If NO Red Flags, continue with CORE Neck Tool Cardiovascular pathology (carotid arterial dissection, concurrent chest pain, myocardial ischemia) can present with neck and shoulder pain.
CORE Neck and Headache Navigator
This is a focused examination for clinical decision-making in primary care. This tool guides primary care providers to recognize common mechanical neck pain and screen for other conditions where management may include investigations, exercise referrals and specific medications. Mechanical neck pain can present with neck, shoulder and/or arm pain. If your patient has an accompanying headache, it is recommended that you treat the headache symptoms first using the Headache Navigator.
If NO Yellow Flags, continue with CORE Neck Tool
A patient with positive Yellow Flag(s) may benefit from education, support and targeted therapies to reduce risk of chronicity and could be screened for psychological conditions (e.g. anxiety, depression). Consider the following resources to support assessment and management of risk factors for chronicity; The Patient Health Questionnaire for Depression and Anxiety (PHQ-4)7; Pain Self Efficacy Questionnaire (PSEQ).8
Headache navigator
The Headache Navigator assists primary care providers in managing primary headache disorders. It is based on the guideline and quick reference algorithm for the Primary Care Management of Headache in Adults produced by Towards Optimized Practice (TOP).
Headache navigator red flags
CORE Neck: Physical examination New
This is an examination which supports or refutes the differential diagnosis while assessing the severity of symptoms for prognosis
and treatment planning. This examination should take 5 minutes of the clinical assessment. The examination has been developed for
primary care providers.
Standing position
Observation
- Giat
- Neck posture
Sitting position
Palpation
- Lymph Node Screen
Movement
- Neck screen
- Cervical Active ROM
- Flexion
- Extension
- Rotation
- Side flexion
- Cervical Active ROM
- Shoulder screen
- Active ROM
Neurological
- Deep tendon reflexes
- Biceps (C5, 6)
- Triceps (C7)
- Myotomes
- C4 – Trapezius
- C5 – Deltoid
- C6 – Biceps
- C7 – Triceps
- C8 – 3rd fingers flexion
- Dermatomes
- C4 – Trapezius
- C5 – Over the shoulder
- C6 – Thumb and part of the forearm
- C7 – Middle finger
- C8 – Smallest fingers and part of the forearm
Radiculopathy
Supine position
- Cervical Distraction Test 15 (Positive if arm pain relieved)
- Upper Motor Neuron Screen
Talking points
If there are no Red flags
“Your examination today does not demonstrate that there are any Red flags present to indicate serious pathology, but if your symptoms persist for >6 weeks, schedule a follow-up appointment.”
CORE Neck: Management
Non-pharmacological options10,16
Neck dominant pain
Acute (<3 months)
Recommended
Patient education and exercise should be included as part of active management and may be delivered solely within primary care office visit.
- Reassurance of good prognosis and full recovery
- Early return to non-painful activities of daily living and work
- Independent stretch, strengthen and aerobic exercise
- Refer to active therapy if education and exercise does not alleviate symptoms.
Treatment may include:
- Short-term cervical mobilization/manipulation
- Cervical stretching and strengthening exercise
- Endurance and balance exercise
- Short term mechanical cervical traction as adjunct treatment for pain relief
Recommended number of treatment sessions = 1-6
Not Recommended
There is inconclusive evidence for the following:
- Rest and immobilization
- Cervical collars
- Neck pillows
- Electrical modalities
- Relaxation massage
Chronic (>3 months)
Recommended
Multimodal therapy and/or goal directed therapy including:
- Patient education and counselling with reassurance for good recovery and encouragement for increased activity levels
Active Rehabilitation therapy may include:
- Short term cervical mobilization/ manipulation
- Cervical stretching, strengthening and aerobic exercise
- Therapeutic clinical massage
- Low level laser therapy
Recommended number of treatment sessions = 6-12 sessions
Not Recommended
There is inconclusive evidence for the following:
- Rest and immobilization
- Strengthening exercises in isolation from other treatment
- Relaxation therapy or relaxation massage
- Electro-acuptuncure
- Cervical collar/neck Pillow
- Mechanical or Manual Traction
Arm dominant pain
Acute (<3 months)
Recommended
In addition to the above treatment regimes for neck dominant pain, patients with arm dominant pain may find additional relief with the following:
- Relieving positions (arm abduction and supported elevation)
- Frequent rest positions
- Manual and Mechanical traction
- Enhance Pharmacological pain management including use of opioids in conjunction with nonpharmacological treatment.
