Recommendations and treatments for Neck and Low Back Pain

Through various decades of research and clinical trials, there is a lot of collected evidence about what treatments may be more effective to manage neck or low back pain.

One of the challenges is to get the right first line treatment. Stratification protocols help clinicians to make informed decisions, based on the probability of developing long-term problems or benefiting from different treatments, depending on risk factors that may be quickly assessed.

Evidence-based guidelines contain recommendations for different situations. Those recommendations may be different for pain in different locations (neck or low back), and in different periods (acute, subacute, or chronic). There is no clear-cut definition of such periods, although it is commonly agreed that the acute period includes the first two weeks after the onset of pain, and that pain sustained for more than 6 months is chronic.

In all cases, the emphasis is removed from rest or pharmacological treatments, and placed on physical and psychological therapies, based on exercise and education, which take into account individual preferences and capabilities, as well as on self-management.

Specific recommendations for Low Back Pain (LBP)

The state of the art in LBP stratification is the STarT Back Screening Tool, which assesses pain felt in various parts of body, as well as other problems that may lead to distress and poor prognostics. Patients are stratified in three risk levels (high, medium or low), for which different care packages are recommended.

Acute LBP may be very distressful, but in the majority of cases it disappears in less than six weeks. To reduce the intensity of pain, and the psychological and social problems that may derive from it and even worsen it, guidelines recommend therapies based on superficial heat, massage, acupuncture, or spinal manipulation.

For chronic LBP pain, guidelines recommend a multidisciplinary approach based on the biopsychosocial model of chronic musculoskeletal disorders. Multidisciplinary interventions are based on personalised therapy plans designed by a small team of physicians, physiotherapists, psychologists or other health care specialists. They are specially effective to facilitate improvement of all aspects functioning, including social participation, and return to work. The same interventions that have been mentioned for acute LBP are also recommended for chronic stages, together with therapies addressed to reduced stress, like Tai-chi, yoga, mindfulness, and cognitive behavioural therapy.

There is low quality evidence about the effectiveness of other methods that sometimes may be heard for the treatment of LBP, like electromyography biofeedback or low-level laser therapy. Pharmacological treatments, like nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants, are generally discouraged; only patients for which the previously mentioned treatments fail should be recommended to take them, after a discussion of known risks and realistic benefits with patients.

Specific recommendations for neck pain (NP)

Neck pain has been less investigated than LBP, except in the specific field of whiplash associated disorders (WAD), which are a typical problem derived from motor accidents, particularly conflictive in some countries due to medico-legal litigation. Five “WAD grades” are defined by Quebec Task Force Classification, defined back in 1995.

NP may be accompanied with mobility deficits in neck flexion and rotation, as well as with problems in motor coordination, headaches, or pain radiating to limbs (“radicular pain”). Stratified risk assessment of NP takes all those and other symptoms.

Many of the guidelines for LBP (recommendation of exercise, reassurance in acute or subacute stages, and cognitive behavioural therapies) also apply to NP. Specific recommendations for NP in all stages include multimodal interventions, specially to improve functioning in the case of mobility deficits. This involves manual mobilisation techniques, and exercise to improve strength, endurance and coordination. For chronic NP, this may be combined with education/advice, and supervised or unsupervised exercise for stress management, yoga, and strength training.

There is low quality evidence of the effectiveness of techniques like transcutaneous electrical nerve stimulation (TENS), or Self-sustained Natural Apophyseal Glide (SNAG). On the other hand the use of cervical collars should be minimised, and not used in recent onset.


  • Bussières, A. E., Stewart, G., Al-Zoubi, F., Decina, P., Descarreaux, M., Hayden, J., … Ornelas, J. (2016). The Treatment of Neck Pain–Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. Journal of Manipulative and Physiological Therapeutics, 39(8), 523-564.e27.
  • Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., … Woolf, A. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet.
  • Kasch, H., Kongsted, A., Qerama, E., Bach, F. W., Bendix, T., & Jensen, T. S. (2013). A new stratified risk assessment tool for whiplash injuries developed from a prospective observational study. BMJ Open, 3(1), e002050.
  • Qaseem, A., Wilt, T. J., McLean, R. M., Forciea, M. A., & for the Clinical Guidelines Committee of the American College of Physicians. (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine, 166(7), 514.
  • 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. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 47(7), A1-A83.