## 2 Case Presentation  
### Initial Examination  
An 85-year-old female presented to physical therapy with a diagnosis of neck pain following referral from her primary physician. Her past medical history was significant for hypertension and atrial fibrillation, treated with beta blockers and anticoagulants, respectively. The patient had no imaging on file related to her condition and no pertinent past surgical history. On subjective examination, she reported right-sided upper neck and occipital pain ongoing for 13 months duration with insidious onset and without previous episodes or previous management (Figure 1). She did not report radiation of pain or symptoms of paresthesia in the upper extremities. Aggravating factors included lying down on her right side at night, turning or side bending her head to the right, and extending her neck to look upward.  
Patient-reported measures of function, pain, and satisfaction were assessed using the Focus on Therapeutic Outcomes (FOTO) Neck Functional Status (Neck FS) [29], a Numeric Pain Rating Scale (NPRS) [30; 31], and the FOTO Patient Satisfaction tool. The Neck FS is a patient-reported outcome measure that uses an item-response theory (IRT)-based 28 item bank. It was administered using computer adaptive testing (CAT) for reduced  
Figure 1: Patient neck pain and headache distribution.  
administration burden (median = 6 items) with a precision similar to that of scores based on all 28 items. Scores are reported on a 0-100 point scale with higher scores indicating better function. The Neck FS CAT has been reported to demonstrate excellent reliability and validity, with no ceiling or floor effects [29; 32]. Additionally, clinical interpretation parameters have been identified, including reliability of point estimates and improvement scores at different levels of confidence, cutting scores of minimal clinically important improvement; from this, a physical functioning staging model was developed [32].  
Score change interpretation for the Neck FS includes a predictive analytic model for risk-adjusted predictions of FS score change, number of therapy visits, and duration of time in days. The models are specific to patients with orthopedic neck impairments and use advanced methods that account for individual variables within the following categories of patient characteristics: age, gender, acuity, severity level, individual comorbidities, payer type, surgical history, post-surgical status/type, exercise history, medication use, and history of previous treatment [33]. Minimal clinically important improvement (MCII) values for the overall score range and per quartile of intake score have been established [32].  
To capture the patients' reported pain level, the NPRS was used, which consists of an 11 point scale, ranging from 0 (no pain) to 10 (worst pain imaginable). The NPRS has demonstrated acceptable responsiveness and validity, along with moderate reliability in patients with mechanical neck pain (intraclass correlation coefficient (ICC) = 0.67) [31] and cervicogenic headache (ICC = 0.72) [30].  
Patient satisfaction was assessed using an unpublished set of eight patient-facing questions used in the FOTO Patient Outcomes measurement system (Net Health Systems, Inc, Pittsburgh, PA, USA), each with a five-point response options scale, producing an overall satisfaction score on the basis of a simple mathematical average. At intake, the patient had a Neck FS score of 61 with a risk-adjusted predicted score change of +4 over nine therapy visits and 41 days, and the Intake NPRS was 8/10 with movement and 2/10 at rest (Table 1). Her goals were to reduce pain without taking medication and to be able to turn her head without pain.  
The pain distributions in the upper cervical and occipital region warranted a differential diagnosis of potential pain sources including the C2-C3 and C3-C4 cervical zygappbyseal joints and dorsal rami [34], as well as muscles of the neck and shoulder girdle [35; 36].