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Neck Pain Care Pathway

Date of last update: August, 2024

3. Health History

 

Taking a patient's history is about forging a therapeutic relationship. Actively and empathetically listening to the patient's story offers insights into their condition and its optimal approach to management.

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Clinicians should exercise judgment during history-taking. Adopting cultural awareness and principles of trauma-informed care could help minimize potential barriers. This might involve reframing questions from "what's wrong with you" to "what happened". This might also involve explaining the rationale behind sensitive questions or tests.

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While history-taking needs to be thorough, it does not need to be linear. Certain topics like prior episodes of neck pain, past care experiences, and recovery expectations are crucial but can be addressed at different times during the patient encounter.

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When re-evaluating existing patients, especially those with new complaints, a thorough clinical examination is as imperative as with new patients. Explore the new issue's onset, duration, and associated factors, and gauge its impact on pre-existing conditions and treatments.

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Meaningful Outcomes:

• Incorporating outcome measures before treatment and reviewing them regularly ensures that care remains patient-centered and evidence-driven. This allows for adapting the management plan to achieve the best possible results. Selected outcome measures should align with the patient’s goals and expectations.

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 jurisidictional 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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