Physical therapy, when treating neck and/or arm pain, is more efficacious if performed in a multi-modal fashion – combining stretch, strength, and manipulation/mobilization components [1-3] or when combined with other treatment options . Systematic reviews of the use of mechanical traction [5, 6] or massage [7, 8] have not revealed strong evidence for their use, although inclusion of these modalities as part of a comprehensive physical therapy program is believed to be warranted. The inclusion of “directional preference” and “centralization” principles has been commonly employed in therapy programs to treat neck pain. [9-11] Cervical stabilization, with or without concomitant mobilization or manipulation, has been beneficial in treating axial neck pain, cervical radiculopathy, or headaches. [12-18] Strategies to overcome barriers to non-adherence to a long-term self-care program would include patient education, promotion of “self-efficacy”, and assistance in overcoming anxiety and fear-avoidance behaviors. [10, 19]
There are various approaches or “schools” of physical therapy for the treatment of cervical spine disorders. These include those of McKenzie (www.mckenziemdt.org) , Sahrmann , Comerford (www.kineticcontrol.com) [22-24], and others [25, 26]. While it is not practical or possible to have PT providers certified, or even well versed, in all of the possible schools of cervical physical therapy, it is important that they be experienced and educated in cervical spine care. They may draw from various PT approaches, based on their level of expertise in each area. It is expected that each therapist may have a primary approach that they employ for spine care, but they are expected to be able to draw from all “schools” in order to provide individualized care to each subject while conforming to the “guidelines” of treatment. Spine physicians should have working relationships with multiple PT facilities and groups so that reasonable PT geographic location options are available to patients. This will greatly enhance patient participation.
A stepped, multi-modal physical therapy approach was taken with the physical therapy protocol (see Appendix III).  It should be emphasized that the protocol represents a guide, and the education and experience of each physical therapist should be matched with the individual needs of each patient/subject. Each of the elements of this protocol should be included, however, for each patient, when possible and appropriate.
Physical Therapy (2-3 times per week for total of 6-12 sessions):
1. Gross, A.R., et al., Clinical practice guideline on the use of manipulation or mobilization in the treatment of adults with mechanical neck disorders. Man Ther, 2002. 7(4): p. 193-205.
2. Kay, T.M., et al., Exercises for mechanical neck disorders. Cochrane Database Syst Rev, 2005(3): p. CD004250.
3. Salo, P.K., et al., Effect of neck strength training on health-related quality of life in females with chronic neck pain: a randomized controlled 1-year follow-up study. Health Qual Life Outcomes, 2010. 8: p. 48.
4. Saal, J.S., J.A. Saal, and E.F. Yurth, Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine (Phila Pa 1976), 1996. 21(16): p. 1877-83.
5. Graham, N., et al., Mechanical traction for neck pain with or without radiculopathy. Cochrane Database Syst Rev, 2008(3): p. CD006408.
6. Graham, N., A.R. Gross, and C. Goldsmith, Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med, 2006. 38(3): p. 145-52.
7. Ezzo, J., et al., Massage for mechanical neck disorders: a systematic review. Spine (Phila Pa 1976), 2007. 32(3): p. 353-62.
8. Haraldsson, B.G., et al., Massage for mechanical neck disorders. Cochrane Database Syst Rev, 2006. 3: p. CD004871.
9. Moffett, J. and S. McLean, The role of physiotherapy in the management of non-specific back pain and neck pain. Rheumatology (Oxford), 2006. 45(4): p. 371-8.
10. Moffett, J.K., et al., Randomized trial of two physiotherapy interventions for primary care neck and back pain patients: ‘McKenzie’ vs brief physiotherapy pain management. Rheumatology (Oxford), 2006. 45(12): p. 1514-21.
11. Kjellman, G. and B. Oberg, A randomized clinical trial comparing general exercise, McKenzie treatment and a control group in patients with neck pain. J Rehabil Med, 2002. 34(4): p. 183-90.
12. Bronfort, G., et al., Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J, 2004. 4(3): p. 335-56.
13. D’Sylva, J., et al., Manual therapy with or without physical medicine modalities for neck pain: a systematic review. Man Ther, 2010. 15(5): p. 415-33.
14. Gross, A., et al., Manipulation or mobilisation for neck pain. Cochrane Database Syst Rev, 2010(1): p. CD004249.
15. O’Leary, S., D. Falla, and G. Jull, Recent advances in therapeutic exercise for the neck: implications for patients with head and neck pain. Aust Endod J, 2003. 29(3): p. 138-42.
16. Jull, G., et al., A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine (Phila Pa 1976), 2002. 27(17): p. 1835-43; discussion 1843.
17. Dusunceli, Y., et al., Efficacy of neck stabilization exercises for neck pain: a randomized controlled study. J Rehabil Med, 2009. 41(8): p. 626-31.
18. Costello, M., Treatment of a patient with cervical radiculopathy using thoracic spine thrust manipulation, soft tissue mobilization, and exercise. J Man Manip Ther, 2008. 16(3): p. 129-35.
19. Jack, K., et al., Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Man Ther, 2010. 15(3): p. 220-8.
20. McKenzie, R. and S. May, The cervical & thoracic spine : mechanical diagnosis & therapy. 2nd ed2006, Raumati Beach, N.Z.: Spinal Publications New Zealand.
21. Sahrmann, S., Movement system impairment syndromes of the extremities, cervical, and thoracic spines2011, St. Louis, Mo.: Elsevier/Mosby.
22. Comerford, M.J. and S.L. Mottram, Movement and stability dysfunction–contemporary developments. Man Ther, 2001. 6(1): p. 15-26.
23. Comerford, M.J. and S.L. Mottram, Functional stability re-training: principles and strategies for managing mechanical dysfunction. Man Ther, 2001. 6(1): p. 3-14.
24. Mottram, S.L. and M.J. Comerford, Management Strategies – Exercise Therapy, in Textbook of musculoskeletal medicine, M.A. Hutson and R.M. Ellis, Editors. 2006, Oxford University Press: Oxford ; New York. p. 469-484.
25. Cooper, G. and E. Chait, Physical therapy prescriptions for musculoskeletal disorders2010, Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
26. Grant, R., Physical therapy of the cervical and thoracic spine. 3rd ed2002, New York: Churchill Livingstone. x, 449 p.