Not Recommended
There has been no proven effectiveness of the following:
- Cervical collars
- Electrical modalities
- Relaxation massage
Chronic (>3 months)
Recommended
In addition to the above treatment regimes for neck dominant pain, patients with arm dominant pain may find additional relief with the following:
- Trial of Acupuncture
- Relieving positions (arm abduction and supported elevation
- Frequent rest positions
- Manual and Mechanical traction
- Enhance Pharmacological pain management including use of opioids in conjunction with nonpharmacological treatment.
Not Recommended
There has been no proven effectiveness of the following:
- Cervical Collars
- Electrical Modalities
- Relaxation Massage
Pharmacological options9,10,16,18
Neck dominant pain
Acute (<3 months)
Recommended
Start with:
- Acetaminophen
- NSAIDs
Add or replace with
- Muscle relaxants (e.g. cyclobenzaprine) for a short duration (few weeks)
Not Recommended
Routine use of opioids:
- Consider judicious use in select patients if other options fail.
- Glucocorticoids for mechanical neck pain.
Inconclusive
- Topical NSAIDs
Chronic (>3 months)
Recommended
Start with:
- Acetaminophen
- NSAIDs
Add or replace with
- Antidepressants
- TCAs (amitriptyline, nortriptyline)
- SNRI (duloxetine, venlafaxine)
- Antiepileptics
- Topiramate
- Pregablin
- Gabapentin
Not Recommended
Routine use of opioids:
- Consider judicious use in select patients if other options fail (please refer to the Canadian Guideline for the safe and effective use of opioids for chronic non cancer pain)19
- SSRIs
- Glucocorticoids for mechanical pain
- Muscle relaxants
Inconclusive
- Topical NSAIDs
Arm dominant pain
Acute (<3 months)
Recommended
Start with:
- Acetaminophen
- NSAIDs
- Opioids for select patients19
- Muscle relaxants (e.g cyclobenzaprine) – short duration 2 weeks
Add or replace with
- Antidepressants
- TCA
- SNRI
- Antiepileptics
- Carbamazepine
- Gabapentin
- Pregablin
For severe radiculopathy consider methylpredinisolone or dexamethasone for 5-7 days.
- Caution in patients with concurrent infections or in type 1 diabetics with a large swing in blood sugars.
Chronic (>3 months)
Recommended
Start with:
- Acetaminophen
- NSAIDs
- Opioids for select patients19
Add or replace with
- Antidepressants
- TCA
- SNRI
- Antiepileptics
- Carbamazepine
- Gabapentin
- Pregablin
CORE Neck: Referrals
Rehabilitation Referral provided to Patient
Patient readiness criteria for spine therapy:
- Absence of red flags
- Pain is managed well and patient can tolerate treatment regime16
- Pain has mechanical directional preference indicated by movement, position or activity
- Patient is ready to be an active partner in goal setting and self-management
Rehabilitation therapist skills for evidence-based treatment include:
- Ability to prescribe and progress exercise20
- Ability to modify, assess and treat limitations pertaining to work, home or fitness pursuits
- Ability to provide manipulative and soft tissue therapy including massage, mobilizations, myofascial release techniques, contract-relax muscle work16,20
- Ability to provide education and facilitate patient self-management20
Surgical Referral
- Failure to respond to evidence based compliant conservative care of at least 12 weeks
- Intolerable constant arm dominant pain
- Worsening nerve irritation tests (Spurling’s compression test)
- Expanding motor, sensory or reflex deficits
- Suspected cervical myelopathy
Pain Management Referrals9,10,18
Consider a referral to the pain management options listed in the table below, if the following criteria are met:
- The recommended non- pharmacological and pharmacological options have been trialed with reasonable compliance for a minimum of 4 weeks.
- And one or more of the following:
- The patient has high constant pain levels interfering with their function despite treatment
- The patient requires escalating/high doses of opioids
Talking points
Pain management and referral
- “You may need pain medication to help you return to your daily activities and initiate exercise more comfortably. It is activity; however, and not the medication that will help you recover more quickly.”20
- Short acting opioid medication may be used for intense pain such as neck dominant constant symptoms related to nerve compression.”9,21
- “Neck pain often recurs. You can learn how to manage neck pain when it happens and use this information to recover without having to see your healthcare provider each time it happens.”
- “Movement and activity can help reduce pain and recover function.”20
Headache navigator
The Headache Navigator is designed to provide guidance to primary care providers in an office based setting to manage primary
headache disorders (e.g. migraine, cluster, tension type headache).
It does not provide guidance for:
- Secondary headaches (e.g. cervicogenic headaches, post-traumatic headaches, temporomandibular joint disorder).
