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Does CPG Adherence Improve Outcomes?

Neck pain remains a concern for many of our patients with the overall prevalence of neck pain ranging from 10% to 20% and the incidence of new neck pain ranging from 10% to 50%. In response, the APTA updated the Neck Pain Clinical Practice Guideline (CPG) in 2017 to help physical therapists diagnose and treat neck pain. One subset of neck pain listed in the CPG is “Neck Pain with Mobility Deficits”, often called mechanical neck pain. While there are issues with classifications, they are better than lumping all patients into a single neck pain category. We don’t however know the effectiveness of implementing the neck pain CPG. This study examined the adherence of physical therapists to recommended treatments within the CPG and the outcomes associated with CPG utilization in patients with mechanical neck pain.

The authors retrospectively reviewed 224 patient charts from multiple outpatient clinics within a single hospital system from 2018 to 2022. Inclusion criteria included receiving PT for neck pain, > 18 years old, attending at least two sessions of PT, and fitting best into the CPG category of “Neck Pain with Mobility Deficits". The authors noted the presence or absence of six CPG-recommended interventions for mechanical neck pain (thoracic manipulation, cervical mobilization, TENS, dry needling, advice to stay active, and scapular resistance exercise). Advice to stay active was defined as any home exercise program (HEP) given to the patient. Each of the six CPG interventions was recorded as present if the intervention was performed at least once during the entire bout of physical therapy. The outcome data included pain, total cervical rotation active ROM, and Neck Disability Index (NDI) score.

The average age of the patients was 60.7 years and 76 (n=33.9%) had chronic neck pain, which we defined as pain lasting in duration equal to or longer than 180 days. Patients received 7.1 treatment sessions on average. For treatment selection, 4.5% of patients received thoracic manipulation, 47.8% of patients received cervical mobilization, 12.5% of patients received TENS, 22.8% of patients received dry needling, 99.1% of patients received a HEP with advice to stay active, and 89.3% of patients received scapular resistance exercise. For the number of interventions used per patient, 3.1% of patients received one intervention, 37.9% of patients received two interventions, 41.5% of patients received three interventions, 14.7% of patients received four interventions, 2.7% of patients received five interventions, and none of the patients received all six interventions.

The number of CPG treatments used did not influence clinical outcomes. Patients who received 4 or more CPG treatments received significantly more visits (for the same outcomes) as those who received 2 or fewer. The authors did not state the magnitude of the difference or whether specific combinations (e.g., exercise plus thoracic manip vs. TENS plus dry needling) mattered. This is a large limitation. Also, the interventions only needed to be completed during a single session to qualify. We do not know if the dosage or intensity was sufficient.

Of note, cervical-specific exercises were not assessed as they were not promoted in the CPG. I think this is one of the biggest gaps of the CPG given the prevalence of disuse atrophy in people with chronic neck pain and the need for localized exercises with adequate intensity and volume to induce hypertrophy. I would bet if cervical exercises were performed, most were for the deep neck flexors. Those exercises can hypertrophy longus colli and they improve performance on the cranio-cervical flexion assessment, but they will not hypertrophy SCM or the cervical extensors and they will have little to no impact on cervical strength and power.

This study suggests ‘CPG adherence’ is a vague term and does not guarantee superior outcomes. We need to assess the dosage and intensity of the supported interventions, not simply whether they were completed at least once to check a box.


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