35 Neck Pain

Neck Pain


Recent clinical guidelines published in the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) suggest a pragmatic approach to the management of neck pain. These guidelines describe four subcategories of neck pain: neck pain with limited motion, neck pain associated with whiplash, headaches related to neck pain, neck and nerve-related pain into the arm (also known as radicular pain) (Blandpied et al., 2017).


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g.’ low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Red Flags for Serious Spinal Pathology

Red flags are signs and symptoms that raise suspicion of serious underlying pathology, for patients with neck pain there are a number of serious spinal pathologies to be aware of, these are spinal fracture, malignancy, and spinal infection (Finucane et al., 2020).

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient-specific Functional Scale
  • Neck Pain and Disability Scale
  • Neck Disability Index

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

  • Vertebral Artery Test
  • Spurling’s Test (Foraminal Compression Test)
  • Cervical Distraction Test
  • Cervical Compression Test
  • Scalene Cramp Test
  • Adson’s Test
  • Halstead Maneuver (Reverse Adson’s Test or Wright’s Test or Hyperabduction Test)
  • Costoclavicular Test (Military Brace)
  • Upper Limb Tension Tests (1, 2, 3, & 4)



Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

Randomized controlled trials have demonstrated that compression at myofascial trigger points (MTrPs) significantly improved subjective pain scores compared with compression at Non-MTrPs and the control treatments for patients suffering from neck pain (Morikawa et al., 2017).

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating people suffering from neck pain may include neurovascular structures and investing fascia of:

  • Upper Cervical Spine (suboccipitals, upper trapezius, splenius cervicis, splenius capitis)
  • Levator Scapula
  • Longus Colli & Capitis
  • Rhomboid Minor and Major
  • Occipitofrontalis
  • Corrugator Supercilii
  • Sternocleidomastoid
  • Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)
  • Temporomandibular Joint
    • Medial Pterygoid
    • Temporalis
    • Masseter
    • Suprahyoid Muscle Group (digastric, stylohyoid, geniohyoid, and mylohyoid)
    • Infrahyoid Muscle Group (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as routine healthy sleeping habits, motor control, yoga/Pilates/Tai Chi/Qigong and strengthening exercises may be useful for people with chronic neck pain (de Zoete et al., 2020).


Clinical practice guidelines for neck pain support the need for a multidimensional therapeutic approach with consistent recommendations including universal provision of information and advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids (Chou et al., 2018). A multidimensional treatment approach can involve several management strategies that include but is not limited to education, reassurance, analgesic medicines and non-pharmacological interventions (Blandpied et al., 2017; Chou et al., 2018).

Massage Sloth: Neck Massage Tutorial

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for neck pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Bier, J. D., Scholten-Peeters, W., Staal, J. B., Pool, J., van Tulder, M. W., Beekman, E., … Verhagen, A. P. (2018). Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain. Physical therapy, 98(3), 162–171. doi:10.1093/ptj/pzx118

Blanpied, P. R., Gross, A. R., Elliott, J. M., Devaney, L. L., Clewley, D., Walton, D. M., … Robertson, E. K. (2017). Neck Pain: Revision 2017. The Journal of orthopaedic and sports physical therapy, 47(7), A1–A83. doi:10.2519/jospt.2017.0302

Bobos, P., MacDermid, J. C., Walton, D. M., Gross, A., & Santaguida, P. L. (2018). Patient-Reported Outcome Measures Used for Neck Disorders: An Overview of Systematic Reviews. The Journal of orthopaedic and sports physical therapy, 48(10), 775–788. doi:10.2519/jospt.2018.8131

Chou, R., Côté, P., Randhawa, K., Torres, P., Yu, H., Nordin, M., … Cedraschi, C. (2018). The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities. European spine journal, 27(Suppl 6), 851–860. doi:10.1007/s00586-017-5433-8

Cohen, S. P., & Hooten, W. M. (2017). Advances in the diagnosis and management of neck pain. BMJ (Clinical research ed.), 358, j3221. doi:10.1136/bmj.j3221

Cook, A. J., Wellman, R. D., Cherkin, D. C., Kahn, J. R., & Sherman, K. J. (2015). Randomized clinical trial assessing whether additional massage treatments for chronic neck pain improve 12- and 26-week outcomes. The spine journal, 15(10), 2206–2215. doi:10.1016/j.spinee.2015.06.049