- Combined assessment and management of headache and neck pain due to the complexity of separating out the underlying pathologies. Use the Headache Navigator to start in assessing and managing the headache elements while also seeking early consultation with a headache specialist.
Neuro-Imaging
- Do not refer patients for routine neuro-imaging (CT and MRI) for the assessment of primary headaches.
- Do not refer patients for neuro-imaging solely to reassure patients.
- Do reassure and educate patients about neuro-imaging. Consider using patient education tools if necessary. Use patient education resources (general headache information)
- Refer to the imaging recommendations in the tool for a quick summary. For more detailed guidance refer to the full Guideline for the Primary Management of Headache in Adults.
Headache Management Highlights
- Screen for red flags in new onset headaches or changes to headaches.
- Acute management of cluster headaches should include the use of intranasal and subcutaneous triptans rather than NSAIDs and
- acetaminophen.
- • Migraine prophylaxis can include topiramate, amitriptyline, propranolol, acupuncture and/or riboflavin.
- • Do not recommend first line or routine use of opioid based medications for the management of acute migraine, tension type and
- cluster headaches. – Use patient education resources to reassure patients (treating frequent headaches with pain relievers).
- • Consider medication overuse headache in patients who have chronic daily headaches (≥ 15 days a month for 3 months) that may be
- related to chronic migraine or chronic tension type headaches. See TOP guidelines for detailed guidance. – Headache diaries can help to monitor, prevent and diagnose (see supporting materials) – Use patient education resources to help reassure patients (medication overuse headache)
- Migraine is the most common headache type and should be considered in patients with recurrent moderate or severe headaches and a normal neurological examination.
- Rule out secondary headache when making a diagnosis of a primary headache disorder.
- Neuroimaging, sinus x-rays, cervical spine x-rays, and EEG are not recommended for the routine assessment of the patient with headache. History and physical / neurological examination is usually sufficient to make a diagnosis of migraine or tension-type headache.
- Comprehensive migraine therapy includes management of lifestyle factors and triggers, acute and prophylactic medications, and migraine self-management strategies.
- ASA, acetaminophen, NSAIDs, and triptans are the primary medications for acute migraine treatment.
Do not:
- Prescribe opioid analgesics or combination analgesics containing opioids or barbiturates as first line therapy for the treatment of migraine.
- Prescribe acute medications or recommend an overthe-counter analgesic for patients with frequent migraine attacks without monitoring frequency of acute medication use with headache diary.
- Offer opioids for the acute treatment of tension-type headache.
- Offer paracetamol, NSAIDs, opioids, ergots or oral triptans for the acute treatment of cluster headache.
- Medication overuse is considered present when patients with migraine or tension-type headache use combination analgesics, opioids, or triptans on 10 or more days per month or acetaminophen or NSAIDs on 15 or more days a month.
Migraine pharmacological management
These recommendations are systematically developed statements to assist practictioner and patient decisions about appropriate health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making. Refer to full guideline for migraine treatment in pregnancy.
- Imaging is not recommended if neurological exam is normal.1,5
- Acute Medication
- Monitor for medication overuse
- Prophylactic medication if headache:
- >3 days/month and acute medication not effective; OR
- >8 days/month (risk of overuse); OR
- Disability despite acute medication
- If the patient’s headaches continue to interfere with function and activity after a trial of multiple treatment options consider the following:
- Referral to headache specialist
- Consider using the CORE Neck tool if the patient has significant neck pain as well.
Pharmacological management
Acute migraine medication
scroll (left-right) for details
Prophylactic migraine medication
Titration
Dosage may be increased every two weeks to avoid side effects. For most drugs, slowly increase to target dose
- Therapeutic trial requires several months
- Expected outcome is reduction, not elimination of attacks
- If target dose not tolerated, try lower dose
- If med is effective and tolerated, continue for at least 6 mos.
- If several preventive drugs fail, consider specialist referral
1st line scroll (left-right) for details
2nd line scroll (left-right) for details
Other scroll (left-right) for details
Over the countre scroll (left-right) for details
Abbreviations: hs – at bedtime; bid – twice a day; tid – three times a day
Adapted with permission from: Towards Optimized Practice. Guideline for primary care management of headache in adults. Edmonton, AB: Towards Optimized Practice. 2012 July. Available from: www.topalbertadoctors.org
Behavioral management
- Headache diary: record frequency, intensity, triggers and medication
- Adjust lifestyle factors: reduce caffeine, ensure regular exercise, avoid irregular and/or inadequate sleep or meals
- Stress management: relaxation, training, CBT,pacing activity, biofeedback
Tension type headache management
These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
- Imaging is not recommended if neurological exam is normal.1,5
- Acute medication
- Monitor for medication overuse
- Prophylactic medication if disability despite acute medication
- If the patient’s headaches continue to interfere with function and activity after trial of multiple treatment options consider the following:
- Referral to headache specialist.
