Informing patients 1: Neck Pain – Benefits and Risks and Treatment Alternatives

An information resource for practitioners

The law on consent require health practitioners to inform patients of the benefits and risks of treatment and alternative treatments.  This article is the first of a series to equip practitioners to inform their patients.  It is to be noted that it is difficult to find information on benefits and risks of treatments so please feel free to provide feedback so we can develop this resource.

This list is a generalised list to use a resource and needs to be applied using your osteopathic expertise, based on the patient’s condition, presentation, preferences and understanding.

N.B. this information is written for practitioners with medical knowledge, if you are suffering with neck pain please seek advice from a health practitioner.

Time and posture improvement

Reassurance symptoms will resolve – tissues heal in known time frames – muscles, ligament etc.  Advice on work-place posture, excessive use of pillows.

Benefits: low-cost option, possibility of full improvement

Risks: Underlying contributing factors may not be resolved increasing likelihood of recurrence, may take a few weeks.

Education Insufficient evidence for use alone

­Realistic expectations, empower patient to lead management of condition.

Identify excessive concerns about neck pain, compensation issues, sickness behaviour, work or family problems, unrealistic expectations about treatment

Benefits: Low-cost, empowers patient

Risks: Yellow-flags may be barriers to improvement

Manual Therapy

Mobilisation, manipulation, exercise, massage.

Passive interventions alone are to be avoided with long-term pain such as massage or electrotherapy due to risk of reliance and lack of patient empowerment.

Benefits: Helps improve range of motion and reduce muscle tension, may help reduce likelihood of recurrence of symptoms.  Faster improvement than time and education alone.

Risks: May have increased tenderness after hands-on treatment for 24-48 hours, improvement may take a few sessions (1 in 2).  Small risk of nerve compression causing temporary tingling and numbness (1 in 100).  Very low risk of stroke and nerve damage with manipulation (1 in #36000).


Benefits: Enables patient to take active role in treatment, shown to improve symptoms in some cases

Risks: Potential for injury if does exercise incorrectly, exacerbation of symptoms

Latest Cochrane review (Gross et al., 2016) evidence:

For chronic neck pain

1) cervico-scapulothoracic and upper extremity (UE) strengthening for moderate to large pain reduction immediately post treatment (IP) and at short-term (ST) follow-up;

2) scapulothoracic and UE endurance training for a small pain reduction (IP/ST);

3) cervical, shoulder and scapulothoracic strengthening and stretching exercise for a small to large pain reduction in the long-term (LT) (SMDp −0.45 [95%CI: −0.72 to −0.18]) and function improvement;

4) cervico-scapulothoracic strengthening/stabilisation exercises for pain and function at intermediate-term (IT) (SMDp −14.90 [95%CI: −22.40 to −7.39]).

5) mindfulness exercises (Qigong) for minor improved function but not GPE (ST).

For chronic Cervicogenic Headache, cervico-scapulothoracic strengthening and endurance exercises including pressure biofeedback for small/moderate improvement of pain, function and GPE (IP/LT).

Psychological intervention – CBT

Pain catastrophizing – repetitive negative thoughts during actual or anticipated pain – is a major determinant of negative outcomes with chronic pain.

Benefits: Addresses psychological aspect of pain.  Educates and provides long-term management strategies

Risks:  Dis-engagement, ineffectiveness


May have short-term benefits

Benefits: Pain reduction

Risks: Infection, pneumothorax, headache, fatigue, bruising

Collars, Electrotherapy, Traction

Insufficient evidence for their use in neck pain.


Medication Benefits Risks Additional Information
Paracetamol No gastrointestinal toxicity, well-tolerated   More effective taken regularly, rather than as required
NSAIDs – Ibuprofen

(naproxen, diclofenac)

Anti-inflammatory Dyspepsia

Gastrointestinal bleeding

Cardiovascular and renal adverse effects

Exacerbate asthma

Not effective for neuropathic pain

Gastroprotection may be required

Combined analgesics  

Combined benefical effects

*Reduces number of tablets to be taken.

Risk of overdose and renal toxicity *Now recommended to be taken as separate tablets apart from chronic stable pain, although limited evidence
Codeine (weak opioid), dihydrocodeine, tramadol Mild-moderate pain treatment, tramadol may be effective with neuropathic pain Constipation, aggravate asthma, risk of dependence, drowsiness, renal side-effects

Tramadol – rarely – convulsions, psychiatric reactions.

Sedative effects can add to psychological factors and exacerbate feelings of helplessness and depression.


Amitryptiline   Drowsiness  
Gabapentin or pregabalin      
Topical NSAID Good for single regional pain relief    



A consideration for chronic pain or nerve root symptoms that are poorly controlled.

Possible procedures

Cervical decompression/discectomy, disc replacement, posterior foraminotomy, posterior laminectomy, cervical fusion,

Decompression surgery – outcomes disappointing, especially for myelopathy – damage to spinal cord or compromise to vascular supply to the cord – benefits don’t outweigh risks – conservative management equally effective in long-term

Risks: Infection – affects 1 in 100, Blood clots in legs or lungs – 1 in 100, Internal bleeding – 1 in 100, pain, partially collapsed lung, fatigue and lack of energy, muscle weakness, nerve damage, swallowing difficulties and voice changes,



Cervical Spine Evidence Table

Gross, A.R.; Paquin, J.P.; Dupont, G.; Blanchette, S.; Lalonde, P.; Cristie, T.; Grahan, N.; Kay, T.M.; Burnie, S.J.; Gelley, G.; Goldshimth, C.H.; Forget, M.; Santaguida, A.J.; Yee, A.J.; Radisic, G.G.; Hoving, J.L.; Bronfort, G. (2016) Exercises for mechanical neck disorders: A Cochrane review update. Manual Therapy (24) pp 25-45

NICE Clinical Knowledge Summaries, available at:


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