients with glaucoma or hypertension.
Complications of Passive Therapies.
* Rare complications of dry needling or acupuncture include pneumothorax, infection, or syncope.
* Cervical vertebral artery dissection can occur with high velocity neck manipulation.
Side Effects and Adverse Events Related to Passive Therapies.
* Acupuncture may result in treatment-related pain or bruising associated with needle insertion.
Recommendations.
Core Requirements.
Recommendation 69. Patients in passive therapy must demonstrate functional progress through validated functional assessment measures. If there is no evidence of functional progress within the time to produce effect, the therapy shall be discontinued and the patient must be referred back to their treating provider for evaluation. Each patient is limited to a maximum of 4 discrete passive therapy trials.
Recommendation 70. Passive therapies must occur concurrently with self-directed exercise or formal active therapy programs (table 19).
Recommendation 71. The frequency of passive therapy must decrease over time.
Recommendation 72. Durations of care beyond those listed as "time to produce effect" and "maximum" are warranted in certain circumstances when treatment to date has resulted in measurable and clinically meaningful functional improvement. These circumstances include:
* re-injury;
* interrupted continuity of care;
* after surgery, particularly multiple surgeries;
* injuries (e.g., fracture); or
* comorbidities.
Specific goals with objective measures of functional improvement must be cited to justify extended durations of care.
Recommendation 73. Manipulation under general anesthesia and manipulation under joint anesthesia are not recommended.
Recommendation 74. Mechanical traction is not generally recommended for neck pain patients with or without radicular symptoms.
Recommendation 75. Due to the absence of quality evidence supporting their use, ultrasound, phonophoresis, low level laser, kinesiotaping, iontophoresis, and motorized traction are not recommended for neck pain.
Time Frames.
Time Frames for Passive Therapies | |||
Time to produce effect (sessions) | Frequency* (sessions/week) | Maximum duration | |
Mobilization and Manipulation | up to 6 | up to 3 times/week | 8 weeks |
Massage | 1 | up to 2 times/week | 8 weeks |
Acupuncture | up to 6 | up to 3 times/week | 15 treatments |
Heat/cold, short-wave diathermy, unattended electrical stimulation (e.g., TENS**) | up to 4 | up to 3 times/week | 8 weeks |
Trigger point / dry needling | up to 4 | up to 2 times/week | 8 weeks |
Traction (manual)*** | up to 3 | up to 3 times/week | 4 weeks |
*See recommendation 71 regarding the expected decreasing frequency over time. **If TENS treatment results in documented functional benefit and is anticipated to extend beyond 4 treatments, consider purchase of a home TENS unit. ***If response is negative after 3 thirty minute treatments, discontinue. | |||
Evidence Tables.
Table 19. Evidence Summary: Passive Therapies |
Passive therapies may provide functional benefit and symptomatic relief in patients with neck pain, especially when paired with an active intervention. The decision to refer a patient for 1 passive therapy over another should be based on patient preference and relative safety, not on the expectation of a greater treatment effect among passive therapy options. |
Table 20. Evidence Table: Manipulation and Mobilization for Neck Pain | ||
Summary: Manipulation and/or mobilization can reduce pain and improve function for patients with neck pain, especially when combined with exercise. | ||
Good evidence | Evidence statement | Design |
Manipulation alone or mobilization alone provides immediate, short-term, and intermediate-term relief for acute, subacute, and chronic neck pain. | Meta analysis | |
Adding exercise in combination with other interventions such as: 1) manipulation alone, or 2) manipulation and mobilization, or 3) mobilization, muscle energy, and stretching, is more effective than manipulation alone, mobilization alone, exercise alone, and other minimal intervention or education alone in reducing neck pain and disability. | Systematic review | |
In patients with neck pain (with or without radicular findings), multiple sessions of thoracic manipulation was more effective in reducing intermediate-term chronic neck pain when compared with multiple sessions of a control. | Meta analysis | |
In people with chronic neck pain, exercise with or without manipulation results in decreased pain and disability compared to home exercise and advice at 12 weeks but not 52 weeks. The percentage of patients with 2.5% decrease in pain at 1 year was 51% with manipulation and exercise, 57% with exercise only, and 41% with home exercise and advice. It is not clear that the expense is worth the outcome long-term. | RCT | |
There is little difference in clinically significant benefit between high-velocity, low-amplitude cervical thrust manipulation and low velocity intervention, like mobilization, using techniques such as muscle energy, myofascial release, and sustained apophyseal natural glides. | Systematic review | |
In the setting of chronic neck pain, an intervention that mobilizes a nearby but asymptomatic spinal segment may be as beneficial as an intervention done directly at the symptomatic level. This may give the clinician additional options regarding the optimal treatment technique to be applied to the patient. | Systematic review | |
Some evidence | A 3-week program of twice weekly home neck exercises with manual physical therapy that includes joint mobilization, muscle energy, and stretching, reduces neck pain and disability compared with a minimal intervention for patients with chronic neck pain at 6 weeks follow-up, but it did not persist at 1 year follow-up. | RCT |
Mobilization, manipulation, and exercise does not provide greater long-term pain relief when compared to exercise alone. | Systematic review | |
