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CLINICAL PRACTICE GUIDELINES

FOR NECK PAIN

By: Theresa A. Schmidt,

PT,DPT,MS,OCS,LMT,CEAS

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• Allied Health Education and the presenter of this webinar do not

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discussed or displayed in this presentation. • There was no commercial support for this presentation.

• The views expressed in this presentation are the views and

opinions of the presenter.

• Participants must use discretion when using the information contained in this presentation.

WELCOME: WHY THIS TOPIC?

• Clinicians lack knowledge in using the APTA's Clinical Practice Guidelines and clinical reasoning to diagnose and manage low back pain. (Showalter, CR, 2014)

• After completing this webinar, the participant will be able to utilize clinical practice guidelines together with clinical reasoning to design a plan of care for managing low back pain.

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1. Discuss the current clinical practice guidelines (CPG) for

patients with neck pain (LBP) as developed by the Orthopedic

Section of The American Physical Therapy Association (APTA)

2.Conduct an examination for patients with neck pain and

interpret the results to diagnose anatomical and functional

impairments and classify people into the associated

impairment-based category

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3. Select intervention strategies to address activity

restriction/limitations and functional mobility impairments based

on the CPG classification of impairments for neck pain.

Do we rely strictly on guidelines? No!

Your clinical experience and individual patient needs add an

important dimension to determine your approach.

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Hour 1 Development of Clinical Practice Guidelines, (CPG) by APTA,

definition of CPG, clinical prediction rule (CPR), CPG impairment

measures, interventions to address limitations and structural and

functional impairments. (30 mins)

(Discussion of proper use of evidence-based functional outcome

measures, and physical impairment analysis measures to document

exam findings and measured response to therapeutic interventions

(30 mins)

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Hour 2 Categorization of neck pain conditions as to the CPG

impairment classification, discussion of selecting ICD and ICF

classifications for neck pain (30 mins) Discussion of effective

intervention types to improve limitations for specific impairment-based

diagnostic categories.

Example: For radicular or non-radicular categories describe CPG

recommendations for provisions of patient education, manual therapy,

neuromuscular and movement reeducation, traction, TENS, and

therapeutic exercise. Summary of professional organization guidelines

for neck pain management with case study examples. (30 mins)

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COURSE DESCRIPTION

Participants will be introduced to the current evidence-based approach to management of neck pain using Clinical Practice Guidelines from the

Orthopaedic Section of the American Physical Therapy Association with

clinical reasoning.

As payers and medical practitioners increasingly depend on evidence-

based Guidelines, clinicians must utilize published recommendations

when selecting examination tools and designing therapeutic programs to direct functional outcomes and to optimize documentation for

reimbursement.

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Helps decide best approach for optimal outcome

Describes, informs physical therapy (PT) practice

Provides standard of care

Less variability in interventions

Diagnosis, prognosis, interventions, assessment

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Best nonsurgical options for management of neck pain

Designed for management of musculoskeletal disorders related to neck pain (NP)

Utilizes orthopedic PT interventions

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Modified Grades A, high, B, moderate C, low, D very low

Considers basic research

Includes consensus expert opinion (D)

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Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman

JM, Sopky BJ, Godges JJ, Flynn TW; American Physical Therapy Association.

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.

J Orthop Sports Phys Ther. 2008 Sep;38(9):A1-A34. Epub 2008

Sep 1.

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Blanpied, PR, Gross, AR, Elliott, JM, et al. Neck Pain: Revision 2017

Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association

J Orthop Sports Phys Ther. 2017;47(7):A1–A83. doi:10.2519/jospt.2017.0302

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Reviewed 4000 articles from 2007-2016

International collaboration on Neck Pain and physical therapists

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Frequently a chronic disability with medical costs

High incidence in computer and office employees

Common recurrence

Whiplash post MVA: 85% people suffer neck pain

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Prior injury

Fear avoidance behavior

Age

High pain intensity

Poor general health

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22-77% people have neck pain at some time

30% become chronic

Recurs 50-85% (Snyder, 2017)

Long-term disability spinal claims 7.6 million

Studies show when not addressed in acute or subacute stage, becomes chronic

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2000-2010 Classify all neck pain types as NAD Neck Associated Disorders

Classified into 4 grades of NAD based on signs or symptoms of pathology

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No signs or symptoms of major structural pathology for grades:

I- little or no interference with ADLs

II- major interference with ADLs

III- includes neurologic signs (DTR, sensory motor deficits)

IV: Positive signs or symptoms of major structural pathology

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ICD International Statistical Classification of Diseases and Related Health Problems categories used, as well as

ICF International Classification of Functioning, Disability and Health

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Multifactorial nature of neck pain

Watch for red flags:

non cervical, cancer, cardiac instability, myelopathy, vascular

injury, fracture

Canadian c-spine rule and cervical myelopathy exam

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Watch for yellow flags

(fear avoidance, catastrophizing)

need pain science counseling and graded exercise

Patient needs: Appropriate for PT?

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CPG informs as to the proper treatment category to match exam findings with best practices for interventions and positive outcomes based on research

Limited by available studies

We must depend on clinical experience

Throughout the episode of care:

Modify category and interventions based on emerging data from current exams, and changing status

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Cervicalgia: Pain with mobility impairments

Headaches (HA) : cervicocranial syndrome: Neck pain w. HA

Thoracic spinal pain

Sprain, strain cervical spine: neck pain w. movement coordination impairments

Spondylosis with radiculopathy: Cervical disc disorder with radiculopathy

(Blanpied, 2017)25

With mobility deficits

With movement coordination impairments and whiplash

With cervicogenic headache

With radicular pain

(Blanpied, 2017)26

Use these categories of Neck pain to classify them:

Headaches

Mobility impairments

Movement coordination impairments

Radiating pain (Blanpied, 2017)

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Assess trauma history,

motion limitation of neck and thorax,

Headache presence

Do they have radiating or referred UE pain

(Blanpied, 2017)28

Using CPG with matched interventions vs. unmatched interventions

Reviewed 274 studies

Results:

Matched CPG patients had more progress in NDI and Pain scores

(Fritz, et al, 2007 )

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Process of classification is ongoing

As patient changes, reassess and recategorize based on current findings

What exams are recommended based on CPG?

