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Management of nonradicular neck pain in adults

Management of nonradicular neck pain in adults
Literature review current through: Jan 2024.
This topic last updated: Jan 12, 2024.

INTRODUCTION — Approximately 10 percent of the adult population has neck pain at any given time, with a prevalence similar to low back pain. However, few patients with neck pain lose time from work and less than 1 percent develop neurologic deficits.

The majority of patients, regardless of the etiology of pain, will recover with conservative therapy [1]. However, those with symptoms severe or persistent enough to require medical attention often present a management challenge due to the variability of patient symptoms and physical examination findings, lack of specificity on diagnostic imaging, and a relative lack of evidence-based treatment guidelines.

The management of neck pain without upper extremity symptoms (radiculopathy) is reviewed here. The evaluation and management of cervical radiculopathy and cervical spondylotic myelopathy are discussed elsewhere. (See "Clinical features and diagnosis of cervical radiculopathy" and "Treatment and prognosis of cervical radiculopathy" and "Cervical spondylotic myelopathy".)

In addition, the evaluation of the adult patient with neck pain is discussed separately. (See "Evaluation of the adult patient with neck pain".)

MANAGEMENT PRINCIPLES — The goals of any treatment plan are to minimize pain, muscle irritability, and spasm; to reestablish normal cervical lordosis; and to restore maximum function. Initial treatment is individualized and based upon the duration and severity of symptoms, the extent of functional disability, and risk factors for the development of chronic pain and is modified if associated neurologic symptoms or signs develop.

We define the duration of neck pain symptoms as follows:

Acute neck pain – Duration of pain less than 6 weeks

Subacute neck pain – Duration of pain from 6 to 12 weeks

Chronic neck pain – Duration of pain greater than 12 weeks

Although degenerative change of the cervical spine is the most common cause of neck pain, there are a number of conditions (eg, cervical strain, discogenic pain, diffuse idiopathic skeletal hyperostosis [DISH], whiplash syndrome, and myofascial pain) that can also cause neck pain (see "Evaluation of the adult patient with neck pain", section on 'Musculoskeletal conditions'). However, in patients with nonradicular neck pain (neck pain without radiculopathy), initial treatment directed at the specific cause of pain has not been shown to lead to improved outcomes compared with nonspecific treatment. There is, however, a lack of high-quality data supporting management approach for these patients; our strategy is based upon our clinical experience.

ACUTE NECK PAIN — Most mild to moderate cervical strains resolve within the first three weeks with conservative measures (see 'Initial treatment for all patients' below). Patients with more severe neck pain, and particularly those with whiplash injuries, may have persistent symptoms, including headache, for longer periods of time [2]. (See 'Patients for whom additional treatment is needed' below.)

The management strategy described below only applies to patients without radicular complaints; if at any point neurologic symptoms or signs develop, the treatment approach will change. (See "Treatment and prognosis of cervical radiculopathy".)

Initial treatment for all patients — Initial treatment for all patients with acute neck pain (duration less than six weeks) includes patient education, postural (mechanical) modification, early mobilization through participation in a home exercise program, and adjunctive pharmacologic therapy if needed. For patients with resolved neck pain, we encourage adherence with proper posture and sleep position, as well as participation in the home exercise program to prevent a recurrence of symptoms.

Patient education and reassurance – The treatment of any patient with neck pain should incorporate education regarding the ubiquity of the condition; the natural history of the condition, including the high likelihood for recovery regardless of anatomic findings; reassurance that the severity of perceived pain is greater the degree of tissue injury; the importance of mental health, physical fitness, proper posture, and ergonomics; and regular, sufficient sleep.

If the patient has already had imaging with "abnormal" findings documented (eg, mild disc herniation, facet osteoarthritis), they should be educated regarding the high prevalence of such abnormal findings even among people without symptoms, and the likelihood that these abnormalities predated symptoms and will persist after symptom improvement. Every effort should be made to help patients avoid fixating on these abnormalities.

Posture and sleep position modifications – Simple posture modifications to correct muscle tension are an essential part of the treatment regimen for neck pain; such modifications include sitting straight with the crown of the head tall, chin minimally tilted down, shoulders down, and the scapula retracted and depressed (picture 1). While doing desk work, the natural tendency is to shrug and round the shoulders forward, crane the neck, and intermittently breath-hold (picture 2). Learning to recognize and adopt a neutral posture and engage in a natural, regular breathing pattern may allow the patient to correct contributors to neck muscle tension.

However, pain is greatly influenced by associations and context; while proper posture and ergonomic setup is encouraged, data are sparse to suggest that appropriate ergonomic setup improves pain [3]. Overemphasis on a single, optimal posture may be misguided. Frequent position adjustments to allow changes in joint position, muscle length, blood flow to spinal structures, and body posture may provide more benefit (movie 1).

For these reasons, avoidance of a sustained seated position is beneficial. Patients should limit time spent sitting in front of a computer monitor, prolonged telephone (handset) use, and excessive fine motor handwork [4]. In addition to maintaining a neutral posture, patients with sedentary jobs should make an effort to stand and walk frequently during the day and perform cervical range of motion exercises while at work.

For those who carry heavy purses or backpacks (particularly ones that are worn over one shoulder), minimization of weight or discontinuation of use may help alleviate acute neck pain.

