J Patient Cent Res Rev. 2017 (Apr 25); 4 (2): 60–68 ~ FULL TEXT
Benjamin Holmes, DC, Ruta Brazauskas, PhD, Laura D. Cassidy, PhD, Rachel A. Wiegand, DC
Institute for Health and Equity,
Medical College of Wisconsin,
PURPOSE: Patient-related predictive factors in responsiveness to directional preference therapy for neck pain with or without upper extremity radiation (NP/R) have not been reported. A directional preference is any neck movement that, when performed repeatedly to end range, results in centralization and/or alleviation of NP/R. It was hypothesized that patient compliance with a prescribed, directional preference-matched home exercise program would improve positive responsiveness to NP/R treatment.
METHODS: Patient-related factors thought to affect responsiveness to care were collected retrospectively from charts and de-identified for patients with NP/R who underwent chiropractic treatment at a multispecialty spine clinic from January 2014 through June 2015. Responsiveness was measured by calculating the percentage change in Neck Bournemouth Questionnaire (NBQ) scores over treatment time. Multiple linear regression was used to identify factors associated with positive responsiveness.
RESULTS: Mean percentage change in patient NBQ score from initial intake to discharge was 50% (standard deviation: 32%). Of 104 patients meeting study inclusion criteria, 86 (83%) reported experiencing improvement after the first treatment session. Bivariate analysis of patient characteristics by compliance with directional preference-matched exercise indicated that compliant patients (n=95, 91%) demonstrated significantly greater responsiveness to care than did noncompliant patients, at 55% versus 25% change in NBQ score, respectively (P=0.0041). Four factors were statistically significant predictors of patient responsiveness to directional preference therapy for NP/R: patient compliance with directional preference-matched exercise (P=0.0023), patient age (P=0.0029), condition chronicity (P<0.0001), and whether the patient reported improvement of symptoms following initial treatment session (P=0.0003).
CONCLUSIONS: The results of this study suggest that patient compliance with directional preference exercise is associated with patient responsiveness to conservative treatment of NP/R, as are age, chronicity and report of immediate symptom improvement.
KEYWORDS: Bournemouth questionnaire; directional preference; neck pain
From the FULL TEXT Article:
Neck pain is common among adults, with
global annual incidence rates reported
between 10.4% and 21.3%.  It is the fourth
leading cause of disability globally.  Neck pain can
be accompanied by upper extremity radiation of
pain, paresthesia, numbness or weakness, sometimes
attributable to cervical radiculopathy. The annual age-adjusted
cervical radiculopathy incidence rate in one
large epidemiological survey in Minnesota was 83 per
100,000 persons. 
Several conservative treatment options are available
for neck pain, including “wait and see,”  spinal
mobilization or manipulation, home exercises, physical
therapy modalities, medications and epidural steroid
injection. Evidence of the efficacy of conservative
management is tenuous. Some evidence suggests that
exercise may be beneficial for neck pain.  Studies
supporting conservative management of neck pain
with upper extremity radiation are even sparser, and
randomized controlled trials are needed to examine the
clinical effectiveness of conservative treatments. 
One conservative treatment approach is called directional preference therapy. Variations of directional
preference therapy have been studied and performed
under different monikers, namely the McKenzie approach  and mechanical diagnosis and therapy (MDT). [4, 8] Directional preference involves manual
therapy, exercise therapy or both, which are predicated
on the discovery of a “directional preference” during
the physical examination. A directional preference is
any specific neck movement that, when performed
repeatedly to end range, results in centralization and/or
alleviation of neck pain with or without upper extremity
radiation (NP/R) as well as improved mechanical
presentation (eg, improved active global range of
motion).  Once the preference has been ascertained,
the directional preference practitioner may utilize,
if necessary, the specific direction when performing
manual therapy to the spine and match the direction in
prescribing home exercises.
Eight clinical trials have assessed directional
preference therapy in treating NP/R, [7, 10–16] but the trials
lack definitive evidence of treatment efficacy. One
systematic review assessed directional preference
therapy for neck pain and concluded that directional
preference therapy may not be significantly more
effective than a “wait and see” approach for neck
pain; however, skillset adequacy of the directional
preference therapists in the included studies was
questioned.  Several studies have evaluated and
supported directional preference therapy for lumbar
spine pathology. [17–23]
This study evaluated characteristics of NP/R patients
and responsiveness to directional preference therapy.
Recognizing both the theoretical value of directional
preference-matched home exercise performance and
the capability of self-management in patient-centered
care to improve health outcomes, the investigators
conducting this study hypothesized that patient
compliance with a prescribed, directional preferencematched
home exercise program would improve
responsiveness to conservative treatment of NP/R.
The local institutional review board determined that
this study, designed primarily as a quality assessment
and improvement project, did not constitute human
A retrospective chart review was conducted for all
patients who presented with axial NP/R and who
demonstrated limited and/or painful active cervical
range of motion, showed a directional preference
on evaluation and underwent directional preference
treatment by a single chiropractor at a spine clinic
within a large health system from January 2014
through June 2015 (N = 245). Patients whose symptoms
and signs did not satisfy the above diagnostic criteria,
who were younger than 18 years, who suspended
care prematurely or for whom outcome data were
incomplete were excluded from the study. Data were
de-identified prior to statistical analysis.