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Mobility

Centralization

Headache

Exercise, conditioning

Pain control

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AROM active range of motion

Segmental mobility neck and thorax

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AROM active neck range of motion

Segmental mobility cervical spine

Cranial cervical flexion test

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Cranial cervical flexion test

Deep neck flexor endurance test

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Deep cervical flexor: longus capitis, colli: strength, endurance

Delayed activation may relate to headache

Spinal stabilization test or as exercise training

Pt. hooklying, cervical neutral

BP cuff under neck, near occiput

Inflate to 20mmHg

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Deep cervical flexor activation: Pt. nods head Yes, slowly

Without lifting head from table

Note pressure rise, by 2mmHg

Hold 5-10s.

Relax to 20 mmHg pressure, hold

https://www.physio-pedia.com/Cranio‐cervical_Flexion_Test

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Be sure patient does not use sternocleidomastoid or scalenes, palpate them and observe,

Be sure pt. remains with neutral cervical spine

Increase pressure to 24 mmHg x 5 sec hold

Relax to 20mmHg

Repeat until achieving 30 mmHg

Repeat entire test 2x without use of SCM or scalenes(palpate)

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If patients is unable to do CCFT without use of SCM or scalenes (palpate)

Use test as a training method

Place neck in slight flexion, at point where pt. does not activate SCM/scalenes while he tires to maintain the level of pressure he is able to without using his superficial neck flexors

Hold 10 secs. X 10 reps

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This Photo by Unknown Author is licensed under CC BY-SA-NC

Spurlings test

Distraction test

Upper limb tension test (ULTT)

Valsalva

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Test with patient sitting, place neck in extension, sidebending and add axial compression

Specificity .88, Sensitivity .50

Use in combo with distraction test, upper limb tension and cervical rotation test for 90% probability of radiculopathy

https://www.physio-pedia.com/Spurling%27s_Test

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Tests for cervical radiculopathyPatient sitting or supine

Examiner grasps occiput & forehead, distracts the head in slight flexion, not slumped

If symptoms are relieved, + test for facet pressure and compressed nerve rootsSpecificity 0.97, sensitivity 0.44

https://www.physio-pedia.com/Cervical_Distraction_Test

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Patient supine, in order, perform:

Depress scapula, abduct shoulder, supinate forearm, extend wrist/fingers

Lateral elevate shoulder, extend elbow,

laterally flex neck to opposite, then to same side

+ test if symptoms produced, opp. SB incr, same side decr.

Elbow extension difference over 10 degrees R/L

Specificity .86, sensitivity .50 https://www.physio-pedia.com/Upper_limb_tension_test_A

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Patient sitting, takes deep breath and holds while exhaling against pressure for 3 secs.

Increases intraabdominal pressure, aggravates nerve symptoms/ radiculopathy

Specificity .94 Sensitivity .22

https://www.physio-pedia.com/Cervicothoracic_tests

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Evidence grade B, neck pain: If:

Patients issues outside usual classification or

Symptoms not improved by therapy

Note: psychosocial or more serious pathology must be considered

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Evidence grade A

Use self reported questionnaires establish baseline:

Patients Specific Functional Scale

Neck Disability Index

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Self reported outcome measure for functional status change

5 activity items of patients choice, scale 0-10 points

0= “unable to perform activity”10= “able to perform activity at the same level as before injury or problem”

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Calculate score: sum activity scores / # of activities = total score

MDC: for average score is 2 points

https://www.physio-pedia.com/Patient_Specific_Functional_Scale

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Most commonly used self reported outcome questionnaire for neck pain

10 items scored 0-5 points from 0-100%, max 50 pts.

Higher disability with higher scores

0= no limitation of activity

50= total limitation of activity

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Assesses patient report of ability in:

work and recreation,

driving, lifting,

sleeping, personal care,

pain, reading,

concentration and headaches

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Disability rating by score

0-4, none5-14, mild

15-24 moderate

25-34, severe35-50, complete

Reliability .50-.98, MDC 10, MCID 5-7 ptshttps://www.physio-pedia.com/Neck_Disability_Index

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Neck pain history

Cycling frequently

Greater than 40 years old

Low back pain

Strength loss in hands

Anxious attitude

Low vitality of poor life quality

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Difficult or impossible to identify the causative factor or which tissue causes pain

Assess nervous, fascial, muscle tissue for dysfunction

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Rule out serious pathology: (Bone & Joint task force cat. IV)

Ligamentous instability in upper neck

Cancer

Cardiac

Infection

Fracture

Cranial nerve involvement

Arterial insufficiency

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Refer and consult for nontraumatic and traumatic neck pain in all stages

Use existing guidelines for referral to order imaging studies

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Use self reporting questionnaires

Establish baseline

Assess change in status

Include function, disability, pain and psychosocial

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Use self reporting questionnaires

Establish baseline

Assess change in status

Include function, disability, pain and psychosocial

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Identify baseline performance, monitor progress

Rule in or out for neck pain with headache, mobility deficits, radiating pain, neurodynamic tests

Classify pain using pressure pain threshold algometric tests

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NOTE: Intervention recommendations are limited based on the available literature reviewed to create the CPG for Neck Pain.