Mechanical adjustment to sleep position is another important postural correction that can decrease neck pain. While sleeping, the head and neck should be aligned with the body. A preferred sleep position is to have the patient lie flat on their back with thighs elevated on pillows with a relatively small pillow under the head and neck, thereby flattening the long spinal muscles. For side sleepers, use of a slightly larger pillow may help maintain proper cervical spine alignment (movie 2). For patients with cervical foraminal stenosis (due to uncovertebral hypertrophy or foraminal disc herniation), avoidance of cervical extension is particularly helpful.

Home exercise program – Early mobilization with participation in a home exercise program helps patients maintain cervical range of motion and encourages them to become active participants in their own care. Gentle stretching exercises, including shoulder rolls and neck stretches, should be performed on a daily basis as tolerated:

Neck rotation (picture 3) – Slowly turn the head to the right. Place tension on the chin with the fingertips. Hold for a few seconds and return to the center. Repeat to the left.

Neck tilting (picture 4) – Tilt the head to the right, trying to touch the ear to the tip of the shoulder. Place tension on the temple with the fingertips. Hold for a few seconds and return to the center. Repeat to the left.

Neck bending – While sitting or standing, try to touch the chin to the chest. Hold for a few seconds and return to the neutral position. Breathe in gradually and exhale slowly with each exercise. Relax the neck and back muscles with each neck bend.

Shoulder rolls – In the sitting or standing position, pull the arms backwards. Try to pinch the shoulder blades together, and then roll the arms forward then backward in a rhythmic, rowing motion.

Scapular retraction (movie 3) – In the seated position, with the head in a neutral position, the shoulders and scapula are drawn backward, similar to shoulder rolls; however, in this exercise, the patient engages in a sustained 10 second hold before relaxing.

Deep neck flexor strengthening (movie 4) – While laying supine, the chin is drawn down and inwards, with the patient actively contracting the anterior neck muscles. The position is sustained for five seconds before relaxing.

Anterior chest wall stretches (movie 5) – While standing in a doorway, the arms are abducted, and elbows are placed against the door frame slightly lower than shoulder level. The body is leaned forward so as to create a stretch of the anterior shoulder and chest muscles. The stretch can be held for 10 to 30 seconds.

Prior to each exercise session, we encourage patients to warm their neck and upper back muscles in a bathtub or shower, or with a heating pad or warmed, moist towels. The muscles should be gently stretched in sets of 10 to 15 repetitions as tolerated. It is best to perform the exercises at least twice daily: in the morning and just before bedtime. They can be performed up to four times daily if possible. (See "Patient education: Neck pain (Beyond the Basics)".)

For those patients whose pain has resolved, the home exercise program should be continued to maintain neck range of motion and flexibility. We encourage patients to perform the stretching exercises three times per week. In a meta-analysis of five randomized trials comparing exercise with education only or with no intervention, the odds of a new episode of neck pain was reduced by 49 percent in the exercise group compared with the education and no intervention groups (95% CI 0.31-0.76); however, conclusions are limited by methodologic shortcomings in several of the included studies [5].

Topical heat or cold – The use of topical heat or cold may help with the short-term pain relief in some patients with acute neck pain. Care should be taken to avoid the application of extreme heat or cold to the skin (eg, if using a heating pad, keep the setting low enough to avoid burning the skin; if using ice, wrap the ice to avoid direct contact with skin) and to limit exposure to 15 minutes at a time. Heat or cold can be applied every two to three hours as needed.

Adjunctive pharmacologic therapy — For patients with acute neck pain and more significant discomfort, we use pharmacologic therapy for additional symptom management. Although nonpharmacologic therapy is generally preferred over pharmacologic therapy, they are commonly used together in clinical practice. The goal of medications is to provide symptomatic relief of pain symptoms while allowing the patient to participate in a home exercise program.

NSAIDs or acetaminophen as first-line pharmacotherapy — We suggest using a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen as first-line adjunctive pharmacotherapy for acute nonradicular neck pain. There is a lack of high-quality evidence supporting the use of one class of medicine over the other [6]; we evaluate patient-specific risk factors and prior response to medication therapy to guide our recommendation.

NSAIDs are associated with possible gastrointestinal, kidney, and cardiovascular side effects; risk factors for complications from NSAID therapy should be assessed before prescribing these medications. (See "Nonselective NSAIDs: Overview of adverse effects" and "NSAIDs: Adverse cardiovascular effects".)

For patients who have previously tried an NSAID with good pain relief, and who are not at increased risk from an NSAID-related complication, we prescribe an NSAID. Examples include:

Ibuprofen 400 to 600 mg orally three times daily as needed

Naproxen 250 to 500 mg orally twice daily as needed

Patients should be encouraged to take the lowest effective dose for the shortest period of time. High-quality data are limited on optimal NSAID dosing strategies for the management of acute neck pain [7,8], but having the patient take a standing dose for one to two weeks, then tapering off is a reasonable approach.

For patients who are unable to take NSAIDs (eg, due to allergy or other intolerance, chronic kidney disease, hypertension, peptic ulcer disease, or cardiovascular disease), or who have previously tried acetaminophen with good pain relief, we advise using acetaminophen. We use acetaminophen 500 to 1000 mg orally three times daily as needed for most adults, although we would use a lower total daily dose for older adult patients and those with any hepatic impairment.

In our clinical experience, no additional pain relief for musculoskeletal neck pain is achieved by taking concurrent NSAID and acetaminophen therapy.

