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Neck Pain Care Pathway

Date of last update: September, 2024

About Neck Pain

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

Effective Management: 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. It is typically managed rather than cured, necessitating a comprehensive and individualized approach. Effective management is ethical, evidence-driven, transparent, flexible, and responsive to the person's needs. Essential interventions include education, reassurance that neck pain is typically of a limited-time nature, addressing psychosocial factors, maintaining daily activities, and self-care practices. Additional interventions are selected through shared decision-making, aiming to optimize function and participation. Continuous monitoring and assessment of outcomes ensure alignment with patient goals. Effective management can also occur through virtual or hybrid care.

About the Care Pathway

  • Principles: Based on recommendations drawn from established clinical guidelines, integrating the best available evidence, clinical expertise, and patient preferences. Treatment considerations are aligned with current guideline-supported practices. Developed with input from professional leaders, clinicians, and researchers.

 

  • Target Audience: Supports clinicians who deliver conservative care and informs those who do not but may see people with these conditions for referral or co-management. Provides essential, concise guidance on key steps of a clinical encounter, with access to detailed information by clicking on specific sections. Includes a downloadable one-page quick guide for quick access to key information.

 

  • Updates: Regular updates are communicated through social media to ensure users have current information. The care pathways are 'living' documents, reflecting the state of clinical practice and research evidence to our best knowledge at the time of development. They may be updated to ensure they remain current and evidence driven.

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

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

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).

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:

  • 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.

  • Core Interventions:

    • Education and reassurance: Provide clear information about the nature of neck pain (e.g., it is commonly a limited-time condition).

    • Address yellow flags (psychosocial factors): Incorporate strategies to mitigate fear-avoidance behaviours and other barriers to recovery.

    • Maintain activities of daily living: Encourage continued movement and activity as much as possible and avoidance of prolonged rest and neck collars.

    • Self-care: Provide recommendations for home-based exercise, balanced nutrition, good sleep hygiene, stress management, maintaining a healthy body weight, and avoiding smoking/substance abuse.

    • Engage in social and work activities: Encourage social and work activities as part of the rehabilitation process.

    • Exercise therapy: Tailored exercise programs to enhance strength, mobility, and aerobic capacity (the specific type of exercise may vary based on the individual).

 

  • Optional Interventions:

    • Manual therapy: E.g., spinal manipulation/mobilization, soft tissue techniques, massage.

    • Psychological support: Cognitive-behavioural therapy (CBT) or other forms of psychological support aimed at managing psychosocial contributors (e.g., anxiety, depression).

    • Mind-body interventions: E.g., mindfulness, meditation.

    • Multimodal care: E.g., combine exercise therapy and manual therapy.

    • Medications: Consult with a medical provider. Short-term use of medications for pain relief (e.g., analgesics, NSAIDs) may be considered after non-pharmacological treatments. Long-term use, especially of opioids and muscle relaxants, should be avoided.

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

 

 

 

 

 

 

Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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