Not all interventions we use are represented in the literature with substantial evidence

Not all available evidence was included in developing the CPG, so it may have limited applicability

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For headaches and neck pain: effective:

Strength, endurance, coordination exercises

Thrust and non thrust manipulation

Combination works best

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Encourage rapid return to activities post trauma

Good prognosis normally

High likelihood of restoration of function

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All work

Improved effectiveness with combined with exercise and manual therapy

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Decreases cervical and arm pain related to neck pain

Types of manipulation or mobilization were not specified in the CPG

Note: limitation: soft tissue mob/manip is not discussed in this area

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Effective for neck pain and symptom reduction

CPG does not describe type of exercise used, number of reps or volume, frequency of use

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Encourage activities that do not reproduce symptoms

Assess functional changes while undergoing therapy

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Neck ROM B

Thoracic manipulation B

UE, scapulothoracic strengthening exercise B

Neck manipulation mobilization C

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Endurance exercise for neck and shoulder girdle B

Neck manipulation, mobilization C

Thoracic manipulation C

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Neck mobilization, manipulation B

Thoracic manipulation B

Traction, intermittent, manual, laser, dry needling B

Neck, scapulothoracic, trunk endurance exercise B C

Education, counseling for activity promotion and to address psychosocial factors C

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Patient education and reassurance B

Recovery expected within 2-3 months B

Minimize collar B

Mobility and posture exercises B

Return to normal activities asap without symptoms

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Multimodal therapy: mobs, exercise, for persistent symptoms B

Strength, endurance, posture, coordination, aerobic, flexibility, functional exercise B

If low risk for chronic: comprehensive exercise C

TENS C

1 visit of exercise, education and counseling C

Monitor for delayed recovery F

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Education, assurance, manage pain C

Submax exercise neck thoracic strength, endurance, coordination, flexibility with mobilization C

Cognitive behavioral therapy guides exercises C

TENS C

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Active mobility exercise supervised by PT B

Self SNAG C1-2self sustained apophyseal slide C

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Neck mobs, manipulation B

Self-SNAG exercise C1-2 C

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Neck and thoracic mobs manipulation

With neck strengthening, flexibility endurance exercise B

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Exercises for stabilization and mobilization,

Short term collar and

laser C

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Intermittent mechanical traction with exercise for strength and flexibility

And mobs manipulation neck and thorax B

Education, counseling to promote actice participation B

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Bobos, Et al: Psychometric properties of outcome measures

8 outcome measures reviewed:

NDI, Northwock Paik Neck Pain Q, Copenhagen Neck Functional

Disability Scae, Neck Pain and Disability Scale, Core Neck Q,

Patient Specific Functional Scale, Whiplash Disability Q, neck

Bourenemouth Q

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NDI: high quality evidence, mod/excel reliability and good/excel internal consistency

NPQ: mod. quality evidence, good reliability and good/excel internal consistency

CNFDS: High qual evid., excel reliability,

NDPS: mod qual. evid.

WDQ: high reliability, excel. Int. consistency (Bobos, 2018)

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Garcia, et al reviewed evidence for reliability of Mechanical Diagnosis

and Therapy MDT system

Looked at synfromes, sub symdromes, centralization and directional

preference and lateral shift

Reported “acceptable reliability” for back pain classification categories by “credentialed” and unacceptable for uncredentialed therapists

For neck pain, conflicting evidence for reliability of the MDT system

(Garcia, 2018)

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Bryans, Et al systematic review 41 RCTs for nonspecific mechanical neck pain

11 interventions recommended

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Manipulation

Manual therapy

Exercise

Best results with multimodal therapies

Stretching, strengthening, endurance exercise used alone

(Bryans, 2013)

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Acute neck pain: manipulationa nd mobilization in combination with

other interventions

Chronic neck pain: mobilization, massage combined with other

interventions

(Bryans, 2013)

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Acute neck pain: exercise by itself, no rec. for thoracic manip or TP

therapy

Chronic neck pain: manipulation alone

No rec. for TENS, thor. Manip, laser, traction for chronic neck pain

(Bryans, 2013: From:

https://www.jmptonline.org/article/S0161-4754(13)00237-6/pdf )

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Bussieres, et al 2016: McGill U. systematic review

Used AMSTAR A Measurement Tool to Assess Systematic reviews

Multimodal care

Work disability

Exercise

Passive modalities

Manual therapy

Education

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Acute neck pain: 0-3 mo. best outcomes with multimodal interventions:

Mobilization, manipulation, ROM home exercise, manual therapy

Progressive strengthening

Chronic worker pain: multimodal self management advice with or

without high intensity strength training (3x/wk x 20 mins x 20 wks)

(Includes neck pain with headache, radiating pain)

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For the following case studies, recognize clinical patterns to correctly categorize the patient case into a CPG diagnostic classification:

implement your treatment plan with the recommended interventions based on the diagnostic classification

Address the participation restriction and activity limitation of the patient with appropriate:

education, exercise, movement reeducation, and manual therapy interventions

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Patient is 23 y/o lacrosse player at season’s start who strained his neck while lifting weights (overhead press) 2 days ago, without proper warmup. c/o inability to turn left, look up or sidebend R due to pain and spasm. No comorbidities, neg neuro, nonradic. Prior hx. MVA whiplash last year. Wants to play in 1st game next week.

Interventions

Neck stretching, Thoracic manipulation UE, scapulothoracic strengthening exercise Neck manipulation/mobilization Home AROM, UE PREs, supine stretch on foam roller, mobs Gr. 1-5 MET stretching to incr. L rot/RSB/ext (to correct FRSR)

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After a week, lacrosse player has 50% greater ROM, still painful to

turn L, lifting 75% of his usual PRE, can’t tol. Overhaed press yet.

Interventions:

Endurance exercise for neck and shoulder girdle

Neck manipulation, mobilization to incr. L rot. MET

Thoracic manipulation

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Lacrosse player reports he wishes he could have made the football team but with neck trouble, decided on lacrosse. He is back to lacrosse but still has intermittent spasm L upper trap/levator, stiff during the game, better after warmup and weight training 90% usual lifting, can do 30 lbsoverhead press, then painful after 20 reps. Using foam roller at home.

Intervention Neck mobilization, cervical thoracic manipulation

Traction, intermittent/ manual, laser, dry needling

Neck, scapulothoracic, trunk endurance exercise

Education, counseling for activity promotion and to address psychosocial factors

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This Photo by Unknown Author is licensed under CC BY

This Photo by Unknown Author is licensed under CC BY

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49 y/o male math teacher reported MVA yesterday, hit in rear at 45 mph, c/o neck pain, stiffness, upper back pain, difficulty teaching due to occipital headache into eyes, called in sick to work. Dizzy when looking up, overall fatigue since MVA, did not hit head, x-rays neg. No prior hx. Overall good health. ER gave cervical collar and NSAIDS.