Skeletal muscle relaxant if NSAID or acetaminophen therapy is inadequate — We prescribe a non-benzodiazepine skeletal muscle relaxant for symptoms not well managed with an NSAID or acetaminophen alone, particularly for those with prominent muscle spasm. Examples include:

Cyclobenzaprine 5 to 10 mg orally three times daily as needed, with one of the doses take at bedtime to help with sleep. The 5 mg dose may be used initially for lower-weight patients or those in whom the risks of sedation are greater (eg, older adults); the dose may be increased to 10 mg as tolerated.

Tizanidine 2 to 4 mg orally three times daily as needed.

Baclofen 5 to 10 mg orally three times daily as needed.

Tizanidine and baclofen may be given during the daytime; if pain symptoms interfere with sleep, the last dose should be given at bedtime. By contrast, cyclobenzaprine is particularly sedating, and we typically prefer to give this medication only at bedtime.

We do not prescribe long-acting preparations of muscle relaxants for acute neck pain. As pain symptoms improve, the dose of muscle relaxant is reduced and tapered off as quickly as tolerated.

If NSAID or acetaminophen and muscle relaxants are insufficient — For patients with acute nonradicular neck pain, for whom NSAID or acetaminophen plus skeletal muscle relaxants fail to adequately control pain symptoms, we either add a small dose of tramadol to their regimen or substitute the tramadol for the skeletal muscle relaxant.

For patients with pain symptoms that are almost, but not entirely, under adequate control, we add tramadol 25 to 50 mg orally three times daily as needed to their regimen. We use the lowest possible dose of tramadol for the shortest period of time, and we caution patients regarding the risk of sedation, particularly when used with muscle relaxants.

For patients with significant pain despite an NSAID or acetaminophen plus a skeletal muscle relaxant, we discontinue the muscle relaxant and prescribe tramadol. We typically initiate tramadol at the lowest dose, particularly in older and opioid-naïve patients (eg, 25 to 50 mg orally three times daily as needed). If additional pain control is needed, we will increase the dose if necessary to 50 to 100 mg orally three times daily as needed.

When tramadol therapy is prescribed, the dose is reduced and tapered to off as quickly as symptoms allow. In addition, we never use a long-acting tramadol preparation in the management of acute neck pain because it interferes with dose titration. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Initiating a trial of opioid therapy'.)

Patients for whom additional treatment is needed — Although the majority of patients with acute neck pain will recover with initial therapy, there are some patients who require additional treatment. Specifically, patients with more severe neck pain, symptoms due to whiplash injury, or risk factors for chronic pain require more intensive management with earlier referral for adjunctive therapies, including physical therapy, manipulation therapy, and psychologic or mind-body therapies. (See 'Therapies for severe or persistent pain' below.)

Patients with more severe symptoms or pain due to whiplash injury – For patients with more severe pain symptoms, particularly those with pain due to whiplash injury, and patients with significant functional impairment and kinesiophobia, we typically refer for physical therapy at approximately four weeks. (See 'Physical and movement-based therapies' below.)

In addition, we refer these patients for adjunctive manual therapy and joint mobilization to be performed concurrent with physical therapy. (See 'Manipulation techniques' below.)

Among those with neck pain due to whiplash injury, certain baseline psychosocial factors (eg, depression and self-reported poor quality of life) are associated with an increased severity and duration of symptoms [9]. Other factors associated with poorer prognosis following whiplash injury include report of headache, neck, or low back pain at injury inception; lower level of education; no seatbelt use; higher Neck Disability Index score; and female sex [10].

Patients with risk factors for chronic pain – We assess patients with significant neck pain for risk factors for developing chronic pain (eg, severe functional impairment, mood disturbance related to pain, and catastrophizing). If such risk factors are present, we refer these patients for physical therapy at approximately four weeks. In addition, we often refer these patients for cognitive behavioral therapy (CBT) at six to eight weeks if significant neck pain persists despite initial treatment, adjunctive pharmacologic therapy, and physical therapy. (See 'Physical and movement-based therapies' below and 'Psychologic and mind-body therapies' below.)

Other predictive factors for persistent neck pain include greater age, accompanying low back pain, neck trauma, headache, radiation of pain, being employed, and prior episodes of neck pain [11]. Psychosocial and neurophysiologic factors include depressed mood, weak cervical muscle endurance, and impaired pain inhibition [12]. In addition, poor sleep is a complicating comorbidity found in 70 percent of patients with chronic neck pain [13].

SUBACUTE AND CHRONIC NECK PAIN

Counseling and self-care advice for all patients — All patients with neck pain that persists beyond six weeks should receive counseling and self-care advice (eg, education and reassurance, advice on postural and sleep position modifications, and instruction on participation in a home exercise program) if they have not yet received it. (See 'Initial treatment for all patients' above.)

Physical therapy for all patients — For all patients with moderate to severe pain that persists beyond six weeks, and which interferes with daily functioning despite initial treatment, we perform imaging and refer for physical therapy. Physical therapy is fundamental to the treatment and prevention of persistent neck pain [14]. The choice of appropriate imaging modality is discussed elsewhere. (See "Evaluation of the adult patient with neck pain", section on 'Imaging' and 'Adjunctive pharmacologic therapy' above and 'Physical and movement-based therapies' below.)

Additional treatments for subacute pain — Other treatments may be used concurrently with physical therapy in some patients with subacute neck pain. As examples, trigger point injections may be useful for those with taut bands or significant muscle tightness, and manual therapy and joint mobilization are useful for patients with whiplash injury. In addition, the use of acupuncture and massage therapy may also provide short-term pain relief for some patients with neck pain. (See 'Therapies for severe or persistent pain' below and 'Adjunctive treatments that may provide pain relief' below.)