- Consider using the CORE Neck tool if the patient has significant neck pain as well.
Pharmacological management
Acute medication
Prophylactic medication
scroll (left-right) for details
Adapted with permission from: Towards Optimized Practice. Guideline for primary care management of headache in adults. Edmonton, AB: Towards Optimized Practice. 2012 July. Available from: www.topalbertadoctors.org
Behavioral management
- Headache diary: record frequency, intensity, triggers and medication
- Adjust lifestyle factors: reduce caffeine, ensure regular exercise, avoid irregular and/or inadequate sleep or meals
- Stress management: relaxation, training, CBT,pacing activity, biofeedback
Cluster headache management
These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.
- Management primarily pharmacological
- Acute medication
- Prophylactic medication
- Early specialist referral recommended
- If considering neuroimaging choose MRI.1,5
Pharmacological management
Acute medication
Prophylactic medication
scroll (left-right) for details
NOTE: If more than two attacks per day, consider transitional therapy while verapamil is built up (e.g. prednisone 60 mg for 5 days, then reduced by 10 mg every 2 days until discontinued)
Adapted with permission from: Towards Optimized Practice. Guideline for primary care management of headache in adults. Edmonton, AB: Towards Optimized Practice. 2012 July. Available from: www.topalbertadoctors.org
Supporting materials
CORE Neck resources
- Opioid Risk Tool: This tool identifies patients who may be at risk for opioid dependency so that appropriate medication management can be planned.
- The Keele STarT Back Screening Tool: This screening tool categorizes patients by risk of persistent symptoms (low, medium or high), which allows the clinician to tailor interventions appropriately.
- Neck Pain Information and Exercise Sheet: The exercise sheet includes images to help identify correct and incorrect posture positions, and lying positions, as well as flexion/ extension, rotation, side flexion, and retraction exercises.
Headache navigator resources
- Headache Diary Sheets: These can be completed by patients to help with headache diagnosis.
Patient Education Resources
- General headache information: A resource that provides answers to patients’ commonly asked questions about headache.
- Medication overuse headache: A resource that provides answers to patients’ commonly asked questions about medication overuse headache.
- Acute migraine management: A resource that provides answers to patients’ commonly asked questions about migraine management.
- Migraine prophylaxis: A resource that provides answers to patients’ commonly asked questions about migraine preventive medications.
- Tension headache management: A resource that provides answers to patients’ commonly asked questions about managing tension-type headaches.
- Treating frequent headaches with pain relievers: Provides tips to help manage frequent headaches and discourages patients from taking pain relievers too often.
References
CORE Neck
- [1]
Kopjar B, Tetreault L, Kalsi-Ryan S, Fehlings M. Psychometric properties of the modified Japanese orthopaedic association scale in patients with cervical spondylotic myelopathy. Spine. 2014. 40(1): E23-28.
- [2]
Hall H. Effective spine triage: Patterns of pain. Ochsner J. 2014 Spring; 14(1): 88-95.
- [3]
Stiell IG, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct; 286(15):1841-8
- [4]
Concussions Ontario [Internet]. 2015 [cited 2016 May 30]. Available from: http://concussionsontario.org/
- [5]
British Columbia Ministry of Health, British Columbia Medical Association. Rheumatoid arthritis: diagnosis, management and monitoring [Internet]. 2012 Sep [cited 2016 Mar 8]. [Figure], Differentiate inflammatory from non-inflammatory arthritis; p. 2. Available from: http://www2.gov.bc.ca/gov/content/health/practitionerprofessional-resources/bc-guidelines/rheumatoid-arthritis
- [6]
New Zealand Guidelines Group. New Zealand acute low back pain guide: Incorporating the guide to assessing psychosocial yellow flags in acute low back pain [Internet]. 2004 Oct [cited 2015 Nov 25]. Available from: http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_communications/documents/guide/prd_ctrb112930.pdf
- [7]
Kroenke K, Spitzer RL, Williams JBW, Lowe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics [Internet]. 2009 Nov-Dec [cited 2015 Nov 20]; 50(6): 613-621. Available from: http://www.psychiatrictimes.com/all/editorial/psychiatrictimes/pdfs/scale-PHQ4.pdf
- [8]
Nicholas MK. The pain self-efficacy questionnaire: Taking pain into account. Eur J Pain. 2007 Feb; 11(2): 153-63.