Thoracic thrust manipulation may improve pain and function for mechanical neck pain. | Meta analysis | |
A combination of exercise and spinal manipulation is more effective than manipulation alone in relieving chronic neck pain, and these advantages remain for more than 1 year after the end of treatment. | RCT | |
Multimodal care consisting of a 3-week program of twice weekly exercise with manual therapy with joint mobilization, muscle energy techniques, and home strengthening and ROM exercises, reduces neck pain and disability compared with a minimal intervention consisting of postural advice, ROM exercise, subtherapeutic ultrasound, and continuation of prescribed medication. | Systematic review | |
A program of 2 sessions of thoracic thrust manipulation followed by a cervical exercise program is more effective than a cervical exercise program alone. | Systematic review | |
In the setting of nonspecific acute or subacute neck pain that limits daily activities but is unaccompanied by radicular signs, weakness, or numbness in the arm, 3 treatment options include spinal manipulative therapy, prescription or nonprescription medication, and home exercise with advice. 12 weeks of spinal manipulative therapy is likely to be marginally more beneficial than medication, but is not more beneficial than home exercise with advice consisting of 2 hours of instruction by a physical therapist, focused on simple self-mobilization exercise of the neck and shoulder joints done 6 to 8 times per day. | RCT | |
Table 21. Evidence Table: Massage for Neck Pain | ||
Some evidence | Evidence statement | Design |
In patients with chronic mechanical neck pain, stabilization exercises with or without connective tissue massage are equally effective for reducing pain, anxiety and physical health while increasing the quality of life. | RCT | |
Table 22. Evidence Table: Trigger Point Dry Needling and Neck Pain | ||
Some evidence | Evidence statement | Design |
4 sessions of trigger point deep dry needling with passive stretching over 2 weeks was significantly more effective in reducing neck pain and improving neck disability than passive stretching alone in the short-term and at 6-month follow-up in people with chronic nonspecific neck pain. | RCT | |
Table 23. Evidence Table: Acupuncture | ||
Summary: Acupuncture may reduce pain and improve function for patients with chronic neck pain. | ||
Good evidence | Evidence statement | Design |
Acupuncture is useful in the treatment of neck pain. | Systematic | |
review | ||
Acupuncturists must be properly trained in aseptic technique. | Systematic review | |
Some evidence | Evidence statement | Design |
Patients with nonspecific chronic neck pain were randomly assigned to 12 acupuncture sessions or 20 one-to-one Alexander Technique lessons with equivalent overall contact time. Both were associated with a significant reduction in neck pain and decreased disability, per the Northwick Park Neck Pain Questionnaire (NPQ), at 12 months compared with usual care. | RCT | |
In the current study, participants with chronic neck pain received a 3-week phase of acupuncture, which included a total of 6 treatments, 3 times per week, each lasting 30 minutes. It was found that up to 12 weeks after treatment ended, those who received classic acupuncture improved significantly more with respect to disability and pain than those who received acupuncture at non-classical sites. Both groups had significant improvement. | RCT | |
Table 24. Evidence Table: Acustimulation and Neck Pain | ||
Good evidence | Evidence statement | Design |
There is no difference between the use of electroacupuncture and sham laser acupuncture on chronic neck pain at 3 months after 9 treatments and 6 months, although both groups improved. | RCT | |
A combination of electrical "acustimulation" to the wrist combined with neck stretching and strengthening exercises for 30 minutes 2 times per week for a period of about 4 weeks demonstrates more improvement in chronic neck pain and patient self-confidence in performing functional activities than neck exercises alone for up to 1 month. | RCT | |
Table 25. Evidence Table: Traction and Neck Pain | ||
Some evidence | Evidence statement | Design |
Intermittent cervical traction does not add therapeutic benefit to a brief course of individualized manual therapy combined with exercise for patients with cervical radiculopathy. | RCT | |
Introduction. Durable medical equipment includes devices that can be used repeatedly to serve a medical purpose. These include braces or splints for supporting, immobilizing, or treating muscles, joint, or skeletal parts that are weak, ineffective, deformed, or injured.
Complications / Side Effects and Adverse Events.
Complications of Durable Medical Equipment.
* Complications of durable medical equipment include deconditioning of the cervical musculature and associated fatigue or pain, and skin irritation resulting from contact with the orthotic.
Recommendations.
Acute and Postoperative Treatment Time Frame Requirements.
Recommendation 76. Soft cervical collars are not recommended for an isolated cervical sprain (table 26).
Recommendation 77. Rigid cervical collars are permitted in the postoperative and emergency setting. Documentation should include directions for duration and frequency of use.
Recommendation 78. Halo immobilization is recommended in the treatment of cervical fracture, dislocation, and instability, at the discretion of the treating surgeon.
Evidence Table.
Table 26. Evidence Table: Cervical Collars for Neck Injury | ||
Some evidence | Evidence statement | Design |
Patients encouraged to continue usual activity have less neck stiffness and headache than patients placed in cervical collars and placed on sick leave following motor vehicle crashes. | RCT | |
Semi-hard collars worn during the day for 3 weeks and then weaned over 3 weeks may hasten resolution of recent onset cervical radiculopathy. | RCT | |
7 CCR 1101-3-17-08-7