Patient education and reassurance

Minimize collar

Mobility and posture exercises

Return to normal activities asap without symptoms

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2 weeks later, still c/o neck stiffness, worse after initial 3 days, better after icepack, NSAIDS, ROM exercise, shoulder rolls. Some fatigue, no headache unless ending forward or looking up for over a min. Hired attorney. Going for massages.

Multimodal: mobs, exercise, for persistent symptoms

Strength, endurance, posture, coordination, aerobic, flexibility, functional exercise

If low risk for chronic: comprehensive exercise TENS , 1 visit of exercise, education and counseling, Monitor for

delayed recovery

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Teacher happy to have off from work for first 2 months, now RTW with incr. pain, stiffness in rot. B, flex/ext, SB B. Only slight dizziness when inverting head. Intermnt H.A

Education, assurance, manage pain, TENS at home

Submax exercise neck/ thorax: strength, endurance, coordination, flexibility with mobilization

Cognitive behavioral therapy approach to exercises

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36 y/o executive secretary c/o neck pain and headaches when working overtime. Has tension HA with occipital temporal pain 7/10, min. blurred vision when working on computer > 30 mins. Up trap/ levator/ scalene spasm, scap elevated/ protracted, unable to rotate > 20 deg. R and 30 degr L, Only SB 15 deg. Multi TPs in cervicals. Forward head. Taking benzodiazepine and aspirin, on work comp

Active mobility exercise supervised

Self SNAG C1-2 self sustained apophyseal slide

Ergonomic/posture education, ROM at computer, taking breaks every

20 min, UE stretches, lumbar roll, ice for HA

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1 week later, secretary c/o persistent HA, pain 3/10, less stiff with ther ex, SNAGs, but can’t look over R shoulder to drive and backup her car, sharp endrange pain at C4-7 on L side.

Able to work at computer 2 hrs. then takes 15 min break. Using ice at work prn for HA. Got better ergo chair and computer positioning. Still has to do o/t

Neck mobs, manipulation to incr. R rot

Self-SNAG exercise C1-2

Posture exercise, use mirror at desk to check posture, takes reg. breaks for stretches and scap stabilizing exercise

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4 months post, secretary has ill child at home, said her HA were worse, more frequent, interfering with work, too tired on muscle relaxants. Must be home for her daughter. Called in sick to work, work comp case/on disability. Better ROM and posture, but has + fear avoidance behavior, secondary gain to be home with daughter out of work.

Neck and thoracic mobs/ manipulation

With neck strengthening, flexibility endurance exercise

Contact MD re meds and fatigue, re-exam: persistent HA without obvious signs, less spasm, improved mobility but complaints worsen

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62 y/o female gardener c/o intermittent pain R cervical traveling into RUE thumb/index with numbness. Tried chiro acup, massage, helps but no carryover. Saw neurosurg, given Vicodin and Celebrex, +MRI C5-C7 HNP R, stenosis mild. Referred to PT. Hx: multiple strains over years of heavy lifting garden rocks, tools. 2 MVAs. + stress after house fire with severe sharp pain from neck into RUE, hands “feels dead: in a.m., better after stretching forward.

Exercises for stabilization and mobilization

Short term collar and laser NOTE: refer to surgeon if not resolving

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Gardener returned 5 months later, pain continued, want to avoid surgery. MD rec. surgery discectomy, can’t take off now due to busy work season. Decr. DTR R C5, C6, decr.sens. R lateral hand, fingers, thumb. Weak grip R 40lb, L 65 lb. Limited rot/SB/Ext 75%, worried about when to sched. surgery.

Intermittent mechanical traction (home) with exercise for strength and flexibility and mobs/ manipulation neck and thorax

Education, counseling to promote active participation, get help with lifting, delegate work to employees, take rests prn

but cont. working for season, sched. Surgery for next month.118

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51 y/o m business manager c/o neck pain, TMJ pain, ear ringing,

difficulty turning head L, pain with extension 50% limited, pain in R shoulder when lifting overhead.

Onset 6 days ago, subacute after moving to new office, lifting boxes, furniture, etc. Neg neuro. PMH: shoulder surgery 5 yrs ago, rotator cuff repair R

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Neck ROM B

Thoracic manipulation B

UE, scapulothoracic strengthening exercise B

Neck manipulation mobilization C

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Endurance exercise for neck and shoulder girdle B

Neck manipulation, mobilization C

Thoracic manipulation C

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18 y/o female college student involved in MVA 2 days ago, hit in rear,

c/o headache, pain above eyes, neck pain and stiffness, dizzy when bending forward. PMH noncontributory.

Multiple TPs, limited guarded ROM flexion/extension/SB/rot.

Vertebral artery test neg. Neuro neg.

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Neck ROM B

Thoracic manipulation B

UE, scapulothoracic strengthening exercise B

Neck manipulation mobilization C

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53 y/o woman teacher c/o headache with neck and upper shoulder pain and stiffness after working overtime for past 2 weeks on computer, stressful environment.

c/o tingling down RUE into her thumb, index, middle fingers when typing on laptop. PMH: multiple MVAs yrs. ago.

X-rays: DJD multilevel, narrowing IVF C4-C7. Weakness in handgrip R 45 lb, L 73lb, R dom.

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Exercises for stabilization and mobilization,

Short term collar and

laser C

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Intermittent mechanical traction with exercise for strength and flexibility

And mobs manipulation neck and thorax B

Education, counseling to promote active participation B

NOTE: refer to surgeon if not resolving

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62 y/o female radio host c/o neck pain and stiffness, dizziness when moving head into extension,

tingling, numbness and radiating pain and weakness in B hands onset gradual over many years, worse this past year.

PMH: Several whiplash injuries.

+ MRI for multilevel HNP impinging on C5,6,7,8 with spinal stenosis. +EMG, NCV cervical radiculopathy.