Multimodal care for chronic neck pain — Many treatment options are available for the treatment of chronic neck pain, although there is a lack of high-quality evidence supporting the efficacy of many of these interventions [15-17]. However, consistent with a biopsychosocial approach to chronic pain management, we refer patients with chronic neck for multimodal care, including psychologic and mind-body therapies as well as movement-based treatment. For all patients with chronic neck pain, multimodal care combining exercise with other therapies has most consistently demonstrated benefit [18].

For all patients with chronic neck pain (pain that persists beyond 12 weeks) despite the above treatments, we refer for cognitive-behavioral therapy (CBT) if they have not yet been referred. In addition, patients are encouraged to continue to exercise through a physical therapy provider or other appropriate exercise program. Particular exercises that we find beneficial include mind-body exercise therapies, such as Tai Chi, Qigong, and yoga. These therapies are appropriate for patients of all ages and fitness levels and can be performed concurrent with CBT. (See 'Psychologic and mind-body therapies' below and 'Physical and movement-based therapies' below.)

In addition, for some patients with chronic neck pain, particularly those with pain due to suspected facet joint syndrome, we may refer for an interventional treatment such as cervical medial branch block and, if successful, a percutaneous radiofrequency neurotomy. (See "Evaluation of the adult patient with neck pain", section on 'Cervical facet osteoarthritis' and 'Interventional treatments' below.)

Other treatments, including manual therapy and joint mobilization, may be helpful for patients with chronic neck pain due to whiplash injury. In addition, acupuncture and massage treatments may provide additional benefits for some patients with chronic neck pain of any etiology, and trigger point injections may be helpful for chronic neck pain patients with taut bands or significant muscle tightness. Treatment with traditional spinal manipulation may be appropriate for younger patients (under age 55 years old) with chronic neck pain and no evidence of central spinal stenosis. (See 'Manipulation techniques' below and 'Adjunctive treatments that may provide pain relief' below and 'Dry needling and trigger point injections' below.)

Adjunctive pharmacotherapy for subacute and chronic neck pain — Our pharmacologic management for patients with subacute and chronic neck pain depends upon a patient's previous response to medications and the duration of prior pharmacologic therapy. (See 'Adjunctive pharmacologic therapy' above.)

For those patients with subacute or chronic neck pain with more significant pain symptoms who have not yet tried any pharmacologic therapy, we follow the same initial pharmacologic treatment strategy as for patients with acute neck pain. (See 'Adjunctive pharmacologic therapy' above.)

For those patients who are being treated with pharmacologic therapy but are unable to discontinue medications due to significant discomfort, we use continued adjunctive pharmacologic therapy for additional symptom management while continuing nonpharmacologic therapies. Medications are used to minimize functional disability and provide sufficient pain relief to allow patient participation in active therapies.

Patients with adequate pain relief on current pharmacotherapy

Patients with adequate relief from NSAIDs or acetaminophen – For patients with adequate pain relief on a nonsteroidal anti-inflammatory drug (NSAID), we reduce the NSAID to the lowest possible dose, and in addition, encourage use only for "flare-ups" (episodes of more severe pain) as needed. The goal is to avoid continuous use of NSAIDs, and to ultimately discontinue them if possible. (See 'NSAIDs or acetaminophen as first-line pharmacotherapy' above.)

For patients taking acetaminophen with adequate pain relief, there are fewer safety concerns about uninterrupted therapy. Nonetheless, we do encourage patients to take the lowest effective dose, discontinue the standing dose, and encourage use only for pain flares. (See 'NSAIDs or acetaminophen as first-line pharmacotherapy' above.)

Patients with adequate relief from muscle relaxants – For patients who have been taking a skeletal muscle relaxant with adequate symptom control (with or without an NSAID or acetaminophen), we continue the medication at the lowest effective dose and frequency. Although there are no high-quality data supporting this approach, for patients with stable symptoms that are well controlled on a lower dose of a skeletal muscle relaxant, we would consider prescribing these medications chronically with periodic attempts to wean off as symptoms permit.

We also prescribe skeletal muscle relaxants for intermittent use for pain flares to be taken alone or for patients on chronic or intermittent NSAID or acetaminophen therapy. (See 'Skeletal muscle relaxant if NSAID or acetaminophen therapy is inadequate' above.)

Patients with adequate pain relief from tramadol – For patients on tramadol therapy (with or without a skeletal muscle relaxant) who have had a good response with sufficient pain control, we may consider continuing long-term therapy. However, tramadol has mixed opiate agonist (and selective serotonin-norepinephrine reuptake inhibitor [SNRI] activity) and does have the potential for abuse and dependency; it should be prescribed with caution in any patient at risk of substance misuse or history of substance use disorder. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Evaluation of risk prior to initiating therapy'.)

If treatment with chronic tramadol is considered, we engage in shared decision-making with the patient, reviewing the risks and benefits of chronic opioid therapy. We prescribe the lowest effective dose, perform appropriate patient monitoring, and attempt to discontinue the drug at regular intervals. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Follow-up and monitoring during chronic opioid therapy' and "Use of opioids in the management of chronic non-cancer pain", section on 'Discontinuing therapy'.)

If, despite providing adequate pain relief, chronic tramadol therapy is not appropriate due to concerns over the potential for misuse or dependency, side effects, or other issues, we would then discontinue and initiate treatment with duloxetine or a tricyclic antidepressant. (See 'Second-line pharmacotherapy' below.)

