Neck Pain Care Pathway

Interventions Not Consistently Supported by Guidelines:

• Needling therapies and electrotherapies (e.g., TENS, IFC, low-level laser) have limited or mixed evidence for benefit or harm.

• These interventions may be considered as adjuncts through shared decision-making with patients.

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​​​Examples

Example 1: Common Chronic Neck Pain (Mechanical or Strain/sprain)

 

Patient Presentation: A patient presents with chronic neck pain persisting for more than 12 weeks, localized below the nuchal line and above the shoulders, with occasional referred pain across the shoulder blades. The pain is sharp and dull, aggravated by prolonged sitting and computer use.

 

1. Education and Reassurance:

   • Frequency: Initial visit and reinforced in follow-up visits.

   • Protocol: Provide a clear explanation of the condition, expected course with treatment (may be 6-12 weeks), and encourage the patient to stay active. Use visual aids or pamphlets for better understanding.

2. Maintain Activities of Daily Living:

   • Frequency: Daily.

   • Protocol: Encourage the patient to continue with normal activities as much as possible, avoiding prolonged bed rest. Provide specific instructions on safe movements and ergonomics.

3. Self-Care Practices:

   • Frequency: Daily.

   • Protocol: Recommend a home exercise program focused on stretching and strengthening exercises tailored to the patient's abilities and pain levels. Advise on proper nutrition, adequate sleep, and stress management techniques.

4. Address Yellow Flags (Psychosocial Factors):

   • Frequency: Regularly, integrated into each visit.

   • Protocol: Identify and address psychosocial factors such as fear of movement, depression, or anxiety. Use cognitive-behavioral strategies to modify negative beliefs about pain.

 

1. Manual Therapy:

   • Frequency: Six sessions over 8 weeks. A second course may be indicated if the patient demonstrates ongoing and significant improvement according to their goals.

   • Protocol: Spinal manipulation/mobilization and soft tissue techniques to relieve pain and improve mobility. Adjust techniques based on the patient's response.

2. Exercise Therapy:

   • Frequency: 3 times per week for up to 20 weeks. Supervised 0-2 times per week for up to 12 weeks.

   • Protocol: Include 20-minute sessions of a combination of aerobic exercises (e.g., walking), and strengthening exercises. Sessions may be supervised initially.

3. Electromodalities (e.g., TENS, IFC, low-level laser):

   • Frequency: 2-3 times per week.

   • Dose: Utilize Transcutaneous Electrical Nerve Stimulation (TENS), Interferential Current Therapy (IFC), or low-level laser therapy to provide temporary pain relief and comfort. Use in conjunction with other interventions.

4. Medications:

   • Frequency: As needed.

   • Protocol: Over-the-counter NSAIDs or acetaminophen for pain relief, used judiciously and in combination with other treatments. Consider muscle relaxants if indicated.

5. Psychological Support:

   • Frequency: Weekly or as needed.

   • Protocol: Cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and other techniques to manage chronic pain and improve mental health.

Follow-Up:

• Regular follow-up at each visit. Reassess pain levels, functional status, and goal achievement every 2-4 weeks and adjust the treatment plan as necessary.

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Example 2: Neck Pain with Radiculopathy (Disc Protrusion/Herniation)

 

Patient Presentation: A patient presents with neck pain radiating down the arm, often to the hand, following a specific dermatomal pattern. The pain is sharp and shooting, exacerbated by bending the head forward.

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1. Education and Reassurance:

   • Frequency: Initial visit and reinforced in follow-up visits.

   • Protocol: Explain the nature of radiculopathy, expected course (may be 4 weeks to 12 weeks), and encourage active participation in the treatment plan. Use visual aids (e.g. diagrams, models, digital resources) to illustrate the condition.

2. Maintain Activities of Daily Living:

   • Frequency: Daily.

   • Protocol: Encourage modified activities to avoid exacerbating the symptoms while staying active. Provide guidance on ergonomics and safe movement strategies.

3. Self-Care Practices:

   • Frequency: Daily.

   • Protocol: Tailored home exercise program focusing on nerve mobilization exercises, gentle stretching, and strengthening. Include lifestyle advice on proper posture, nutrition, and sleep.

4. Address Yellow Flags (Psychosocial Factors):

   • Frequency: At each visit.

   • Protocol: Identify and address factors such as fear of movement, poor recovery expectations, depression, anxiety, work-related or family issues, litigation or compensation claims, and maladaptive coping mechanisms. Provide appropriate reassurance, counseling, or referrals to mental health professionals as needed.

 

1. Manual Therapy:

   • Frequency: Six sessions over 8 weeks. A second course may be indicated if the patient demonstrates ongoing and significant improvement according to their goals.

   • Protocol: Spinal mobilization techniques to alleviate pain and improve function. Techniques should be adjusted based on patient response and pain levels.

2. Exercise Therapy:

   • Frequency: Daily for 6 weeks. Supervised 4 times in the first 6 weeks.

   • Protocol: Include specific exercises to relieve nerve tension (e.g., directional exercises), core stabilization, and aerobic conditioning. Begin with supervised sessions and transition to the home program.

3. Electromodalities (e.g., TENS, IFC, low-level laser):

   • Frequency: 2-5 times per week for 3 weeks.

   • Protocol: Utilize TENS, IFC, or low-level laser therapy to provide temporary pain relief and comfort. Use as an adjunct to other therapies.

4. Medications:

   • Frequency: As needed.

   • Protocol: NSAIDs or acetaminophen for pain management, possibly combined with muscle relaxants for short-term relief of acute symptoms.

5. Psychological Support:

   • Frequency: Weekly or as needed.

   • Protocol: Cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and other techniques to manage chronic pain and improve mental health.

Follow-Up:

• Regular follow-up at each visit. Reassess pain levels, functional status, goal achievement every 2-4 weeks and adjust the treatment plan as necessary.