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Intermittent mechanical traction with exercise for strength and flexibility

And mobs manipulation neck and thorax B

Education, counseling to promote actice participation B

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23 y/o college football player, 2 wks ago he tackled another player by spearing,

c/o burning sensation down L side of neck into LUE and hand immediately post tackling another player using his head as a ram.

Saw MD, dx. Cervical “burner” radiculopathy due to traumatic hyperlateral flexion injury to cervical spine.

Numbness in L hand, pain radiating down L arm, mod.spasmin neck and upper back, weakness L grip and finger extension.

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Exercises for stabilization and mobilization,

Short term collar and

laser C

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32 y/o teacher, mother of 3 c/o chronic pain all over, fatigue, headaches, (temporal) TMJ pain, poor sleep,

digestive problems, neck and shoulder stiffness and pain to reach overhead. Trouble grooming her hair and managing young kids.

Dx. Fibromyalgia. Neck range WNL with multi TPs in neck, traps, levator, pects, erectors with referred pain.

Weak deep neck flexors 3/5, weak rotators/SB 3+/5, fatigues easily after 7 reps.

Does not exercise due to body pain. Neuro neg. PMH: stress and poor eating habits.

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Teacher happy to have off from work for first 2 months, now RTW with incr. pain, stiffness in rot. B, flex/ext, SB B. Only slight dizziness when inverting head, intermnt H.A.

Education, assurance, manage pain, TENS at home

Submax exercise neck/ thorax: strength, endurance, coordination, flexibility with mobilization

Cognitive behavioral therapy approach to exercises

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59 y/o male CPA c/o occipital pain, neck pain and morning stiffness, pain in B trapezeii, worse when typing, better with movement.

Onset several months. He does not exercise. PMH: HTN, lumbar disc disease, and recently had 2 dental implants.

Neuro neg. Range limited 50% all ranges except flexion, has mod. Forward head, protracted shoulders, limited shoulder elevation.

Overall deconditioned due to lack of exercise, prolonged sitting at work. Weakness in all cervical ranges, poor strength of deep cervical flexors and scapular stabilizers.

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Education, assurance, manage pain C

Submax exercise neck thoracic strength, endurance, coordination, flexibility with mobilization C

Cognitive behavioral therapy guides exercises C

TENS C

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CC BY-NC-ND

This Photo by Unknown Author is licensed under CC BY-NC-ND

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CPG for neck pain

What is your opinion?

Have you used CPGs to decide case management before? What was your experience?

Does applying CPG make a difference in outcomes?

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Author: Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS,Chy,DD

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Physical therapist specializing in orthopedic rehab, muscle energy, myofascial, craniosacral, precision

exercise, bioenergy, functional training and evidence-based integrative medicine.

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Theresa A. Schmidt, PT,DPT,MS,OCS,LMT,CEAS,CHy,DD is the founder of Educise.com continuing education, in Long Island, NY. She is a Board-certified Specialist in Orthopedic Physical Therapy, massage therapist, certified professional speaker, Reiki Master, and hypnotherapist. Her work integrates the best of traditional and alternative medicine with inspirational resources to achieve results that change lives. Her practice integrates complementary and medical rehabilitation, ergonomics and wellness programs. She focuses on holistic health and wellness with myofascial and craniosacral therapy, Biosynchronstics®, precision exercise, muscle energy/PNF, positional release, mobilization, acupressure, IET, shamanic and Karuna Reiki, and Therapeutic Touch®. She received her Doctorate in Physical Therapy from University of New England and served as faculty of the Physical Therapy and PTA Programs at Touro College in New York City. She served as adjunct professor at Nassau Community and CUNY Queens Colleges, presented for Fascia Research Congress, NASA Inomedic Health, APTA, AOTA, AMTA/NY, IDEA, ACE, Cleveland Clinic, Johns Hopkins, private companies, hospitals and clinics. She is a best-selling author, and published research in MOJ Orthopedics and Fascia Research Congress III. Her seminars empower clinicians with results-oriented evidence-based education and hands-on skills to make a real difference. Educise informs clinical decision-making with real life examples, current research, educational resources and interactive live and on-line programs. Participants apply what they learn immediately in clinical practice. Learn more with free videos and resources at www.educise.com.

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LIMITATIONS OF RESEARCH

POTENTIAL RISKS

As with all research, more studies must be done with larger sample

sizes, improved data analysis, and correction of the study design

limitations, statistical data limitations, bias, or impact limitations. Many

of the studies are population-specific, age-specific, or region-specific, which may limit application of the results to a broader audience.

As more studies are conducted, a greater body of knowledge will

emerge, resulting in greater applicability of the findings to a larger population.

Clinical practice guidelines References

• Anstey, R., Kongsted, A., Kamper, S., & Hancock, M. J. (2016). Are people with whiplash-associated neck pain different from people with nonspecific neck pain?. Journal of Orthopaedic & Sports Physical Therapy, 46(10), 894-901.

• Bahat, H. S., Feigelson, E., & Vulfsons, S. (2017). The Potential Effect of Cervical Taping on Pain, Disability and Kinematics in Patients with Chronic Neck Pain-A Quasi-Experimental Study. MOJ Yoga Physical Ther, 2(4), 00032.

• Bertozzi, L., Gardenghi, I., Turoni, F., Villafañe, J. H., Capra, F., Guccione, A. A., & Pillastrini, P. (2013). Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials. Physical therapy, 93(8), 1026-1036.

• Bier, J. D., Kamper, S. J., Verhagen, A. P., Maher, C. G., & Williams, C. M. (2017). Patient Nonadherence to Guideline-Recommended Care in Acute Low Back Pain. Archives of physical medicine and rehabilitation, 98(12), 2416-2421.

• Bier, J. D., Ostelo, R. W., Koes, B. W., & Verhagen, A. P. (2017). Validity and reproducibility of the modified STarT Back Tool (Dutch version) for patients with neck pain in primary care. Musculoskeletal Science and Practice, 31, 22-29.

• Bier, J. D., Scholten-Peeters, W. G., Staal, J. B., Pool, J., van Tulder, M. W., Beekman, E., ... & Verhagen, A. P. (2017). Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain. Physical therapy.

