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Neck Pain Care Pathway

Date of last update: November, 2024

About Neck Pain

Neck pain is a common condition that can be acute or persistent, presenting as a dull ache or sharp pain. Most cases respond well to conservative care, although serious underlying pathologies requiring medical attention are possible.

 

Given its multifactorial and recurring nature, influenced by physical, psychological, social, and environmental elements, there is no one-size-fits-all treatment for neck pain. Effective management must be ethical, evidence-driven, transparent, flexible, and responsive to individual needs. Incorporating shared decision-making ensures care aligns with patient goals. Continuous monitoring and assessment of outcomes help maintain a person-centered approach. Management may also be delivered through virtual or hybrid care.

About the Care Pathway

  • Purpose: This pathway offers structured, evidence-based guidance for clinicians delivering conservative care, covering key steps of the clinical encounter. It also serves as a resource for referral or co-management for those not directly providing conservative care. Key information is available in a one-page quick guide, with more detailed content accessible through specific sections.

 

  • Development: ​​This pathway draws on current best practices synthesized from clinical guidelines wherever available and systematic reviews where guidelines are not available. Content is periodically reviewed to ensure recommendations remain current and evidence based. Where evidence is evolving or conflicting, guidance is refined using the most robust available sources. Input from clinicians, educators, and researchers facilitates alignment with real-world needs and encourages ongoing improvement.

 

  • Disclaimer: This care pathway is not intended to replace advice from a qualified healthcare provider.

  • Updates: Communicated through social media.

CLICK HERE FOR A ONE-PAGE QUICK GUIDE: Neck Pain Quick Guide

1. Record Keeping

 

  • Document findings and recommendations using structured notes (e.g., SOAP format) at each visit, adhering to jurisdictional standards..

2. Informed Consent

 

  • Obtain and document verbal consent for history taking, examinations, and contact in sensitive areas; secure written consent for treatments per jurisdictional standards.

3. Health History

 

  • ​Apply cultural awareness and trauma-informed care principles.

  • Sociodemographic information: Age, gender, sex, race/ethnicity.

  • Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.

  • Body systems review: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.

  • Health, lifestyle, and history: Past medical conditions, medications (including opioids, oral contraception, etc.), supplements, injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.

  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social isolation.

  • Previous treatments and responses: Document prior treatments, effectiveness and any adverse effects.

  • Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.

  • Flag considerations: Identify red, orange, and yellow flags for potential referrals [see Sections 4 – 6].

Outcome AssessmentsPrioritize approaches that align with the patient’s specific goals and clinical presentation.

  • Pain: Use pain scales (e.g., NRS) and diagrams.

  • Function and participation: Evaluate impact on daily activities (PSFS, WHODAS, NDI, MYMOP, MYMOP Follow-up).

  • Recovery: Use self-rated recovery scales.

  • Quality of life: Assess using tools such as SF-12.

  • Work/school status: Monitor return to activities.

  • Individual goals: Set SMART goals (Specific, Measurable, Achievable, Relevant, Timely).

  • Patient feedback: Gather and integrate patient experience and satisfaction.

4. Red Flags: Differential Diagnoses Requiring Medical Referral

 

ACTION: Refer immediately to emergency care:

  • Cervical myelopathy: Gait disturbances, hand clumsiness, non-dermatomal numbness/weakness (upper/lower extremities), bowel/bladder dysfunction, hyperreflexia, hypertonia, pathological reflexes (e.g., positive L’Hermitte sign, finger escape sign).

  • Meningitis: Neck stiffness, severe headache worsening with neck flexion, fever, vomiting, rash, altered mental status, lethargy/drowsiness, photophobia, flexed hip/knee posturing, positive Brudzinski/Kernig signs.

  • Spinal infection: Progressive neck pain (worse at night), constitutional symptoms (e.g., fever/chills), recent infection/surgery, immunosuppression, TB history, IV drug use, poor living conditions, tenderness on palpation or tap test.