Second-line pharmacotherapy — For patients with neck pain that persists beyond six weeks, and who have had inadequate pain relief with tramadol (or if chronic tramadol therapy is not a consideration), we initiate therapy with duloxetine or a tricyclic antidepressant. We typically prefer duloxetine over a tricyclic antidepressant in older patients and in patients with a coexisting mood disorder. In patients for whom sleep is significantly impacted by pain symptoms, a tricyclic antidepressant may be preferred.

Duloxetine – Duloxetine, an SNRI, is started at 30 mg orally once daily and is increased to 60 mg orally once daily after one to two weeks if tolerated.

Duloxetine may cause nausea, drowsiness, headache, and dizziness and may not be tolerated by all patients, particularly at the higher dose.

Duloxetine is indicated for the treatment of chronic musculoskeletal pain. It is an antidepressant and may have additional potential benefit for patients in whom there is coexisting depression. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Duloxetine' and "Unipolar major depression in adults: Choosing initial treatment", section on 'Treatment options'.)

If tramadol therapy is continued with duloxetine, a lower dose should be used (eg, 25 to 50 mg orally three times daily standing or as needed), and the patient should be monitored for the development of serotonin syndrome.

Tricyclic antidepressants – Of the available tricyclic antidepressants, we prefer nortriptyline due to its tolerability, although bedtime dosing is still preferred to its sedating effects. We start at 10 mg orally once daily at bedtime and increase the dose by 10 mg per week to a maximum dose of 50 mg orally once daily at bedtime.

Adverse effects include sedation, dry mouth, dizziness, constipation, and urinary retention; side effects may be more pronounced in older adults, and we use this medication with caution in these patients. (See "Tricyclic and tetracyclic drugs: Pharmacology, administration, and side effects", section on 'Nortriptyline'.)

Third-line pharmacotherapy — For patients who continue to have neck pain that causes significant pain and functional impairment despite the medical and pharmacologic therapies reviewed above, we discontinue antidepressants and tramadol and begin treatment with gabapentin.

Gabapentin is initiated at 300 mg orally once daily at bedtime and titrated up to a goal dose of 600 mg orally three times daily as tolerated. We accomplish the titration by adding an additional 300 mg to the total daily dose every three days. Side effects of gabapentin may include dizziness and sedation, particularly in older patients; a slower titration or lower doses may be used if side effects occur. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Antiseizure medications'.)

THERAPIES FOR SEVERE OR PERSISTENT PAIN — There are many different treatments and therapies available for patients with severe or persistent neck pain, significant pain due to whiplash injury, and risk factors for chronic pain. For all such patients, structured physical therapy is first-line treatment. (See 'Physical and movement-based therapies' below.)

Interventional treatments are reserved for patients with persistent pain and in particular those with prominent myofascial pain (ie, trigger point injections and dry needling) or cervicogenic headaches, whiplash injury, and facet joint arthropathy (ie, cervical medial branch block and percutaneous radiofrequency neurotomy). (See 'Interventional treatments' below.)

Noninterventional therapies — Noninterventional therapies include physical and movement-based therapy and manipulation techniques.

Physical and movement-based therapies

Physical therapy – Although physical therapy programs can vary widely in their content, components generally include patient education, postural modification, and activities that encourage movement, improve strength, and preserve or increase range of motion. The goal of physical therapy is patient independence with their exercise regimen and avoidance of chronic dependence on other treatments. In addition, physical therapists can also provide insights into worksite and recreational ergonomics.

When prescribing physical therapy, the clinician should include a diagnosis (eg, neck pain), a proposed frequency and duration of sessions (eg, two times a week for six weeks), and any comorbidities that may negatively impact an exercise regimen (eg, poor bone density, evidence of severe stenosis or nerve compression on imaging studies, diminished pain or temperature sensation that may increase the risk of burns from a hot pack, and the presence of implanted metal devices that might be affected by electrical stimulation).

There are a wide range of different physical therapy techniques, but there is a lack of high-quality data to suggest the superiority of one modality over another. In a meta-analysis of 39 trials in patients with chronic neck pain, resistance and motor control exercises were effective for reducing neck pain and improving disability, when measured at three to five months [19]. Motor control exercises were most effective for improving disability compared with other exercises. In another meta-analysis including 27 trials, different exercise interventions in people with neck pain were evaluated [15]. In patients with chronic neck pain, exercises that included cervical and shoulder strengthening and stabilization had a beneficial effect on pain at intermediate-term follow-up (between 3 to 12 months).

The optimal number of physical therapy sessions is not clear [20], and the benefit of physical therapy and supervised exercise may differ between settings and between specific subgroups of patients with chronic neck pain. As an example, in a randomized trial of patients with chronic neck pain due to whiplash injury comparing exercise and advice, there was no difference in pain at 12 months between those participating in 20 sessions of a comprehensive exercise program and those receiving only advice [21].

In addition, the results of supervised activity for the management of neck pain are mixed. In a randomized trial of 180 female office workers with neck pain greater than six months' duration, strength training and dynamic neck exercise were compared with no intervention for the treatment of neck pain [22]. More workers in the strength training and neck exercises group experienced substantial or complete relief of pain at one year compared with the no intervention group (73, 59, and 21 percent, respectively) [22]. However, in another randomized trial of female office workers, dynamic muscle training and relaxation training were no more effective than ordinary activity for pain relief [23].