• Blanpied, P. R., Gross, A. R., Elliott, J. M., Devaney, L. L., Clewley, D., Walton, D. M., ... & Boeglin, E. (2017). Neck pain: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 47(7), A1-A83.

• Bobos, PT, MacDermid, JC, Walton, DM Gross, A, Santaguida, L, An Overview of Systematic Reviews on Patient-Reported Outcome Measures Used on Neck Disorders. Journal of Orthopaedic & Sports Physical Therapy 0 0:0, 1-76

• Braun, M., Schwickert, M., Nielsen, A., Brunnhuber, S., Dobos, G., Musial, F., ... & Michalsen, A. (2011). Effectiveness of traditional Chinese “gua sha” therapy in patients with chronic neck pain: a randomized controlled trial. Pain Medicine, 12(3), 362-369.

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• Brosseau, L., Wells, G. A., Tugwell, P., Casimiro, L., Novikov, M., Loew, L., ... & Kresic, D. (2012). Ottawa panel evidence-based clinical practice guidelines on therapeutic massage for neck pain. Journal of Bodywork and Movement Therapies, 16(3), 300-325.

• Bryans, R., Decina, P., Descarreaux, M., Duranleau, M., Marcoux, H., Potter, B., ... & White, E. (2014). Evidence-based guidelines for the chiropractic treatment of adults with neck pain. Journal of Manipulative & Physiological Therapeutics, 37(1), 42-63.

• Buscemi, V., Chang, W. J., Liston, M. B., McAuley, J. H., & Schabrun, S. (2017). The role of psychosocial stress in the development of chronic musculoskeletal pain disorders: protocol for a systematic review and meta-analysis. Systematic reviews, 6(1), 224.

• Cameron, J. A., & Thielen, K. M. (2017). Autologous Platelet Rich Plasma for Neck and Lower Back Pain Secondary to Spinal Disc Herniation: Midterm Results. Spine Research, 3(2).

• Carlesso, L. C., Gross, A. R., Santaguida, P. L., Burnie, S., Voth, S., & Sadi, J. (2010). Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review. Manual therapy, 15(5), 434-444.

• Carlesso, L. C., MacDermid, J. C., Gross, A. R., Walton, D. M., & Santaguida, P. L. (2014). Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey. Chiropractic & Manual Therapies, 22(1), 11.

• Carroll, L. J., Cassidy, J. D., Peloso, P. M., Giles-Smith, L., Cheng, C. S., Greenhalgh, S. W., ... & Nordin, M. (2009). Methods for the best evidence synthesis on neck pain and its associated disorders: the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of Manipulative & Physiological Therapeutics, 32(2), S39-S45.

• Childs, J. D., Cleland, J. A., Elliott, J. M., Teyhen, D. S., Wainner, R. S., Whitman, J. M., ... & Dyriw, G. M. (2008). Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 38(9), A1-A34.

• Chou, R., Côté, P., Randhawa, K., Torres, P., Yu, H., Nordin, M., ... & Cedraschi, C. (2018). The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low-and middle-income communities. European Spine Journal, 1-10.

• Clair, D. A., Edmondston, S. J., & Allison, G. T. (2006). Physical therapy treatment dose for nontraumatic neck pain: A comparison between 2 patient groups. Journal of Orthopaedic& Sports Physical Therapy, 36(11), 867-875.

• Coppieters, I., De Pauw, R., Kregel, J., Malfliet, A., Goubert, D., Lenoir, D., ... & Meeus, M. (2017). Differences between women with traumatic and idiopathic chronic neck pain and women without neck pain: Interrelationships among disability, cognitive deficits, and central sensitization. Physical therapy, 97(3), 338-353.

• Côté, P., Wong, J. J., Sutton, D., Shearer, H. M., Mior, S., Randhawa, K., ... & Lindsay, G. M. (2016). Management of neck pain and associated disorders: a clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Spine Journal, 25(7), 2000-2022.

• Côté, P., Wong, J. J., Sutton, D., Shearer, H. M., Mior, S., Randhawa, K., ... & Lindsay, G. M. (2016). Management of neck pain and associated disorders: a clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Spine Journal, 25(7), 2000-2022.

• Cramer, H., Klose, P., Brinkhaus, B., Michalsen, A., & Dobos, G. (2017). Effects of yoga on chronic neck pain: a systematic review and meta-analysis. Clinical rehabilitation, 31(11), 1457-1465.

• De Meulemeester, K. E., Castelein, B., Coppieters, I., Barbe, T., Cools, A., & Cagnie, B. (2017). Comparing trigger point dry needling and manual pressure technique for the management of myofascial neck/shoulder pain: a randomized clinical trial. Journal of Manipulative & Physiological Therapeutics, 40(1), 11-20.

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• Dziedzic, K., Hill, J., Lewis, M., Sim, J., Daniels, J., & Hay, E. M. (2005). Effectiveness of manual therapy or pulsed shortwave diathermy in addition to advice and exercise for neck disorders: a pragmatic randomized controlled trial in physical therapy clinics. Arthritis Care & Research, 53(2), 214-222.

• Farooq, M. N., Mohseni-Bandpei, M. A., Gilani, S. A., Ashfaq, M., & Mahmood, Q. (2018). The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. Journal of bodywork and movement therapies, 22(1), 24-31.

• Fehlings, M. G., Tetreault, L. A., Riew, K. D., Middleton, J. W., & Wang, J. C. (2017). A clinical practice guideline for the management of degenerative cervical myelopathy: introduction, rationale, and scope.

• Fritz, et al, 2007 ) (Fritz JM, Brennan GP, Preliminary Examination of a Proposed Treatment-Based Classification System for Patients Receiving Physical Therapy Interventions for Neck Pain. Phys Ther. 2007 May;87(5):513-24. Epub 2007 Mar 20

• Furlan, A. D., Yazdi, F., Tsertsvadze, A., Gross, A., Van Tulder, M., Santaguida, L., ... & Skidmore, B. (2012). A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evidence-Based Complementary and Alternative Medicine, 2012.

