How to manage neck pain in general practice?

Management of Neck Pain in General Practice

For non-specific neck pain, first-line treatment should focus on education, self-management, and exercise, avoiding interventional procedures which are strongly recommended against by current guidelines. 1

Initial Assessment

• Screen for "red flags" that require urgent evaluation:

  • History of trauma, malignancy, prior neck surgery
  • Spinal cord injury symptoms
  • Systemic diseases (ankylosing spondylitis, inflammatory arthritis)
  • Suspected infection, IV drug use history
  • Intractable pain despite therapy
  • Tenderness over a vertebral body
  • Progressive neurological deficits 1

• Avoid routine imaging for non-specific neck pain without red flags

  • Imaging findings correlate poorly with symptoms 1
  • Degenerative changes are common in asymptomatic individuals 1

Evidence-Based Treatment Algorithm

Step 1: First-Line Treatments (0-6 weeks)

• Patient Education

  • Reassurance about favorable natural history (most acute episodes resolve within 2 months) 2, 3
  • Explanation that imaging is not necessary without red flags 1
  • Advice to maintain normal activities as tolerated

• Exercise Therapy (strongest evidence for effectiveness)

  • Progressive resistance exercises for neck and shoulders 1
  • Postural correction and scapular strengthening 4
  • Home exercise program with specific instructions 1

• Physical Modalities

  • Heat therapy for pain relief 1
  • Cold packs for acute pain/inflammation 1
  • Massage for short-term relief 1

Step 2: Additional Non-Pharmacological Options

• Manual Therapy (only in conjunction with exercise, not as standalone treatment) 1

  • Spinal manipulation or mobilization
  • Soft tissue techniques

• Behavioral Approaches

  • Breathing exercises and relaxation techniques 1
  • Cognitive interventions to enhance sense of control 1

Step 3: Pharmacological Management (short-term use only)

• NSAIDs for acute pain if no contraindications 1

  • Monitor for gastrointestinal, renal, and cardiovascular side effects
  • Use lowest effective dose for shortest duration

• Muscle Relaxants for acute pain with muscle spasm 1, 3

  • Short-term use only (3-7 days)
  • Caution regarding sedation and fall risk

• Avoid Opioids for chronic neck pain 1

  • Limited evidence for effectiveness
  • Risk of dependence and adverse effects

Step 4: For Persistent Pain (>6 weeks)

• Referral to Physical Therapy for structured rehabilitation program 2

  • Supervised progressive exercises
  • Manual therapy as adjunct to exercise

• Consider Complementary Approaches with moderate evidence:

  • Acupuncture 5
  • Yoga 5

What to Avoid

• Strong recommendation AGAINST interventional procedures for chronic neck pain 1:

  • Joint radiofrequency ablation
  • Epidural injections of local anesthetic, steroids, or combinations
  • Joint-targeted injections
  • Intramuscular injections of local anesthetic with/without steroids

• Avoid routine imaging unless red flags are present 1

  • Radiographic findings correlate poorly with symptoms
  • May lead to unnecessary interventions

• Avoid bed rest or prolonged activity restriction

  • May delay recovery and lead to deconditioning

Special Considerations

• For cervical radiculopathy:

  • Conservative management is first-line (most cases resolve spontaneously) 1
  • Consider MRI only after 6 weeks of failed conservative management 1
  • Referral to specialist if progressive neurological deficits 1

• For older adults:

  • Exercise programs should be tailored to functional capacity
  • Greater caution with NSAIDs due to increased risk of adverse effects

Monitoring and Follow-up

• Reassess after 2-4 weeks of initial treatment
• If symptoms persist beyond 6 weeks with appropriate conservative care, consider:
  • Reassessment for missed red flags
  • Psychosocial factors that may impede recovery
  • Referral to specialist for persistent radicular symptoms

The evidence clearly shows that simple, non-invasive approaches focusing on education, exercise, and appropriate short-term pain management are most effective for neck pain in general practice, while interventional procedures should be avoided.