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Neck Pain Care Pathway

Date of last update: February, 2024

Diagnosis for Non-specific Neck Pain (Includes NAD I and NAD II classifications)

Clinical Cornerstone:

  • Diagnosis is primarily clinical, relying on patient history and clinical examination, and aims to exclude identifiable pathologies.

  • Definition: Neck pain not attributable to a discernible, specific pathology (i.e. not attributable to infection, tumor, osteoporosis, disc herniation, etc).

  • Prevalence: Approximately 90% of all neck pain cases.

  • Risk Factors: Include psychosocial factors (e.g., stress, lack of social support, anxiety, depression); sociodemographic factors (e.g., female sex, older age); physical factors (e.g., repetitive strain, poor posture, prolonged periods of sitting or using computers and mobile devices); lifestyle factors (e.g., low physical activity, obesity); work-related factors (e.g., heavy physical labour, awkward  postures, prolonged use of computers).

  • Pain Location: Typically localized to the neck and upper shoulders.

  • Duration: Pain can be acute (lasting less than 6 weeks), subacute (6 to 12 weeks), or chronic (more than 12 weeks). Duration of the complaint helps to inform subsequent treatment recommendations  (e.g. consider adding low-level laser therapy for chronic non-specific neck pain, consider adding supervised strength training for acute neck pain with radiculopathy). (If there was a history of previous conservative treatment, imaging may be a consideration for persistent non-specific neck pain while referral may be a consideration for persistent neck pain with radiculopathy).

  • Signs and Symptoms:

    • Pain can be sharp, dull, shooting, or aching.

    • Pain intensity can vary from mild to severe.

    • Pain may be aggravated by specific movements, postures, or activities and relieved by others.

    • There may be associated muscle stiffness or spasms.

    • Referred pain into the arms may or may not be present.

  • Neurological Examination: Typically, there are no neurological deficits. If present, they are mild and do not follow a specific nerve root distribution.

  • Response to Conservative Management: Often responds to conservative treatments such as education, exercise, and manual therapy.

  • Psychosocial Factors: Consider psychosocial factors (yellow flags) that might influence pain perception and recovery (e.g., beliefs about pain, fear of movement, catastrophizing).

Conduct patient assessment

Red flags present

Red flags present

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Refer to appropriate emergency or healthcare provider

  • Structured patient education

  • Exercise (strength, range of motion)

  • Manual therapies (e.g., spinal manipulation or mobilization, massage)

  • Low-level laser therapy

  • Psychological / social support

  • Medicines

  • Referral

Major symptom/sign change

Goals not achieved


Adjust treatment and management plan or refer

References or links to primary sources

  • Bussières A.E, et al. The treatment of neck pain -associated disorders and whiplash-associated disorders: A clinical practice guideline. J Man Phys Ther. 2016; 39(8):P523-564.


  • Bussières AE, Taylor JAM, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. Journal of manipulative and physiological therapeutics. 2008;31(1):33-88. doi:10.1016/j.jmpt.2007.11.003


  • Berman, Daniel MD; Holtzman, Ari MD; Sharfman, Zachary MD, MS; Tindel, Nathaniel MD. Comparison of Clinical Guidelines for Authorization of MRI in the Evaluation of Neck Pain and Cervical Radiculopathy in the United States. Journal of the American Academy of Orthopaedic Surgeons 31(2):p 64-70, January 15, 2023. | DOI: 10.5435/JAAOS-D-22-00517


  • Côté P, et al. Management of neck pain and associated disorders: A clinical practice guidelines from the Ontario Protocol for Traffic Injury (OPTIMa) Collaboration. Eur Spine J. 2016; 28:2000-2022.



  • Shearer HM, Carroll LJ, Côté P, Randhawa K, Southerst D, Varatharajan S, Wong JJ, Yu H, Sutton D, van der Velde G, Nordin M. The course and factors associated with recovery of whiplash-associated disorders: an updated systematic review by the Ontario protocol for traffic injury management (OPTIMa) collaboration. European Journal of Physiotherapy. 2021 Sep 3;23(5):279-94.


  • Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA. 2001;286(15):1841–1848. doi:10.1001/jama.286.15.1841

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