• Garcia, AN, Costa, LD, et al, Reliability of Mechanical Diagnosis and Therapy System in Patients With Spinal Pain: A Systematic Review. Journal of Orthopaedic & Sports Physical Therapy, 2018 Volume:0 Issue:0 Pages:1–39 DOI: 10.2519/jospt.2018.7876

• Gattie, E. R., Cleland, J. A., & Snodgrass, S. J. (2017). Dry Needling for Patients With Neck Pain: Protocol of a Randomized Clinical Trial. JMIR research protocols, 6(11).

• González-Iglesias, J., Fernandez-De-Las-Penas, C., Cleland, J. A., & del Rosario Gutiérrez-Vega, M. (2009). Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial. journal of orthopaedic & sports physical therapy, 39(1), 20-27.

• Griffin, A., Leaver, A., & Moloney, N. (2017). General Exercise Does Not Improve Long-Term Pain and Disability in Individuals With Whiplash-Associated Disorders: A Systematic Review. journal of orthopaedic & sports physical therapy, 47(7), 472-480.

• Groeneweg, R., Haanstra, T., Bolman, C. A., Oostendorp, R. A., van Tulder, M. W., & Ostelo, R. W. (2017). Treatment success in neck pain: the added predictive value of psychosocial variables in addition to clinical variables. Scandinavian journal of pain, 14, 44-52.

• Groeneweg, R., van Assen, L., Kropman, H., Leopold, H., Mulder, J., Smits-Engelsman, B. C., ... & van Tulder, M. W. (2017). Manual therapy compared with physical therapy in patients with non-specific neck pain: a randomized controlled trial. Chiropractic & manual therapies, 25(1), 12.

• Guallar, E., & Laine, C. (2014). Controversy over clinical guidelines: listen to the evidence, not the noise. Annals of internal medicine, 160(5), 361-362.

• Haller, H., Lauche, R., Cramer, H., Rampp, T., Saha, F. J., Ostermann, T., & Dobos, G. (2016). Craniosacral therapy for the treatment of chronic neck pain: a randomized sham-controlled trial. The Clinical journal of pain, 32(5), 441.

• Hawk, C., Schneider, M. J., Haas, M., Katz, P., Dougherty, P., Gleberzon, B., ... & Weeks, J. (2017). Best practices for chiropractic Care for Older Adults: a systematic review and consensus update. Journal of Manipulative & Physiological Therapeutics, 40(4), 217-229.

• Healey, C. D., Spilman, S. K., King, B. D., Sherrill, J. E., & Pelaez, C. A. (2017). Asymptomatic cervical spine fractures: Current guidelines can fail older patients. Journal of Trauma and Acute Care Surgery, 83(1), 119-125.

• Horn, M. E., George, S. Z., & Fritz, J. M. (2017). Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 1(3), 226-233.

• Hoving, J. L., de Vet, H. C., Koes, B. W., Van Mameren, H., Devillé, W. L., van der Windt, D. A., ... & Bouter, L. M. (2006). Manual therapy, physical therapy, or continued care by the general practitioner for patients with neck pain: long-term results from a pragmatic randomized clinical trial. The Clinical journal of pain, 22(4), 370-377.

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• Jangi, M., Ferandez-de-las-Penas, C., Tara, M., Moghbeli, F., Ghaderi, F., & Javanshir, K. (2018). A systematic review on reminder systems in physical therapy. Caspian journal of internal medicine, 9(1), 7.

• Jones, D. J., Barkun, A. N., Lu, Y., Enns, R., Sinclair, P., Martel, M., ... & Sung, J. (2012). Conflicts of interest ethics: silencing expertise in the development of international clinical practice guidelines. Annals of internal

medicine, 156(11), 809-816.

• Kelly, J., Ritchie, C., & Sterling, M. (2017). Clinical prediction rules for prognosis and treatment prescription in neck pain: A systematic review. Musculoskeletal Science and Practice, 27, 155-164.

• Kjaer, P., Kongsted, A., Hartvigsen, J., Isenberg-Jørgensen, A., Schiøttz-Christensen, B., Søborg, B., ... & Hansen, I. R. (2017). National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy. European Spine Journal, 26(9), 2242-2257.

• Ladeira, C. E., Cheng, M. S., & da Silva, R. A. (2017). Clinical Specialization and Adherence to Evidence-Based Practice Guidelines for Low Back Pain Management: A Survey of US Physical Therapists. journal of orthopaedic & sports physical therapy, 47(5), 347-358.

• Lauche, R., Cramer, H., Hohmann, C., Choi, K. E., Rampp, T., Saha, F. J., ... & Dobos, G. (2012). The effect of traditional cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: a randomised controlled pilot study. Evidence-based complementary and alternative medicine, 2012.

• Leaver, A. M., Maher, C. G., McAuley, J. H., Jull, G., Latimer, J., & Refshauge, K. M. (2013). People seeking treatment for a new episode of neck pain typically have rapid improvement in symptoms: an observational study. Journal of physiotherapy, 59(1), 31-37.

• Lemeunier, N., da Silva-Oolup, S., Chow, N., Southerst, D., Carroll, L., Wong, J. J., ... & Murnaghan, K. (2017). Reliability and validity of clinical tests to assess the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders: Part 1—A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration. European Spine Journal, 26(9), 2225-2241.

• Lin, I., Wiles, L. K., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., ... & O’sullivan, P. P. (2018). Poor overall quality of clinical practice guidelines for musculoskeletal pain: a systematic review. Br J Sports Med, 52(5), 337-343.

• Ludvigsson, M. L., Peterson, G., O’Leary, S., Dedering, Å., & Peolsson, A. (2015). The effect of neck-specific exercise with, or without a behavioral approach, on pain, disability, and self-efficacy in chronic whiplash-associated disorders: a randomized clinical trial. The Clinical journal of pain, 31(4), 294.

• Machado, G. C., Maher, C. G., Ferreira, P. H., Day, R. O., Pinheiro, M. B., & Ferreira, M. L. (2017). Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Annals of the rheumatic diseases, 76(7), 1269-1278.

