Examination Techniques
All panel members in the current study reported using segmental joint assessment and diagnostic palpation ‘Often’ or ‘Always’ when examining patients with non-specific neck pain. Palpation techniques include both static and dynamic (motion) methods, which are often used to identify areas of tissue pain and dysfunction, target manual and manipulative therapies and determine effectiveness of the intervention (31). Previous research has shown osteopaths examine patients with neck pain using palpation (32) among other examinations (33) albeit the reliability of diagnostic palpation for patients with NSNP is poor (34). Given panel members reported that it is essential that segmental joint assessment and diagnostic palpation is performed in the examination of patients with non-specific neck pain (NSNP), further research could delve into the rationale for their inclusion. This exploration may shed light on the nuances of these examination techniques and their contribution to the diagnosis of NSNP by osteopaths.
Panel members deemed active and passive cervical ROM assessment essential for NSNP examination, aligning with studies showing reduced cervical ROM in patients with cervical spine dysfunction (35, 36). ROM assessment is widely used to evaluate impairment severity (37, 38), treatment outcomes (35, 39–43) and disease classification. Its frequent use in trials (38, 41, 44) suggests osteopaths may be using ROM assessment to identify the relationship between joint dynamics and dysfunction location (45). This use by experienced osteopaths appears consistent with the literature, which demonstrates acceptable levels of reliability for active ROM measurements in the cervical spine (40, 46). However, given many of these studies are over 19 years old and investigated reliability in asymptomatic individuals (42, 43, 47) or used visual estimation (48), exploring the clinical decision-making of more recently graduated osteopaths could reveal if practice has changed.
Additional manual testing was also identified as being a component of the panel’s approach to examination of patients with NSNP. Nine panel members reported using Kemp’s test either ‘Sometimes’ or ‘Often’ when examining patients with NSNP, with one panel member reporting they never use it, and one reporting they use it ‘Always’. However, it was included in the final consensus for the examination section. Kemp’s has been described in the literature as being potentially useful in diagnosing facet joint pain (or “facet syndrome”) (49) so it may be that the panel consider it essential to rule in/out facet joint involvement for patients presenting with NSNP. The cervical compression and distraction test is used to detect the presence of cervical radiculopathy (50). While often/sometimes used, the reliability of the cervical compression and distraction test is questionable (34). This suggests osteopaths may use these movements to reinforce a suspected NSNP diagnosis or simply include it routinely regardless of reliability. The consensus here indicates the panel views this test as valuable for both cervical radiculopathy and broader NSNP assessment. Further research is needed to understand the rationale for using Kemps and cervical compression and distraction in NSNP presentations.
Similarly, the panel considered an upper limb neurological examination as essential, however no panel member performed the technique ‘Always’. It may be that to identify a patient as having NSNP, it is important to rule out neurological involvement. It would be useful to ask osteopaths what type of neurological exam they consider essential and to explore their reasons for considering it essential, even if they only use it infrequently.
This study highlights the need for further research into the decision-making processes behind using examination techniques with limited validity, as clinical judgment was not specifically assessed in the current work. This exploration may reveal that panel members employ reasoning approaches such as hypothetico-deductive reasoning, pattern recognition, and narrative reasoning, as outlined by (18) in selecting working diagnoses. Furthermore, the study could explore whether the panel members are influenced by their training, leading them to seek specific tissues they believe to be responsible for the patient's pain. This expanded research could contribute valuable information to enhance the reliability and effectiveness of osteopathic diagnostic practices.
Treatment Techniques (Intervention)
Osteopaths reached moderate agreement on essential treatment techniques for NSNP (30), particularly the use of muscle energy technique, HVLA and soft tissue techniques. There is a range of evidence supporting the positive patient outcomes associated with their use in NSNP. For example, several studies have demonstrated positive outcomes with respect to pain and range of motion with MET, including when combined with cervical traction or therapeutic exercise (51). Similar outcomes have been observed with the use of HVLA and soft tissue techniques. Further, these techniques are amongst the most used by Australian osteopaths, regardless of the presenting complaint. What is not clear from the current work is when the application of these techniques is indicated for NSNP, and the moderate level of agreement amongst the expert panel suggests variability in practitioner treatment choices, aligning with research showing technique-focused approaches in osteopathic care (19). Differences in osteopathic training programs and continuing professional development could contribute to this variation, as well as the non-specific nature of the condition. How osteopaths choose one technique over another, or why they choose to apply a certain technique before another requires exploration through qualitative research methods. For example, interviewing osteopaths in a clinical setting to explore why they choose certain techniques would provide valuable insight into where osteopaths sit on a clinical reasoning continuum described by (18) and whether this is linked to treatment effectiveness.
Soft tissue techniques for the cervical and shoulder girdle were the most frequently used treatment techniques among the panel, aligning with prior research (11–13, 15, 52). While effective for chronic neck pain (53, 54) further research is needed to determine the specific benefits of soft tissue techniques for NSNP, particularly within a multimodal treatment approach.