Aside from the chiropractor, this study’s clinic
team comprised an orthopedic spine surgeon,
three orthopedic physician assistants and four pain
proceduralists. Occasionally throughout the course
of individual patient care, other treatment modalities
were utilized as prescribed/performed by team
physicians, assistants and proceduralists, including
the prescription of anti-inflammatory, muscle relaxant,
analgesic and anti-epileptic medication and epidural
steroid injection. Treating members of the clinic team
along with individual patients made the decision
to utilize these modalities on a case-by-case basis.
Anti-inflammatory, muscle relaxant and analgesic
medications were prescribed in the presence of either
neck pain alone or neck pain with upper extremity
radiation. Anti-epileptic medication and epidural
steroid injections were recommended only in cases of
neck pain with upper extremity radiation.
Responsiveness to directional preference therapy was
measured by changes in scores reported by the patient
on the Neck Bournemouth Questionnaire (NBQ)
pre- and post-treatment span. The NBQ is a reliable,
responsive and efficient outcomes measurement
tool (Figure 1) to assess the effects of patients’ neck
conditions on seven aspects of their lives: pain,
activities of daily living, social activities, anxiety,
depression, work and fear-avoidance beliefs, and
locus of control. [24–27]
This study assessed patient compliance with
prescribed directional preference-matched home
exercises as a predictive factor of positive response
to directional preference therapy. Other patient
characteristics analyzed as factors in responsiveness
were: age, body mass index, comorbidities of anxiety
or depression, diagnosis, sex, whether the patient
reported improvement immediately following the first
treatment session, payor, treatment dosage, number of
treatments throughout course of care, smoking status,
condition chronicity, and prescription medication
usage (including epidural steroid injection).
On initial presentation to the chiropractor, the patient
complaining of neck pain with or without upper
extremity pain, numbness, paresthesia or weakness
underwent directional preference assessment. The
directional preference assessment process is well-described
in the literature [9, 28] (and a synopsis is
provided in this paper’s introduction). Following the
ascertainment of a directional preference in the patient
with NP/R, exercise and manual therapies matched to
the preferred direction were performed. NBQ scores
were assessed at intake and every 2–4 weeks thereafter
until the patient’s condition was determined fixed and
stable, and the patient was released from care.
Occasionally, NP/R symptoms returned after the
patient was released and care was reinitiated, creating a
subsequent course of treatment. After the NBQ scores
were collected, the percentage change was calculated,
meaning the difference between a patient’s NBQ score
at intake and at the conclusion of the treatment course,
divided by the score at intake, and multiplied by 100,
with positive percentages indicating improvement and
negative percentages indicating decline. 
Patient characteristics were summarized with
descriptive statistics. Patient-related factors were
compared between exercise-compliant and exercisenoncompliant
groups using Wilcoxon rank-sum test
for continuous variables and χ2 test for categorical
Multiple linear regression analysis was used to model
patient responsiveness to directional preference therapy
in relation to: age; body mass index; comorbidities of
anxiety and/or depression (as determined by presence
of anxiety and/or depression diagnoses in the patient’s
electronic medical record); NP/R primary diagnosis
variation (neck pain without upper extremity radiation
or neck pain with upper extremity radiation); sex;
reported improvement after first treatment session
(yes or no); payor (commercial or noncommercial
insurance, the latter of which includes self-pay,
personal injury, workers’ compensation, Medicaid
and Medicare); reported compliance with the home
exercise program as prescribed; treatment dosage
(number of treatments per days of treatment span);
total number of treatments throughout the course of
care; smoking status; chronicity of symptoms (acute/
subacute or chronic/acute-on-chronic); and the use of
prescription substances (anti-inflammatories, muscle
relaxants, analgesics, anti-epileptics and/or epidural
steroids). A backward elimination model selection
procedure was used to identify statistically significant
covariates to include in the model. Significance was
defined as P<0.05 throughout. SAS OnDemand for
Academics software (SAS Institute, Cary, NC) was
used to perform statistical analysis.
A total of 104 patients, undergoing a total of 119
treatment courses, met the inclusion criteria and
were included in the analysis. The largest number
of treatment courses per patient was four (which
occurred in 1 patient); 8 of the 104 patients underwent
two treatment courses and 2 patients underwent three
courses. The average number of treatment sessions
per course of care was 6.8 (Table 1). For analysis
purposes, only a patient’s first treatment course of
NP/R was considered.