Côté, P., Wong, J. J., Sutton, D., Shearer, H. M., Mior, S., Randhawa, K., … Salhany, R. (2016). Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European spine journal, 25(7), 2000–2022. doi:10.1007/s00586-016-4467-7

Côté, P., Yu, H., Shearer, H. M., Randhawa, K., Wong, J. J., Mior, S., … Lacerte, M. (2019). Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration. European journal of pain (London, England), 23(6), 1051–1070. doi:10.1002/ejp.1374

de Zoete, R. M., Armfield, N. R., McAuley, J. H., Chen, K., & Sterling, M. (2020). Comparative effectiveness of physical exercise interventions for chronic non-specific neck pain: a systematic review with network meta-analysis of 40 randomised controlled trials. British journal of sports medicine, bjsports-2020-102664. Advance online publication. https://doi.org/10.1136/bjsports-2020-102664

Farag, A. M., Malacarne, A., Pagni, S. E., & Maloney, G. E. (2020). The effectiveness of acupuncture in the management of persistent regional myofascial head and neck pain: A systematic review and meta-analysis. Complementary therapies in medicine, 49, 102297. https://doi.org/10.1016/j.ctim.2019.102297

Farrell, S. F., Smith, A. D., Hancock, M. J., Webb, A. L., & Sterling, M. (2019). Cervical spine findings on MRI in people with neck pain compared with pain-free controls: A systematic review and meta-analysis. Journal of magnetic resonance imaging: JMRI, 49(6), 1638–1654. doi:10.1002/jmri.26567

Finucane, L. M., Downie, A., Mercer, C., Greenhalgh, S. M., Boissonnault, W. G., Pool-Goudzwaard, A. L., Beneciuk, J. M., Leech, R. L., & Selfe, J. (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. The Journal of orthopaedic and sports physical therapy, 50(7), 350–372. https://doi.org/10.2519/jospt.2020.9971

Greening, J., Anantharaman, K., Young, R., & Dilley, A. (2018). Evidence for Increased Magnetic Resonance Imaging Signal Intensity and Morphological Changes in the Brachial Plexus and Median Nerves of Patients With Chronic Arm and Neck Pain Following Whiplash Injury. The Journal of orthopaedic and sports physical therapy, 48(7), 523–532. doi:10.2519/jospt.2018.7875

Kjaer, P., Kongsted, A., Hartvigsen, J., Isenberg-Jørgensen, A., Schiøttz-Christensen, B., Søborg, B., … Povlsen, T. M. (2017). National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy. European spine journal, 26(9), 2242–2257. doi:10.1007/s00586-017-5121-8

Morikawa, Y., Takamoto, K., Nishimaru, H., Taguchi, T., Urakawa, S., Sakai, S., … Nishijo, H. (2017). Compression at Myofascial Trigger Point on Chronic Neck Pain Provides Pain Relief through the Prefrontal Cortex and Autonomic Nervous System: A Pilot Study. Frontiers in neuroscience, 11, 186. doi:10.3389/fnins.2017.00186

Nakashima, H., Yukawa, Y., Suda, K., Yamagata, M., Ueta, T., & Kato, F. (2015). Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine, 40(6), 392–398. doi:10.1097/BRS.0000000000000775

Pico-Espinosa, O. J., Aboagye, E., Côté, P., Peterson, A., Holm, L. W., Jensen, I., & Skillgate, E. (2020). Deep tissue massage, strengthening and stretching exercises, and a combination of both compared with advice to stay active for subacute or persistent non-specific neck pain: A cost-effectiveness analysis of the Stockholm Neck trial (STONE). Musculoskeletal science & practice, 46, 102109. https://doi.org/10.1016/j.msksp.2020.102109

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Skelly, A.C., Chou, R., Dettori, J.R., Turner, J.A., Friedly, J.L., Rundell, S.D., … Ferguson, A.J.R. (2020). Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update. Agency for Healthcare Research and Quality (US). DOI: https://doi.org/10.23970/ AHRQEPCCER227

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Thomas, L., & Treleaven, J. (2020). Should we abandon positional testing for vertebrobasilar insufficiency?. Musculoskeletal science & practice, 46, 102095. https://doi.org/10.1016/j.msksp.2019.102095

Walton, D. M., & Elliott, J. M. (2017). An Integrated Model of Chronic Whiplash-Associated Disorder. The Journal of orthopaedic and sports physical therapy, 47(7), 462–471. doi:10.2519/jospt.2017.7455


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Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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