Aerobic exercise – The addition of regular, aerobic exercise to neck-specific exercises or physical therapy may benefit patients with neck pain. As an example, in a randomized trial including 140 patients with chronic neck pain, the addition of aerobic training (cycling and brisk walking for at least 30 minutes daily, two days per week) to physical therapy reduced pain and disability at six months compared with physical therapy alone [18].

Tai Chi, Qigong and yoga – We routinely refer patients with chronic neck pain for participation in Tai Chi, Qigong, or yoga exercises when these programs are available; these exercises are adaptable for patients of all fitness and flexibility levels.

Qigong (Tai Chi is a form of Qigong) is a Chinese mind-body exercise involving slow movements, breathing exercises, and meditation and is an effective exercise strategy for those with chronic musculoskeletal pain, including neck pain. As examples, in two small randomized trials of patients with chronic neck pain, Qigong was compared with exercise therapy [24,25]. Qigong was more effective than no treatment and in both trials was as effective as exercise therapy in reducing pain and disability at six months. In one trial, patients were followed for an additional six months and improvements in the Qigong and exercise therapy arms were similarly maintained [24]. Larger trials are needed to compare Qigong with other active treatments such as traditional exercise therapy and behavioral therapy in the treatment of neck pain.

Yoga is a mind-body practice that includes physical postures, breathing control, and meditation. In addition, yoga actively incorporates the cognitive strategies of mindfulness and finding ease in discomfort. In meta-analyses of randomized trials including patients with chronic neck pain, yoga was effective in decreasing short-term neck pain and pain-related disability [26,27].

In one meta-analysis, mindfulness-based exercises (yoga, Qigong, or Pilates) were most effective for reducing pain compared with no therapy or other exercise therapies at the end of treatment [19].

Manipulation techniques — Manipulation techniques broadly include manual therapy and joint mobilization. Manual therapy and joint mobilization are "hands-on" manipulation techniques typically used by chiropractors, osteopathic clinicians, and physical therapists to increase joint and soft tissue mobility and flexibility. These techniques may be performed at low velocity and not beyond the normal end-range of movement. Spinal manipulation refers to a form of manual therapy that involves the movement of a joint near the end of its clinical range of motion, but it is not limited to low-velocity manipulations. (See "Spinal manipulation in the treatment of musculoskeletal pain".)

Manual therapy and joint mobilization – Manual therapy with gentle mobilization may be an appropriate adjunctive treatment modality for some patients with acute neck pain (eg, those with more severe pain, whiplash injury, significant functional impairment and kinesiophobia) in combination with physical or movement-based therapy. As an example, in a randomized trial of 94 patients with mechanical neck pain, a combination of manual therapy plus exercise (biweekly for three weeks) led to decreased disability scores at both short and long term, greater pain relief at short term, and increased patient perception of recovery compared with minimal care (advice, mobility exercise, and sham ultrasound) [28].

Spinal manipulation – In the absence of myelopathy or radiculopathy, spinal manipulation is an option for symptomatic management of patients with subacute and chronic neck pain who fail to improve despite education, home exercise, postural modification, and analgesics. Spinal manipulation may also be used as an adjunctive therapy for the management of acute pain flares in these patients.

We do not refer patients with acute neck pain for traditional high-velocity manipulation of the cervical spine as first-line treatment, given the unproven benefit and the small risk for serious adverse outcomes [29,30]. (See "Spinal manipulation in the treatment of musculoskeletal pain", section on 'Neck pain and headache'.)

Spinal manipulation may be effective for managing neck pain, but it is no more effective than other forms of therapy including exercise. In one trial of 270 patients with acute or subacute neck pain (2 to 12 weeks' duration) randomly assigned to spinal manipulation, pharmacotherapy, or home exercise, spinal manipulation resulted in decreased neck pain at 52 weeks compared with pharmacotherapy [31]. However, those receiving two sessions of home exercise instruction experienced similar pain reduction compared with those undergoing 15 spinal manipulation sessions.

In addition, like manual therapy, spinal manipulation is likely of benefit only when performed in conjunction with exercise or physical therapy. In a systematic review of randomized trials, spinal manipulation and/or mobilization for mechanical neck pain were not helpful when done alone but were beneficial when performed in conjunction with exercise [32]. In addition, the review also concluded that neither manipulation nor mobilization was superior to the other. (See "Treatment and prognosis of cervical radiculopathy".)

There are theoretical risks of serious adverse effects associated with cervical spinal manipulation, particularly among those with central spinal stenosis. For example, in a systematic review of patients with neck pain, while there were short-term benefits of cervical spinal manipulation, there was also a very small risk for serious adverse outcomes (5 to 10 per 10 million manipulations), including permanent impairment or death [29]. In other large studies, however, no association between cervical spinal manipulation and stroke was found [33], even among patients age 66 years and older [34].

Interventional treatments — Some patients with significant, persistent pain (in particular, those with prominent myofascial pain, whiplash injury, and facet joint arthropathy) are referred for interventional treatments to manage pain symptoms.

Dry needling and trigger point injections — Dry needling involves the insertion of a needle into palpably taut muscle bands, muscle knots, and trigger points. With each insertion, the needle is redirected in several planes; no medication is injected with this technique. Trigger point injections commonly refer to a similar technique but with the additional intramuscular injection of an anesthetic agent. An intramuscular injection of corticosteroid provides no additional benefit and should be avoided due to its propensity to cause local muscle necrosis.