 

  • Intracranial/brain lesion: Sudden intense headache (thunderclap) or progressive headache (± neck pain), dizziness, visual changes, nausea/vomiting, focal neurological signs. Worse in the morning, with coughing/straining, or forward bending; cranial nerve abnormalities, motor and sensory deficits in limbs, papilledema, positive Romberg test (coordination and balance issues), signs of increased intracranial pressure (e.g., Cushing’s triad: hypertension, bradycardia, irregular respirations).

 

  • Vertebral/carotid artery dissection: Severe neck pain, “worst headache ever”, double vision, difficulty swallowing/speaking/walking, dizziness, facial numbness/sensory deficits, drop attacks, nausea, nystagmus, contralateral trunk sensory deficits, focal neurological signs.

 

  • Traumatic spinal fracture: Severe localized pain following trauma (e.g., pedestrian struck, high-speed collision, rollover, ejection from motor vehicle, fall ≥3 feet/5 stairs, axial load to head), age ≥65, extremity weakness/tingling/burning, inability to rotate neck 45° left/right, midline cervical spine tenderness (Canadian C-Spine Rule).

 

ACTION: Refer to appropriate medical provider:

 

  • Non-traumatic spinal fracture: Sudden severe neck pain, osteoporosis, corticosteroid use, female sex, age >60, spinal fracture/cancer history, point tenderness over vertebra, inability to rotate neck 45°, extremity neurological signs.

 

  • Spinal malignancy: Progressive pain (worse at night/unrelieved by rest), cancer history, constitutional symptoms (e.g., fatigue, weight loss, night sweats), localized tenderness, neurological deficits.

 

  • Inflammatory arthritides: Neck and joint pain/stiffness, morning stiffness >1 hour, systemic symptoms (e.g., fatigue, weight loss, fever), joint swelling/tenderness/deformity.

    • Spondyloarthropathies (e.g., ankylosing spondylitis): Pain/stiffness radiating to shoulders/upper back, improves with activity, may include uveitis/psoriasis.

    • Rheumatoid arthritis: Symmetrical joint involvement, joint deformities.

    • Systemic lupus erythematosus (SLE): Butterfly rash, photosensitivity, organ involvement (e.g., kidney or pleuritis).

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

  • Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   

  • Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.

  • Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

 

ACTION: Refer to appropriate medical/mental health provider:

  • Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

 

ACTION: Co-management by non-medical/mental health providers:

  • Triage: Ensure primary management by medical/psychiatric providers.

  • Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.

6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

  • Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.

  • Social: Lack of family/social support, limited connections.

  • Socioeconomic: Employment status, financial stress, litigation/compensation.

  • Environmental/cultural: Social inequality, unsafe/unsupportive environments.

  • Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).

  • Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

 

ACTION: Co-management by non-medical/mental health providers: 

7. Physical Examination

 

  • Observation: Evaluate for abnormalities, asymmetries, posture, balance, gait, movements, facial expressions.

 

  • Range of motion (ROM): Assess active, passive, and resisted cervical spine ROM in flexion, extension, lateral flexion, and rotation. Note regional or segmental hypo-/hypermobility and aberrant movements.

 

  • Palpation: Examine for tenderness, swelling, tightness, or temperature changes in bones, joints, and soft tissues of the cervical region.

  • Neurological examination: 

    • Motor strength testing: Assess for asymmetry or weakness in key muscle groups:

      • C5: Shoulder abduction

      • C6: Wrist extension

      • C7: Wrist flexion and finger extension

      • C8: Finger flexion

      • T1: Finger abduction/adduction

    • Sensory testing: Assess for sensory deficits in dermatomal distributions:

      • C5: Lateral arm

      • C6: Lateral forearm, thumb, index finger

      • C7: Middle finger

      • C8: Ring and small finger, medial forearm

      • T1: Medial arm

      • T2: Axilla

    • Reflex testing: Assess for asymmetry, diminished/absent reflexes:

      • C5: Biceps

      • C6: Brachioradialis

      • C7: Triceps

    • Cranial nerve testing:

      • CN I (olfactory): Sense of smell

      • CN II (optic): Visual acuity and visual fields

      • CN III, IV, VI (oculomotor, trochlear, abducens): Eye movements, pupil response

