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Neck Pain Care Pathway

Date of last update: August, 2024

4. Differential Diagnosis Requiring Medical Attention

 

Red Flags: Immediate Referral to Emergency Care:

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1. Cervical Myelopathy

  • Pain Location: Neck pain may or may not be present.

  • Signs/Symptoms/Red Flags: Wide-based disturbances, hand clumsiness, non-dermatomal numbness or weakness in upper and lower extremities, bowel/bladder dysfunction.

  • Physical and Neurological Examination: Hyperreflexia, hypertonia, pathological reflexes, finger escape sign, lower extremity weakness, positive L’Hermitte sign.

  • Action: Immediate referral to emergency care.

 

2. Meningitis

  • Pain Location: Neck stiffness, generalized headache.

  • Signs/Symptoms/Red Flags: Severe headache worse with neck flexion, fever, vomiting, rash, altered mental status, lethargy or drowsiness, photophobia, flexed hip and knee posturing.

  • Physical and Neurological Examination: Positive Brudzinski sign, positive Kernig sign.

  • Action: Immediate referral to emergency care.

 

3. Spinal Infection

  • Pain Location: Neck pain and stiffness.

  • Signs/Symptoms/Red Flags: Progressive or constant pain, pain worse at night, unexplained constitutional symptoms (e.g. fever/chills), immunosuppression, recent infection or surgery, TB (tuberculosis) history, IV drug use, poor living conditions.

  • Physical and Neurological Examination: Tenderness on palpation or tap test, possible redness or heat.

  • Action: Immediate referral to emergency care.

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4. Intracranial/Brain Lesion

  • Pain Location: Headache, may or may not be accompanied by neck pain.

  • Signs/Symptoms/Red Flags: Sudden intense generalized headache (thunderclap); unexplained headache, dizziness, or visual changes; aggravated by coughing or straining; worse in the morning or after prolonged recumbency; possible vomiting or focal neurological signs.

  • Physical and Neurological Examination: Headache provoked by forward bending; possible cranial nerve abnormalities, papilledema, motor and sensory deficits in limbs, positive Romberg test (coordination and balance issues), signs of increased intracranial pressure (e.g., Cushing’s triad – hypertension, bradycardia, irregular respirations).

  • Action: Immediate referral to emergency care.

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5. Vertebral/Carotid Artery Dissection

  • Pain Location: Neck pain, may or may not be accompanied by headache.

  • Signs/Symptoms/Red Flags: Severe neck pain or headache (“worst pain ever”); double vision, difficulty swallowing, speaking, walking; dizziness, drop attacks, facial numbness, nausea, nystagmus.

  • Physical and Neurological Examination: Facial sensory deficits, contralateral trunk sensory deficits, focal neurological signs.

  • Action: Immediate referral to emergency care.

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6. Traumatic Fracture

  • Pain Location: Localized pain in the neck.

  • Signs/Symptoms/Red Flags: Sudden onset of severe pain following trauma, age ≥65 years, dangerous mechanism (e.g., pedestrian struck, high-speed collision), extremity weakness/tingling/burning, inability to rotate neck 45° left and right, midline cervical spine tenderness.

  • Physical and Neurological Examination: Point tenderness over the affected vertebra, extremity neurological signs (weakness/tingling/burning).

  • Action: Immediate referral to emergency care.

 

Refer to Medical Provider:

 

1. Non-traumatic Spinal Fracture

  • Pain Location: Localized pain in the neck.

  • Signs/Symptoms: Sudden onset, severe pain, osteoporosis, corticosteroid use, female sex, age >60 years, history of spinal fracture or cancer.

  • Physical and Neurological Examination: Point tenderness over the affected vertebra, inability to rotate neck 45° left and right, possible extremity neurological signs (weakness/tingling/burning).

  • Action: Referral to appropriate medical provider.

 

2. Spinal Malignancy

  • Pain Location: Severe, progressive, localized neck pain.