Although there is a lack of high-quality data supporting the routine use of trigger point injections for all patients with neck pain [35], it is a low-risk intervention that some find helpful in the management of patients with isolated muscle spasm and taut bands [36,37].

There is some evidence to support the short-term benefit of trigger point injections in patients with chronic neck pain. As an example, in a systematic review of randomized trials including patients with chronic neck pain, intramuscular injection of lidocaine was superior to placebo for short-term pain relief [8]. (See "Evaluation of the adult patient with neck pain", section on 'Myofascial pain syndrome' and "Overview of soft tissue musculoskeletal disorders", section on 'Myofascial pain syndrome'.)

Cervical medial branch blocks — Cervical medial branch blocks anesthetize the innervation of the cervical zygapophyseal (facet) joint and are used for both diagnosis and treatment of cervical zygapophyseal joint-mediated neck pain. (See "Evaluation of the adult patient with neck pain", section on 'Cervical facet osteoarthritis'.)

In a randomized trial of 120 patients with chronic neck pain due to facet syndrome, medial branch blocks with steroid and local anesthetic were compared with local anesthetic alone [38]. After one injection, both groups experienced pain relief and functional improvement at 14 to 16 weeks with no difference between groups; for both treatment groups, a series of injections (average of 3.5 injections over one year) were required to provide adequate pain relief for 11 months. The quality of the study, however, was limited by a lack of a placebo group.

Percutaneous radiofrequency neurotomy — Percutaneous radiofrequency neurotomy (PRN) is a nerve ablation procedure and is an option after demonstration of a successful response to previous cervical medial branch block. Patients with severe or persistent neck pain due to whiplash injury, cervical facet arthropathy, or cervicogenic headaches are good candidates for PRN [39].

In a systematic review including six randomized trials of patients with chronic neck pain, PRN showed modest short-term relief of pain related to the zygapophyseal joint [40]. In one of the included trials involving 24 patients with whiplash injury, however, PRN resulted in longer-term pain relief than the placebo treatment (263 days versus 8 days) [41].

Psychologic and mind-body therapies — Cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) are among the mind-body techniques we use in the management of chronic neck pain. However, access to CBT, MBSR, and similar programs for patients with chronic pain may be limited by the availability of local providers, insurance coverage, and out-of-pocket costs. In addition, clinicians may encounter patient resistance to participation in such therapies, which may further limit use of this valuable resource.

Cognitive-behavioral therapy – CBT may help relieve neck pain symptoms through relaxation, stress reduction, and chronic pain management techniques. In a 2015 systematic review including 10 randomized trials of patients with neck pain of one to three months' duration, CBT was better than other types of interventions at reducing pain at short-term follow-up, although there was no difference in disability [42]. For patients with chronic neck pain, CBT was more effective than no treatment but did not improve pain compared with other interventions. (See "Approach to the management of chronic non-cancer pain in adults", section on 'Cognitive-behavioral therapy'.)

Mindfulness-based stress reduction – MBSR is a mind-body relaxation program that improves a person's ability to relax, cope with stress, and help manage pain. We refer patients with chronic neck pain to MBSR programs, where available, as adjunctive treatment to physical and movement-based therapy. (See "Approach to the management of chronic non-cancer pain in adults", section on 'Nonpharmacologic therapies'.)

ADJUNCTIVE TREATMENTS THAT MAY PROVIDE PAIN RELIEF — Although there is a lack of high-quality data supporting the efficacy of the following therapies in the management of neck pain, we do not discourage patients from using or pursuing these treatments. There is a lack of evidence of harm with these therapies, and patients may experience improvement in symptoms based upon expectations.

Massage therapy — Massage therapy for neck pain is difficult to evaluate due to the variety of massage techniques used. In a 2012 systematic review, evidence for the efficacy of massage for relief of neck pain was inconclusive due to methodologic flaws in existing studies [43]. However, these studies do not exclude the possibility that massage may provide an immediate or short-term benefit.

Acupuncture — Acupuncture traditionally consists of inserting small, fine needles into predetermined acupuncture points and is widely used in the management of musculoskeletal pain syndromes. The results of studies of acupuncture in patients with neck pain are mixed, and when a benefit was seen the durability of the benefit was unclear [44,45]. For example, in trial of 75 adults with subacute neck pain, those undergoing acupuncture were compared with patients treated with physical therapy alone [46]. Upon completion of treatment, both groups experienced moderate pain relief, with results sustained in both groups at six months. By contrast, in a systematic review of randomized trials of patients with subacute and chronic neck pain, acupuncture was slightly superior to both sham acupuncture and inactive treatment but was effective only for short-term pain relief [47]. (See "Overview of the clinical uses of acupuncture".)

THERAPIES THAT WE DO NOT ROUTINELY RECOMMEND — We do not routinely recommend or refer for the following treatments due to lack of high-quality data demonstrating benefit and/or the possible risk of harm.

Cervical collar – Routine use of cervical collars for neck pain should be discouraged since regular use may actually delay improvement [2,48,49]. As an example, in a systematic review of 11 randomized trials of patients with acute neck pain due to whiplash injury, those treated with rest and neck immobilization experienced more pain than those for whom exercise or the advice to remain active were recommended [50].

Nevertheless, brief use of a soft cervical collar may be helpful during periods of increased pain, particularly during sleep if disrupted by pain. However, it is important to stress that collars should be worn for short periods of time (three hours or less) during the day, and only for a period of one to two weeks, in order to avoid the development of muscle atrophy.