      • CN V (trigeminal): Facial sensation, mastication muscles

      • CN VII (facial): Facial expressions (smile, frown), taste (anterior 2/3 of the tongue)

      • CN VIII (vestibulocochlear): Hearing and balance

      • CN IX, X (glossopharyngeal, vagus): Gag reflex, palate elevation, swallowing

      • CN XI (accessory): Shoulder shrug, head rotation

      • CN XII (hypoglossal): Tongue movements (deviation)

    • Upper motor neuron signs: Asses for increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate central nervous system disorders (e.g., myelopathy, multiple sclerosis, stroke).

    • Lower motor neuron signs: Assess for muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate systemic neurological conditions (e.g., radiculopathy, peripheral neuropathy, ALS).

 

  • Special/orthopedic tests: Perform as clinically indicated.

 

  • Advanced diagnostics: Radiography is is generally not recommended without red flags or specific individual factors  (e.g., contraindications to treatment).

8. Diagnostic Criteria for Neck Pain Amenable to Conservative Care

 

Common Neck Pain: (e.g., non-specific neck pain, mechanical cervicalgia, facet joint irritation, cervical strain/sprain, whiplash associated disorders (WAD) I-II, osteoarthritis, myofascial pain)

  • Accounts for 90% of neck pain cases.

  • Pain between the nuchal line and cervicothoracic junction, with/without radiation to the head, shoulders, or arms.

  • Sharp, dull, shooting, or aching pain; aggravated by movement/posture; associated muscle stiffness/spasms.

  • Pain reproducible with tests; no significant neurological deficits.

 

Neck Pain with Radicular Pain/Radiculopathy: (from disc protrusion/herniation, foraminal stenosis, WAD III)

  • Less common than neck pain without radiculopathy; disc herniation is more frequent in younger adults; foraminal stenosis is more common in older adults.

  • Pain radiates down the arm in a dermatomal pattern, potentially reaching the hand.

  • Sharp, burning pain with possible numbness, tingling, or weakness in the affected limb; symptoms may worsen with movements like bending the head forward, lifting, coughing, or sneezing.

  • Positive tests (e.g., Spurling’s, cervical distraction, Bakody/shoulder abduction sign, Valsalva, upper limb tension tests); sensory deficits, muscle weakness, altered reflexes.

9. Treatment Considerations for Neck Pain Amenable to Conservative Care

       Applicable to common neck pain, neck pain with radicular pain/radiculopathy from disc pathology and WAD III.

Guideline-Supported Interventions for Neck Pain:
Treatments should integrate clinician experience, patient preferences, and individual needs with a multimodal approach to reduce pain, optimize function, and promote participation in daily life. Informed consent must follow a comprehensive report of findings.

1. Education and Self-Management (Blanpied et al., 2017; Côté et al., 2016; Bussières et al., 2016)

    These interventions address modifiable prognostic factors for recovery [see Section 10].

 

  • Education & reassurance: Emphasize neck pain’s often self-limiting nature. Use tailored, evidence-based information in various formats (written, digital, visual) to empower individuals. Limited evidence suggests no single superior type of education for improving patient outcomes, but consistent reinforcement improves understanding and engagement.

  • Self-care: Encourage regular exercise, nutrition, sleep hygiene, stress management, weight maintenance, and avoidance of smoking/substance abuse. Employ SMART goals and Brief Action Planning for sustained engagement.

  • Daily activities: Promote continued movement and daily activity participation; discourage prolonged rest, immobilization, or the use of neck collars. Maintaining normal activity reduces recovery time and prevents disability.

  • Social & work engagement: Encourage participation using pacing strategies and workplace accommodations to support social interaction and productivity.

 

2. Exercise Therapy (Blanpied et al., 2017; Côté et al., 2016; Bussières et al., 2016)

  • Tailor individualized programs to improve strength, mobility, and aerobic capacity.

  • Exercise reduces pain, improves quality of life, and enhances function. No single type is superior; selection should align with patient preferences and needs.