  • Signs/Symptoms: History of cancer; persistent pain, worse at night, not relieved by rest, constitutional symptoms (night sweats, unexplained weight loss, fatigue, fever).

  • Physical and Neurological Examination: Localized tenderness, possible neurological deficits.

  • Action: Referral to appropriate medical provider.

 

3. Inflammatory Arthritides

1. Spondyloarthropathies (e.g., ankylosing spondylitis, psoriatic arthritis, reactive arthritis):

  • Pain Location: Neck pain, may radiate to shoulders and upper back.

  • Signs/Symptoms: Morning stiffness >1 hour, pain improves with activity, pain worse at night, presence of other inflammatory signs (e.g., uveitis, psoriasis), systemic symptoms (fatigue, weight loss, fever).

  • Physical Examination: Possible reduced neck mobility, tenderness over cervical spine and other joints.

  • Action: Referral to appropriate medical provider.

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2. Rheumatoid Arthritis

  • Pain Location: Diffuse joint pain including the neck.

  • Signs/Symptoms: Symmetrical joint pain, morning stiffness >1 hour, systemic symptoms (fatigue, weight loss, fever).

  • Physical Examination: Joint swelling, tenderness, and deformity.

  • Action: Referral to appropriate medical provider.

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3. Systematic Lupus Erythematosus (SLE)

  • Pain Location: Can include neck and other joints.

  • Signs/Symptoms: Joint pain and swelling, fatigue, butterfly-shaped rash on the face, photosensitivity, systemic symptoms (fatigue, weight loss, fever).

  • Physical Examination: Joint tenderness and swelling, skin rashes, signs of organ involvement such as kidney issues or pleuritis.

  • Action: Referral to appropriate medical provider.

1. Record Keeping

  • Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).

  • Adhere to jurisdictional standards.

2. Informed Consent

  • Document verbal consent for health history taking, physical examination, contact in sensitive areas.

  • Obtain written consent for treatment.

  • Adhere to jurisdictional standards.

3. Health History

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

  • Sociodemographic: Age, gender, sex.

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

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

  • Health, lifestyle, family, social, and occupational 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, isolation.

  • Previous treatments and responses: Effectiveness and any adverse events.

  • Beliefs and expectations: Understanding of their condition, treatment expectations.

  • Red, yellow, and orange flags (sections 4 – 6).

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Meaningful Outcomes:

4. Differential Diagnosis Requiring Medical Attention

 

ACTION: Refer to emergency care immediately for red flags:

  • Cervical Myelopathy: Gait disturbances, hand clumsiness, non-dermatomal numbness, lower extremity numbness or weakness, bowel or bladder dysfunction.

  • Meningitis: Neck stiffness, severe headache worsening with neck flexion, fever, vomiting, rash, altered mental status, photophobia.

  • Spinal Infection: Immunosuppression, recent infection or surgery, TB (tuberculosis) history,  unexplained constitutional symptoms (e.g., fever/chills), IV drug use, poor living conditions.

  • Intracranial/Brain Lesion: Sudden intense headache (thunderclap); unexplained headache, dizziness, or visual changes.

  • Vertebral/Carotid Artery Dissection: Severe neck pain or headache (“worst pain ever”), double vision, difficulty swallowing, facial numbness, difficulty walking, drop attacks, nausea, nystagmus.

  • Traumatic Spinal Fracture: Age ≥65 years, dangerous mechanism (e.g., pedestrian struck, high-speed motor vehicle collision, rollover, ejection from motor vehicle, fall from elevation ≥3 feet or 5 stairs, axial load to head), extremity weakness/tingling/burning, inability to actively rotate neck 45° left and right, midline cervical spine tenderness (Canadian C-Spine Rule).

 

ACTION: Refer to appropriate medical provider:

  • Non-traumatic Spinal Fracture: Sudden severe pain, osteoporosis, corticosteroid use, female sex, age >60, spinal fracture/cancer history.