• Manchikanti, L., Boswell, M. V., Kaye, A. D., Helm, I. S., & Hirsch, J. A. (2017). Therapeutic role of placebo: evolution of a new paradigm in understanding research and clinical practice. Pain physician, 20(5), 363-86.

• Markovitz, A. A., Hofer, T. P., Froehlich, W., Lohman, S. E., Caverly, T. J., Sussman, J. B., & Kerr, E. A. (2018). An Examination of Deintensification Recommendations in Clinical Practice Guidelines: Stepping Up or Scaling Back?. JAMA internal medicine, 178(3), 414-416.

• Mintken, P. E., McDevitt, A. W., Michener, L. A., Boyles, R. E., Beardslee, A. R., Burns, S. A., ... & Cleland, J. A. (2017). Examination of the Validity of a Clinical Prediction Rule to Identify Patients With Shoulder Pain Likely to Benefit From Cervicothoracic Manipulation. Journal of Orthopaedic& Sports Physical Therapy, 47(4), 252-260.

• Moll, L. T., Jensen, O. K., Schiøttz-Christensen, B., Stapelfeldt, C. M., Christiansen, D. H., Nielsen, C. V., & Labriola, M. (2017). Return to Work in Employees on Sick Leave due to Neck or Shoulder Pain: A Randomized Clinical Trial Comparing Multidisciplinary and Brief Intervention with One-Year Register-Based Follow-Up. Journal of occupational rehabilitation, 1-11.

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• Moser, N., Lemeunier, N., Southerst, D., Shearer, H., Murnaghan, K., Sutton, D., & Côté, P. (2017). Validity and reliability of clinical prediction rules used to screen for cervical spine injury in alert low-risk patients with blunt trauma to the neck: part 2. A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration. European Spine Journal, 1-15.

• Philadelphia Panel Members, Clinical Specialty Experts, Albright, J., Allman, R., Bonfiglio, R. P., Conill, A., ... & Shekelle, P. (2001). Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for neck pain. Physical Therapy, 81(10), 1701-1717.

• Pincus, D., Kuhn, J. E., Sheth, U., Rizzone, K., Colbenson, K., Dwyer, T., ... & Wasserstein, D. (2017). A Systematic Review and Appraisal of Clinical Practice Guidelines for Musculoskeletal Soft Tissue Injuries and Conditions. The American journal of sports medicine, 45(6), 1458-1464.

• Pool, J. J., Ostelo, R. W., Hoving, J. L., Bouter, L. M., & de Vet, H. C. (2007). Minimal clinically important change of the Neck Disability Index and the Numerical Rating Scale for patients with neck pain. Spine, 32(26), 3047-3051.

• Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 166(7), 514-530.

• Rodríguez-Huguet, M., Gil-Salú, J. L., Rodríguez-Huguet, P., Cabrera-Afonso, J. R., & Lomas-Vega, R. (2018). Effects of myofascial release on pressure pain thresholds in patients with neck pain: a single-blind randomized controlled trial. American journal of physical medicine & rehabilitation, 97(1), 16-22.

• Rudolfsson, T., Björklund, M., Svedmark, Å., Srinivasan, D., & Djupsjöbacka, M. (2017). Direction-Specific Impairments in Cervical Range of Motion in Women with Chronic Neck Pain: Influence of Head Posture and Gravitationally Induced Torque. PloS one, 12(1), e0170274.

• Schellingerhout, J. M., Verhagen, A. P., Heymans, M. W., Koes, B. W., Henrica, C., & Terwee, C. B. (2012). Measurement properties of disease-specific questionnaires in patients with neck pain: a systematic review. Quality of Life Research, 21(4), 659-670.

• Seong, H. Y., Lee, M. K., Jeon, S. R., Roh, S. W., Rhim, S. C., & Park, J. H. (2017). Prognostic Factor Analysis for Management of Chronic Neck Pain: Can We Predict the Severity of Neck Pain with Lateral Cervical Curvature?. Journal of Korean Neurosurgical Society, 60(4), 456.

• Sewell, J., Dixon, C., Morris, R., & Stuart, S. (2018). Anatomical distribution of musculoskeletal disorders following a road traffic collision in litigants presenting to physiotherapists within a private-clinic in North-East England. Physiotherapy theory and practice, 1-11.

• Sherman, K. J., Cook, A. J., Wellman, R. D., Hawkes, R. J., Kahn, J. R., Deyo, R. A., & Cherkin, D. C. (2014). Five-week outcomes from a dosing trial of therapeutic massage for chronic neck pain. The Annals of Family Medicine, 12(2), 112-120.

• Stochkendahl, M. J., Kjaer, P., Hartvigsen, J., Kongsted, A., Aaboe, J., Andersen, M., ... & Jensen, L. D. (2017). National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. European Spine Journal, 1-16.

• Taimela, S., Takala, E. P., Asklöf, T., Seppälä, K., & Parviainen, S. (2000). Active treatment of chronic neck pain: a prospective randomized intervention. Spine, 25(8), 1021-1027.

• Villafañe, J. H., Perucchini, D., Cleland, J. A., Barbieri, C., de Lima e Sá Resende, F., & Negrini, S. (2017). The effectiveness of a cognitive behavioral exercise approach (CBEA) compared to usual care in patients with a Whiplash Associated Disorder: A quasi-experimental clinical trial. Journal of back and musculoskeletal rehabilitation, 30(5), 943-950.

54

DISCLOSURE

As required by the appropriate boards/associations:

I declare that I do not have an affiliation with or financial interest in a commercial

organization that could pose a conflict of

interest during this presentation.

Instructor is paid a speaking honorarium for this program.

Sam Barrow of Primal Pictures Ltd. provided copyright

permission to use the anatomy pictures from the Primal Pictures.

Ltd. DVD: Interactive Functional Anatomy, Second Edition

www.primalpictures.com

Primal Pictures Ltd. 4th Floor, Tennyson House, 159-165 Great

Portland St.

London, W1W5PA, UK

Other pictures used from Creative Commons or original work by

Theresa Schmidt

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Thank You from Theresa Schmidt & Educise™

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