New Manual Therapy Delphi Study – Clinical Patterns for Neck Pain

[Scott Resetar]

Hey everyone,
I just loved this article from the newest issue of manual therapy. I cut out the meat and potatoes of the article into the first attachment, and the full article is the second attachment.

As new grads who are developing our clinical pattern recognition, this article is really awesome. I particularly love the motor control dysfunction subset, as I believe that I currently under-diagnose this subset and would like to focus on this in the future.

Take a look at this study and comment on anything that sticks out to you!

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[August Winter]

Hey Scott,
Thanks for posting the article. While a bit busy, I think that this article definitely does a nice job summarizing some relevant subjective and objective features of different neck pain types, which like you said, can be helpful to have as a student/new grad. A few things stuck out to me:

– Maybe someone with more familiarity with Delphi studies can explain this to me, but isn’t Round 3 of this process pretty prone to group think biases? Like if I didn’t highly rate a particular aspect in Round 1 but everyone else did, aren’t I more likely to fall in line with other people when the voting occurs again in Round 3?
– What do you guys think of only 21 experts being involved in the final voting?
– Curious what everyone’s thoughts were on this quote from the discussion: “Regarding the ‘input’-related dysfunctions, the authors are aware that an anatomical-based classification of symptoms seems undesirable. Nevertheless, despite the assumptionthat pathoanatomical factors are of low importance in clinical decision making (Weiner, 2008), their relevance cannot be erroneously disregarded (Ford and Hahne, 2013). It is clinically important to distinguish between different tissues (Woolf et al., 1998)”
– Finally, it’s mentioned in the discussion, but how many of you guys are using the slump for neck pain???

[Aaron Hartstein]

I am really glad to see that this article caught the attention of the residents. I think this falls well in line with what we discussed for the lumbar spine and its continual evolution with regards to subgrouping over the last 10 years. It does seem, in general, that evidence regarding classification for the cervical spine has lagged behind the lumbar spine somewhat. There are some reasons for this, but why do you guys think this is so? Do you think that this classification captures those folks with chronic non specific neck pain well enough?

As for the slump test, and especially the long-sit slump test for cervical spine dysfunction – this is commonly discussed with cervicogenic headache presentations.

[August Winter]

Aaron, I stand corrected on the slump for neck pain I guess! I’ll be on the look out for it more when it comes to HA literature.

As for why cervical classification may lag behind lumbar, my first instinct has to do with the money related to each issue. Injury and pain in the lumbar spine leads to a great deal of lost productivity and chronic use of money and resources. At least attempting to match interventions as previous classifications have done, or highlight interventions which are not well supported, or identify those people who may develop chronic cases all potentially improve patient outcomes and thus decrease the use of resources. I would imagine that the studies that are most likely produce results that lead to an increase in productivity and thus decrease in spending get the most support and funding in governmental grants. I don’t have good comparison values for the lumbar and cervical spine, but my guess would be that low back pain is more costly in terms of care/imaging/productivity.

I think that this article describes non specific chronic neck pain well enough with the central dysfunction category. This section hits the biggest things that stick out to me, with allodynia, maladaptive behaviors or thoughts, pain persisting past tissue healing, and a widespread, seemingly non-anatomic distribution of pain.

[Erik Lineberry]

One of the limitations the study discusses is the oversimplification of classification systems in the treatment of neck disorders. We have talked about this before with the lumbar spine and I thought is was good of the authors to bring this up. I’m sure we all see a great deal of patient’s that would fall into more than one category or not quite fit into any. Another portion of this system that I thought was oversimplified was the input vs. processing vs. output conditions. I think there is an argument to be made as to whether the Central and Sensorimotor dysfunctions could be both processing and output rather than one or the other.

As for whether central dysfunction covers a chronic neck pain patient well enough, I think the study did a good job of covering the variable presentation you would expect. One thing that was covered, but I think could have been expanded upon was the fear-avoidance and catastrophizing behaviors. This was discussed, but I think the patient’s history and catastrophizing behaviors are the most useful in determining chronic pain conditions and I think the article could have expanded on these topics some more.

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