Muscle Energy Technique (MET) is a manual therapy approach commonly used by osteopaths to address musculoskeletal dysfunction, including neck pain (15), and was rated as often used by 82% of panel members.
The use of High Velocity Low Amplitude Technique (HVLA) applied to the cervical spine was ‘Often/Sometimes’ in clinical practice for individuals experiencing NSNP. Research has shown that osteopaths often employ HVLA for patients with neck pain (15) with some demonstrable effectiveness (55) by impacting the nervous system via stimulation to the sensory nerves in the spinal joints, thereby diminishing pain signals (56–58). Additionally, these investigations propose that neck manipulation may have an impact on muscle tone and enhance joint proprioception, thereby contributing to an improved overall function of the neck (56, 58).
Prognosis
The panel indicated the importance of the Neck Disability Index (NDI) for compensable cases of NSNP. Which aligns with research on PROM use by osteopaths (59) and the NDI's widespread use for neck pain (60). The panel also agreed on using a visual analogue scale (VAS) or numerical pain rating scale (NPRS) for pain monitoring, supported by their reliability in assessing neck pain impact (61, 62). The VAS's simplicity likely contributes to its inclusion for prognosis assessment.
Panel members also shared a consensus that a moderately conservative approach, encompassing 2–3 treatments, is deemed adequate for effectively addressing and resolving NSNP. Clinical trials typically adopt a protocol of one treatment session per week over a span of 4–6 weeks (3, 32, 63–65) to assess the efficacy of osteopathic treatment for neck pain. It is plausible that the osteopaths in the current study may have focused on patients experiencing acute pain rather than those dealing with chronic pain, a condition often accompanied by comorbidities. It is also possible that the panel guides the patient towards self-care strategies, encompassing self-care exercises and other management approaches. Further research is warranted to delve into the rationale behind opting for 2–3 treatments specifically for patients with NSNP, shedding light on the potential factors influencing this therapeutic approach.
While research has shown that PROMs are important in clinical practice to evaluate patient outcomes (66), the current study found that their infrequent use is consistent with Australian osteopathic practice (59). Research has identified various barriers to PROM use including clinician capacity concerns, fear of judgment, lack of organisational support, and workflow integration challenges (67–69). Further investigation is needed to determine whether these factors impacted the panel's reported limited use of PROMs.
Based on the findings in the current study, osteopaths should: |
- Master essential examination techniques: Become proficient in Cervical Compression/Distraction, Kemp's Test, comprehensive neurological examination, and target assessments specific to the cervical spine. |
- Prioritise validated outcome measures: Track patient progress with the Neck Disability Index, diligently monitor pain levels and range of motion, and aim for noticeable improvement within 2–3 treatments, especially in compensable cases. |
- Recognise the importance of consensus: While specific treatment methods may vary, align your practice with the broader expert consensus on NSNP examination and management to deliver consistent, high-quality care. |
Limitations
The study aimed to attain a consensus level of W = 0.6 for the survey as a whole as well as for each section, prompting consideration for an additional survey round to meet this goal. However, recognising the potential burden on the expert panel and aiming to avoid restricting the essential techniques osteopaths view as vital for neck pain treatment, in alignment with the analyses of Rounds 1 and 2, a 'moderate' level of agreement was deemed acceptable, provided that all items in the Round 3 survey, including those from each section, reached a 'good' level of agreement (W = > 0.6). Further, conducting an additional round to establish a consensus on a treatment approach involving various techniques for a non-specific condition might constrain the range of techniques deemed necessary by the expert panel.
Absence of face-to-face meetings in this study may have deprived the experts from exchanging important information, such as clarification of reasons for disagreements. However, ensuring participant anonymity in this study likely reduced the effects of dominant individuals, and potentially reduced coercion to conform to certain viewpoints (70). The asynchronous nature of the data collection process and feedback rounds used in this study allowed panel members to contribute without the need for simultaneous coordination, reducing logistical challenges.
While consensus methods pose potential biases like participant selection (71), this study's careful approach likely mitigates these concerns. The research team focused on expertise when selecting the panel, balanced the number of participants, used open-ended questions, and had defined consensus criteria. These steps strengthen the validity and reliability of the findings.
Further, the strategic inclusion of open-ended questions in the initial and subsequent rounds of the study offered the opportunity to add additional detail from the expert panel, decreasing the likelihood of constraining responses and thereby enhancing the depth and breadth of the data collected.
Okoli and Pawlowski (72) argue the effectiveness of modified Delphi studies may be contingent upon the clarity of the initial problem statement, and ambiguous or ill-defined issues could hinder the consensus-building process. To mitigate this potential issue in the current study, two rounds of questionnaires with open-ended responses were utilised, providing panel members the opportunity to input appropriate responses that capture their approach when managing patients with non-specific neck pain. This approach allowed for the emergence of clearer questions and preamble on the survey rounds from the collective expertise of the panel, ensuring that subsequent questions posed in each round of the study were relevant and focused.