Early physical therapy for neck and back pain: a referral guide

Neck pain, cervicogenic headache and radiculopathy

The neck pain guideline supports combined manual therapy and exercise with patient education; manual therapy and exercise for cervicogenic headache; and, for neck pain with radiating arm pain, intermittent traction combined with other interventions such as manual therapy and strengthening.¹

Whiplash-associated disorders

For whiplash, the guideline recommends education and advice to stay active, exercise, and minimizing collar use.¹ Prognosis is variable: about half of people with whiplash-associated disorders still report neck pain a year after injury, and greater early pain and disability predict slower recovery.² Because concussion and post-traumatic BPPV can accompany whiplash, every post-accident patient we see also receives an oculomotor, positional and balance screen.

Low back pain

• American College of Physicians: for acute and subacute low back pain, start with non-drug treatments such as superficial heat, massage, acupuncture or spinal manipulation. For chronic low back pain, first-line options include exercise, multidisciplinary rehabilitation, mindfulness-based stress reduction and other non-drug therapies.³
• Physical therapy guideline: exercise, manual therapy combined with exercise, and pain neuroscience education combined with exercise.⁴
• Imaging: avoid routine imaging without red flags.⁵
• Timing: in a large primary care cohort with new low back pain, early physical therapy (within 14 days) was associated with lower risk of advanced imaging, additional physician visits, surgery, injections and opioid use, and with lower costs, compared with delayed physical therapy.⁶ Early, guideline-adherent physical therapy has been linked to lower utilization in other cohorts too.⁷

Post-operative spine rehabilitation

After lumbar disc surgery, exercise programs starting four to six weeks after surgery led to faster improvement in pain and disability than no treatment, with no evidence that activity restrictions are needed after first-time surgery.⁸ We follow each surgeon's protocol for cervical and lumbar procedures and send progress notes at key milestones.

Red flags that need medical evaluation first

• Possible cauda equina syndrome: new urinary retention or incontinence, saddle anesthesia, bilateral or progressive leg weakness
• Possible infection: fever with spinal pain, IV drug use, a recent spinal procedure or immunosuppression
• Possible malignancy: history of cancer with new back pain, unexplained weight loss, or night pain unrelieved by position
• Possible fracture: significant trauma, or osteoporosis or long-term steroid use with new pain
• Possible cervical myelopathy: bilateral hand clumsiness or gait disturbance
• Possible cervical arterial dissection: neck pain or headache with dizziness, visual change or other neurologic signs after trauma or manipulation

These follow the international framework for red flags for serious spinal pathology.⁹

What our neck and spine evaluation includes

• A 60-minute, 1-on-1 evaluation with Dr. Manan Patel, PT, DPT, a certified Therapeutic Pain Specialist and Certified Vestibular Specialist
• Red-flag and medical screening, with prompt communication if a referral back is needed
• Neurological screening, movement and strength testing, and standardized outcome measures such as the Neck Disability Index
• Oculomotor, positional and balance screening when neck pain comes with dizziness, headache or a head injury
• A written plan of care faxed to your office within 48 hours of the first visit

How to write the referral

"Physical therapy: evaluate and treat" with the diagnosis is enough. For post-operative patients, attach the surgical protocol and note the procedure and surgery date. Our printable referral pad includes evaluate and treat, spine surgery protocol and neck and spine check boxes.

Keep reading

• Herniated disc on your MRI? What the findings really meanWhat disc bulges and degeneration mean, and how often herniations shrink on their own.4 min read · Patients
• After a car accident: a guide to whiplash, concussion and dizzinessWhat to do after a crash, delayed symptoms, and how whiplash and concussion are treated.3 min read · Patients
• All guidesBrowse the full learning center.

Related conditions we treat

References

1. Blanpied PR, et al. Neck Pain: Revision 2017. Journal of Orthopaedic & Sports Physical Therapy. 2017.
2. Carroll LJ, et al. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008.
3. Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2017.
4. George SZ, et al. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. Journal of Orthopaedic & Sports Physical Therapy. 2021.
5. Chou R, et al. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Annals of Internal Medicine. 2011.
6. Fritz JM, et al. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine. 2012.
7. Childs JD, et al. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Services Research. 2015.
8. Oosterhuis T, et al. Rehabilitation after lumbar disc surgery. Cochrane Database of Systematic Reviews. 2014.
9. Finucane LM, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. Journal of Orthopaedic & Sports Physical Therapy. 2020.

Clinically reviewed by Dr. Manan Patel, PT, DPT, TPSDoctor of Physical Therapy, Certified Vestibular Specialist and one of the few certified Therapeutic Pain Specialists in North Atlanta, with 15+ years of outpatient care. About Dr. Patel

This guide is general education, not a diagnosis or a substitute for an examination. If you have new or worsening symptoms, contact your doctor.