  • Spinal Malignancy: Progressive pain, cancer history, constitutional symptoms (e.g., fatigue, weight loss, night pain), progressive headache worse with exertion.

  • Inflammatory Arthritides (e.g., spondyloarthropathies, rheumatoid arthritis, systemic lupus erythematosus): Morning stiffness >1 hour, systemic symptoms (e.g., fatigue, weight loss, fever), symmetrical joint pain, joint swelling/deformity, skin lesions.

5. Psychiatric Disorders (Orange Flags)

  • Symptoms of major depression, personality disorders, PTSD, substance addiction and abuse.

  • Screening tools: PHQ-9,  GAD-7.

  • Action: Refer to appropriate provider/psychiatric specialist.

6. Psychosocial Factors (Yellow Flags)

  • Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims, maladaptive coping mechanisms.

  • Screening tools: PHQ-9,  GAD-7, FABQ, ORT, PCS.

  • Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.

7. Physical Examination

  • Observation: Abnormalities, asymmetries, posture, balance, gait, movements, facial expression.

  • Range of Motion: Active, passive, resisted (flexion, extension, lateral flexion, rotation).

  • Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.

  • Neurological Examination: Motor strength, sensory and reflex testing (C5, C6, C7, C8, T1); upper and lower motor neuron signs; cranial nerves screening (including facial numbness; facial movements such as smile, tongue deviation, eye movements).

  • Special/Orthopedic Tests: Select as appropriate based on clinical judgment.

  • Advanced Diagnostics: Radiography is not routinely recommended in the absence of red flags or other specific individual factors (e.g., potential contraindications to treatment).

8. Diagnostic Criteria for Neck Pain Amenable to Conservative Care

A. 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):

  • Pain: Arising below the nuchal line and above the cervicothoracic junction.

  • Signs/Symptoms: Sharp, dull, shooting, or aching pain; aggravated by specific movements; associated muscle stiffness or spasms; may include head, trunk or arm pain.

  • Exam: Pain reproduced by tests; no neurological deficits.

 

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

  • Pain: Neck pain radiating down the arm.

  • Signs/Symptoms: Sharp, shooting, or burning pain; numbness, tingling, weakness associated with a nerve root.

  • Exam: Positive tests (e.g., Spurling’s, Bakody, cervical distraction, upper limb tension tests); sensory deficits, muscle weakness, altered reflexes.

9. Treatment Considerations for Neck Pain Amenable to Conservative Care

(Common neck pain, neck pain with radicular pain/radiculopathy from disc pathology and WAD III)

After providing a report of findings and obtaining written informed consent.

  • Essential Interventions:

    • Education and reassurance

    • Encouragement to maintain activities of daily living

    • Address yellow flags (psychosocial factors)

    • Self-care (exercise, nutrition, sleep, stress management, healthy body weight, no smoking/substance abuse)

    • Engage in social and work activities

 

  • Optional Interventions (with Rationale and Shared Decision Making):

    • Exercise therapy

    • Manual therapy (e.g., spinal manipulation/mobilization, soft tissue techniques, clinical or relaxation massage)

    • Electrotherapies (e.g., low-level laser therapy)

    • Medications (e.g., acetaminophen, ibuprofen/prescription). Discuss options/risks with medical provider.

    • Psychological or social support

    • Mind-body interventions (e.g., mindfulness, meditation)

    • Needling therapies

    • Multicomponent biopsychosocial care (e.g., exercise therapy, cognitive behavioural therapy, structured education and social support)

10. Prognosis

  • Recovery: Most people recover, but neck pain can recur or persist.

  • Negative Prognostic Factors: Smoking, obesity, higher initial pain and disability levels, poor recovery expectations, mental health issues, arm pain, work-related factors, previous neck pain.

11. Ongoing Follow-up

  • Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgement.

  • Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).

12. Criteria for Discharge

  • Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).

  • ​Discuss post-discharge plans, including self-management strategies and potential follow-ups.

References 

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Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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