Also shown in Table 1, the mean age of study
population was 47 years (standard deviation: 12.0),
and 68% of patients were female. The mean change in
NBQ score with respect to initial reported score was
50% ± 32%; 86 patients (83%) reported experiencing
improvement after the first treatment session, and
95 patients (91%) reported being compliant with
the prescribed home exercise program. A majority
of patients (n = 65, 62.5%) suffered from chronic or
acute-on-chronic pain as opposed to acute/subacute
pain. Chronic pain was defined as neck and/or upper
extremity pain that had been persistent for greater
than 3 months, acute pain defined as less than 7 days,
subacute pain defined as lasting between 7 days and 3
months, and acute-on-chronic pain defined as a flare-up
of acute or subacute pain in the presence of underlying
Table 2 shows the results of the bivariate analysis
of patient characteristics by compliance with
prescribed directional preference-matched home
exercise. Exercise-compliant patients (“exercisers”)
demonstrated significantly improved responsiveness
to care compared with noncompliant patients
(“nonexercisers”), with a 55% and 25% change in
NBQ score, respectively (P = 0.0041). Only 25% of
exercisers experienced depression compared with
78% of nonexercisers (P = 0.0010). Payor classification
varied significantly between the two groups as well —
91% of exercisers were commercially insured, whereas
44% of nonexercisers were noncommercially insured
(P = 0.0024). No statistically significant difference
between exercisers’ and nonexercisers’ chronicity of
symptoms was found.
Results of multiple linear regression are summarized
in Table 3. Compliance with a prescribed directional
preference-matched home exercise program was
positively associated with responsiveness to directional
preference therapy (P = 0.0023), and condition chronicity
was negatively associated (P<0.0001). Patient age ≥ 55
years and noted improvement of symptoms following
the initial treatment session also were both positively
associated with responsiveness to therapy (P = 0.0029
and P = 0.0003, respectively).
Patient responsiveness to directional preference therapy
based on combinations of patient characteristics within
the best-fit linear regression was estimated (Table 4).
Analysis was repeated to include all treatment episodes.
Results of this secondary analysis (data not shown) were
very similar to the presented analysis, which involved
only the first treatment episode.
The general agreement among health scientists is that
patient engagement and participation in health care,
such as via home exercise performance, are beneficial;
however, clinical trials and reviews specifically
evaluating directional preference therapy for NP/R are
sparse and insufficiently informative. While the results
of this study are consistent with previous studies that
support the use of directional preference therapy in
treating NP/R, [7, 10–16 our results also explicate specific
patient-related factors in responsiveness to directional
preference therapy outside the practitioner-related
factors studied prior. For instance, these findings
suggest a possible mechanism behind limited
responsiveness of neck pain patients to directional
preference therapy reported in the systematic review
by Takasaki and May,  as 61 of the 100 patients
from two of the five trials studied by the authors had
suffered from neck pain for more than 3 months. Our
finding that chronicity of symptoms is a predictive
factor in patient responsiveness to care may provide
an explanation of limited responsiveness to directional
preference therapy in those two trials.
This study has limitations. Several data points are
patient-reported, such as NBQ scores, chronicity,
improvement following initial treatment session,
compliance with directional preference home
exercises and smoking status. These data are
subjective reports and potentially carry social
desirability bias (for example, the underreporting of
smoking and overreporting of exercise compliance).
Also, some of these reports relate to the patient’s
experience with pain. Because pain and its effects are
a subjective experience, some level of subjectivity is
inescapable. Nevertheless, by comparing percentage
change of NBQ scores — which are intrapersonal
ratios and therefore control for personalization  of the
pain experience — instead of raw NBQ scores, data
volatility is maximally neutralized and interpersonal
comparability maximally facilitated. Small patient
numbers limited some comparisons, particularly
Because the study population was predominantly
Caucasian and commercially insured — a make-up
that accurately reflects the overall patient population
at our clinic — findings are not generalizable.
However, they will inform processes to assess and
improve quality at our institution (and perhaps
those that are similar) as well as motivate and guide
further research of directional preference therapy for
NP/R. These findings may inform further assessment
of larger samples in more demographically diverse
settings. Dissemination of these results may motivate
patients to comply with directional preference home
exercises and also encourage regional clinicians to
enlist patient involvement when treating NP/R. Local
directional preference practitioners also can use
these findings to inform themselves and patients of
likelihood of responsiveness to care at the early outset
of treatment, which could be financially, emotionally
and therapeutically beneficial to the patient.
Patient compliance with directional preference
exercise is associated with patient responsiveness to
directional preference therapy in conservative care
treatments of neck pain. Patients 55 years of age or
older, those with acute/subacute chronicity and those
who report symptom improvement following the first
treatment session showed significant improvement.
Implementation of these findings could improve care
of patients with neck pain, with or without upper
extremity radiation, at a local level.
Patients experiencing persistent neck pain
with or without arm symptoms have several
treatments at their disposal. Often, a conservative
course of “directional preference” therapy is
Directional preference refers to neck movements
that, when performed repeatedly, result in
centralization or alleviation of pain. Patients
using directional preference therapy may
be assigned home exercises as part of their
The authors found that compliance with these
exercises, along with patient factors such as
age ≥ 55 and noted improvement after initial
treatment session, contributed significantly to
success of therapy.
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