  • Monitor psychological responses to exercise; refer to medical/mental health providers if signs of distress or aversion arise.

 

3. Manual Therapy (Blanpied et al., 2017; Bussières et al., 2016)

  • Include spinal manipulation/mobilization, soft tissue techniques, and massage.

  • Manual therapy should be integrated into a broader care plan to improve pain and function.

 

4. Psychosocial and Psychological Support (Blanpied et al., 2017; Côté et al., 2016; Shearer et al., 2021)

  • Address barriers: Screen for psychosocial factors (e.g., fear-avoidance behaviors, low recovery expectations, anxiety) using tools (e.g., FABQ, PHQ-9, GAD-7). Addressing these factors enhances engagement and recovery. Provide education and strategies within the scope of care to support recovery (e.g., stress management, self-efficacy building, social/occupational engagement, mindfulness, meditation, relaxation techniques) [see Sections 5 and 6].

  • Resources & instruction: Offer resources (e.g., online tools, written materials, mindfulness programs). Refer to mind-body practitioners (e.g., yoga, meditation, tai chi) for further support when conservative care is insufficient.

  • Medical/mental health referral: Refer for persistent or severe psychological symptoms impacting recovery [see Sections 5 and 6].

 

5. Medication (Blanpied et al., 2017; Bussières et al., 2016)

  • Short-term use of medications (e.g., analgesics, NSAIDs) may be considered for pain relief, in consultation with a medical provider.

  • Long-term use of opioids or muscle relaxants should be avoided due to risks of dependency and side effects.

 

6. Multimodal Care (Blanpied et al., 2017; Côté et al., 2016; Bussières et al., 2016)

  • Integrate physical, psychological, and social interventions tailored to individual needs, particularly for persistent neck pain, to support function, work, and community engagement through predominantly non-pharmacologic care.

10. Risk and Prognostic Factors for Neck Pain

 

Common Risk Factors (Kazeminasab et al., 2022):

  • Individual: Female sex, older age, history of neck pain, poor general health (e.g., smoking, chronic illness, sleep disturbances, frequent tiredness).

  • Physical: Repetitive strain, prolonged static postures (e.g., sitting, using computers or mobile devices), awkward neck positions, poor ergonomics, heavy lifting, vibration exposure, physical inactivity.

  • Psychological: Stress, anxiety, depression, and fear-avoidance behaviors.

  • Occupational: Work-related neck postures, high job stress, lack of workplace support, repetitive tasks, prolonged use of screens/devices.

  • Lifestyle: Obesity, sedentary lifestyle, poor posture, and smoking.

 

Prognosis (Shearer et al., 2021; Kazeminasab et al., 2022):

  • Most individuals with neck pain recover within weeks to months, though some experience chronic or recurrent symptoms.

  • Negative Prognostic Factors:

    • High initial pain intensity and disability levels.

    • Psychological factors: Anxiety, depression, high pain catastrophizing, poor coping strategies, low recovery expectations.

    • Social and occupational factors: Job dissatisfaction, low social support, high physical job demands, repetitive or sustained neck postures.

    • Poor general health: Smoking, obesity, sleep disturbances, chronic pain conditions, poor self-rated health.

    • History of neck pain or previous injuries, such as whiplash.

11. Ongoing Follow-up

 

  • Adjust treatment plan: Continuously realign the treatment plan based on the patient’s evolving goals, feedback, clinical outcomes, and professional judgment.

  • Referral/co-management: Consider referring or co-managing the patient with other providers if there is no significant improvement within the established treatment timeline (e.g., 6-8 weeks).

12. Criteria for Discharge

 

  • Discharge criteria: Establish clear criteria, such as achieving initial goals, reaching a plateau in progress, or significant improvement/management of signs and symptoms.

  • ​Post-discharge planning: Discuss strategies for self-management and provide guidance on potential follow-ups or future care needs.

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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.

All content and media on the Canadian Chiropractic Guideline Initiative (CCGI) website is created and published online for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. Always seek the guidance of a qualified health professional with questions, concerns or management regarding your health.

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