Guidelines - Neck Pain

This tool provides information to facilitate the management of recent onset and persistent neck pain for adults.

Focused examination

1. Patient History 

  • Rule out major structural or other pathologies. If required, refer to an appropriate healthcare provider.

  • Identify and assess other conditions and co-morbidities. Manage using appropriate care pathways.

  • Address prognostic factors that may delay recovery.

Major structural or other pathologies (red flags):

  • Cancer (history of cancer, unexplained weight loss, nocturnal pain, age >50), vertebral infection (fever, intravenous drug use, recent infection), osteoporotic fractures (history of osteoporosis, use of corticosteroid, older age), traumatic fracture (positive Canadian C-Spine rule), myelopathy - severe/progressive neurological deficits (painful stiff neck, arm pain and weakness, sensory changes in lower extremity, motor weakness and atrophy, hyper-reflexia, spastic gait), carotid/vertebral artery dissection (sudden and intense onset of headache or neck pain), brain haemorrhage/mass lesion (sudden and intense onset headache), inflammatory arthritis (morning stiffness, swelling in multiple joints)

Examples of other conditions/co-morbidities:

  • Physical conditions: back pain, headache

  • Psychological conditions: depression, anxiety

  • Co-morbidities: diabetes, heart disease

Examples of prognostic factors that may delay recovery:

  • Symptoms of depression or anxiety, passive coping strategies, job dissatisfaction, high self-reported disability levels, disputed compensation claims, somatization

2. Physical Examination

  • Rule out major structural or other pathologies and grade IV NAD.

  • Assess for neurological signs.

  • Identify type of neck pain.

Grade I: No signs or symptoms of major structural pathology and no or minor interference with activities of daily living
Grade II: No signs or symptoms of major structural pathology but major interference with activities of daily living
Grade III: No signs or symptoms of major structural pathology but presence of neurologic signs
Grade IV: Signs and symptoms of major structural pathology

3. Management 

  • Offer information on nature, management, and the course of neck pain. See patient handouts for more information to provide to patients.

  • Discuss the range of effective interventions with the patient and, together, select a therapeutic intervention.

Patient Handouts

 

Management of recent-onset (0-3 months symptom duration) neck pain, grades I-II

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

Consider range of motion exercise

​​Consider multimodal careᶧ

  • combination of range of motion exercise and manipulation or mobilization

Consider a short course of muscle relaxants (as indicated)

Do not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat

Do not offer or recommend acetaminophen as a routine intervention

Management of persistent (4-6 months symptom duration) neck pain, grades I-II

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

Consider range of motion and strengthening exercises, qigong, yoga ​

Consider clinical massage

Consider low-level laser therapy

Consider multimodal careᶧ

  • combination of range of motion exercise and manipulation or mobilization

Consider non-steroidal anti-inflammatory drugs (NSAIDS) (as indicated)

Do not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections

Management of recent-onset (0-3 months symptom duration) neck pain, grade III

 

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and the following therapeutic intervention*:

Consider supervised strengthening exercise

Do not offer structured patient education alone, cervical collar, low-level laser therapy, or traction

Management of persistent (4-6 months symptom duration) neck pain, grade III

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and the following therapeutic intervention*:

Consider referring to an appropriate healthcare provider for investigation and management for patients who continue to experience neuro-logical signs and disability more than 3 months after injury

Do not offer a cervical collar

*Interventions are recommended if guidelines used terms such as ‘recommended for consideration’ (e.g., ‘offer’, ‘consider’), ‘strongly recommended’, ‘recommended without any conditions required’, or ‘should be used’. Recommendations from low-quality evidence are not listed.
ᶧMultimodal care: treatment involving at least two distinct therapeutic modalities, provided by one or more health care disciplines.

Care Pathway for the management of neck pain, grades I and II

Care Pathway for the management of neck pain, grade III

Exercise Videos

The neck pain videos are based on the recommendations from the Clinical Practice Guideline for the Treatment of Neck Pain Associated with Whiplash and Associated Disorders (2016). Select a link below to view the patient exercise videos for neck pain.

 

4. Reevaluation and Discharge

  • Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered.

  • Monitor for any emerging factors that may delay recovery.

5. Referrals and Collaboration

  • Refer the patient to an appropriate healthcare provider for further evaluation at any time during their care if they develop worsening symptoms and new physical or psychological symptoms.

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CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

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