- [9]
Cervical and thoracic spine disorders. In Hegmann KT, editor. Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine; 2011.
- [10]
National Institute for Health and Clinical Excellence. Neck pain – non-specific. Clinical Knowledge Summaries. 2015 Apr.
- [11]
Canadian Association of Radiologists. Section D: Musculoskeletal system. Diagnostic Imaging Referral Guidelines. 2012. Available from: http://www.car.ca/en/standards-guidelines/guidelines.aspx
- [12]
Canadian Association of Radiologists. Section J: Trauma. Diagnostic Imaging Referral Guidelines. 2012. Available from: http://www.car.ca/en/standards-guidelines/guidelines.aspx
- [13]
Cook C, Hegedus E. Orthopedic physical examination tests: An evidence-based approach. Upper Saddle River, N.J.: Pearson Education, 2013.
- [14]
Yung E, Asavasopon S, Godges JJ. Screening for head, neck, and shoulder pathology in patients with upper extremity signs and symptoms. J Hand Ther. 2010 Apr-Jun; 23(2): 173-85.
- [15]
Wainner RS, et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003 Jan 1; 28(1): 52-62.
- [16]
Cote P, et al. Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Management (OPTIMa) Collaboration. Eur Spine J. 2016 Mar 16.
- [17]
Rampersaud YR, Alleyne J, Hall H. Managing leg dominant pain. J Current Clinical Care. 2013 Jan; Educational Suppl.: 32-39.
- [18]
National Institute for Health and Clinical Excellence. Neck pain – cervical radiculopathy. Clinical Knowledge Summaries. 2015 Apr.
- [19]
National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain [Internet]. 2010 [cited 2016 May 30]. Available from: http://nationalpaincentre.mcmaster.ca/opioid/
- [20]
Childs JD, et al. Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. 2008. J Orthop Sports Phys Ther. 38(9):A1-A34.
- [21]
Hall H, Alleyne J, McIntosh G, Cote P. A pain in the neck. Journal of Current Clinical Care. 2015; 5(1):24-34.
Headache navigator
- [1]
Headache Imaging Pathway. Developed as part of the Diagnostic Imaging Appropriateness (DI-APP) Tools in Primary Care project by University Health Network, Health Quality Ontario, Ministry of Health and Long-Term Care. 2015.
- [2]
Toward Optimized Practice. Guideline for primary care management of headache in adults. Edmonton, AB: Toward Optimized Practice. 2012 July. Available from: www.topalbertadoctors.org
- [3]
National Institute for Health and Clinical Excellence. Headaches: Diagnosis and management of headaches in young people and adults. Clinical guideline 150: Methods, evidence and recommendations. 2012 Sep.
- [4]
Choosing Wisely Canada, Canadian Association of Radiologists. Imaging tests for headaches: When you need them – and when you don’t. 2014. Available from: http://www.choosingwiselycanada.org/
- [5]
Canadian Association of Radiologists. Section A: Central nervous system. Diagnostic Imaging Referral Guidelines. 2012. Available from: http://www.car.ca/en/standards-guidelines/guidelines.aspx
Acknowledgments and legal
This Tool was developed as part of the Knowledge Translation in Primary Care Initiative which is led by CEP with collaboration from Ontario College of Family Physicians and Nurse Practitioners’ Association of Ontario. Clinical leadership for the development of the tool was provided by Drs. Julia Alleyne MD, CAC(SEM), FCFP and Arun Radhakrishnan MSc, MD, CM CCFP and was subject to external review by primary care providers and other relevant stakeholders. This Tool was funded by the Government of Ontario as part of the Knowledge Translation in Primary Care Initiative.
This Tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice. Primary care providers and other health care professionals are required to exercise their own clinical judgment in using this Tool. Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, nor any of their respective agents, appointees, directors, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this Tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this Tool by an individual including, but not limited to, primary care providers or entity, including for any loss, damage or injury (including death) arising for or in connection with the use of this Tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any external sources referenced in this Tool (whether specifically named or not) that are owned or operated by third parties, including any information or advice contained therein.
CORE Neck Tool and Headache Navigator is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear on all copies, modifications, and distributions. Use of CORE Neck Tool and Headache Navigator for commercial purposes or any modification of the tool are subject to charge and use must be negotiated with Centre for Effective Practice (Email: info@effectivepractice.org).
For statistical and bibliographic purposes, please notify the Centre for Effective Practice (info@effectivepractice.org) of any use or reprinting of the tool. Please use the below citation when referencing the tool: Reprinted with Permission from Centre for Effective Practice (Summer 2016). CORE Neck Tool and Headache Navigator. Toronto. Centre for Effective Practice.
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