Low-level laser therapy – Low-level laser therapy (LLLT) is a non-thermal, single wavelength of light directed at the area of discomfort. Although the exact mechanism of action is not known, it is believed that LLLT may aid tissue repair and stimulate acupuncture points. LLLT is not widely used in the treatment of neck pain.

In a meta-analysis of 11 small trials of patients with neck pain of varying duration, LLLT reduced pain intensity, with results sustained to 22 weeks [51]. However, the included trials were small, treatment regimens varied widely, and there were concerns of bias with multiple trials.

LLLT may be beneficial in treating musculoskeletal pain syndromes, but larger trials with standardized regimens need to be done before the application can be recommended for the treatment of neck pain.

Cervical traction – In cervical traction, gentle pressure is applied to the head, stretching the neck to increase the space between the discs and vertebrae. In a meta-analysis including seven trials of patients with nonradicular neck pain, those receiving intermittent cervical traction were compared with those receiving sham traction [52]. Although those receiving intermittent traction did experience more pain relief immediately following the treatments compared with the control group, the relief was not sustained, and there was no improvement in neck pain disability.

Botulinum toxin injections – Meta-analyses of randomized trials in patients with neck pain have found no benefit of botulinum toxin intramuscular injections in the short-term (four weeks) or long-term (six months), when compared with placebo [53,54].

Transcutaneous electrical nerve stimulation – Although transcutaneous electrical nerve stimulation (TENS) is widely used in the management of musculoskeletal pain syndromes, the evidence of its efficacy is uncertain.

In a systematic review including seven trials of TENS in the treatment of chronic neck pain, no definitive conclusions could be drawn due to the heterogeneity in study interventions and measured outcomes [55]. Even when including only the two trials comparing TENS with placebo (sham TENS treatment) for neck pain, there was very low certainty evidence for similar short-term pain outcomes.

Electromagnetic therapy – Low-energy pulsed electromagnetic therapy (PEMT) is a therapy that can be performed at home [56,57]. In a systematic review of PEMT in patients with neck pain of variable duration, there was low-quality evidence of minimal benefit (limited to immediate post-treatment pain relief) among those with chronic neck pain or whiplash syndrome [58].

Surgical intervention – Surgical intervention is rarely appropriate and infrequently used in patients with persistent nonradicular neck pain. A discussion of treatment options for cervical radiculopathy and cervical spondylotic myelopathy is presented separately. (See "Treatment and prognosis of cervical radiculopathy" and "Cervical spondylotic myelopathy".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Upper spine and neck disorders".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Neck pain (The Basics)" and "Patient education: Muscle strain (The Basics)" and "Patient education: Bacterial meningitis (The Basics)")

Beyond the Basics topic (see "Patient education: Neck pain (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Most mild to moderate neck strains resolve within three weeks – Most mild to moderate cervical strains resolve within the first three weeks with conservative measures; patients with more severe neck pain, and particularly those with whiplash injuries, may have persistent symptoms, including headache, for longer periods of time. The management strategy described below only applies to patients without radicular complaints; if at any point neurologic symptoms or signs develop, the treatment approach will change. (See 'Acute neck pain' above.)

Initial conservative therapy for all patients – Initial treatment for all patients with acute neck pain (duration less than six weeks) includes patient education, postural (mechanical) modification (picture 1), early mobilization through participation in a home exercise program (picture 3 and picture 4 and movie 1 and movie 2 and movie 3 and movie 4 and movie 5), and adjunctive pharmacologic therapy if needed. For patients with resolved neck pain, we encourage adherence with proper posture and sleep position, as well as participation in the home exercise program to prevent a recurrence of symptoms. (See 'Initial treatment for all patients' above.)

Early adjunctive therapy for patients with more severe neck pain or risk factors for chronic pain – Patients with more severe neck pain, symptoms due to whiplash injury, or risk factors for chronic pain require more intensive management with earlier referral for adjunctive therapies, including physical therapy, manipulation therapy, and psychologic or mind-body therapies. (See 'Patients for whom additional treatment is needed' above.)

For patients with more severe pain symptoms, particularly those with pain due to whiplash injury, and patients with significant functional impairment and kinesiophobia, we typically refer for physical therapy at approximately four weeks. In addition, we refer these patients for adjunctive manual therapy and joint mobilization to be performed concurrent with physical therapy.

Patients with risk factors for developing chronic pain (eg, severe functional impairment, mood disturbance related to pain, and catastrophizing) are referred for physical therapy at approximately four weeks. In addition, we often refer these patients for cognitive-behavioral therapy (CBT) at six to eight weeks.

Adjunctive pharmacotherapy for patients with more severe acute neck pain – For patients with acute neck pain and more significant discomfort, we use pharmacotherapy for additional symptom management.

For these patients, we suggest the use of a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen as first-line adjunctive pharmacotherapy rather than other medications (Grade 2C). We evaluate patient specific risk factors and prior response to medication therapy to guide our choice. No additional pain relief is achieved by using concurrent NSAIDs and acetaminophen. (See 'NSAIDs or acetaminophen as first-line pharmacotherapy' above.)

For patients with symptoms not well managed with an NSAID or acetaminophen alone, particularly for those with prominent muscle spasm, we add a non-benzodiazepine skeletal muscle relaxant. (See 'Skeletal muscle relaxant if NSAID or acetaminophen therapy is inadequate' above.)

For patients with acute neck pain, for whom NSAID or acetaminophen plus skeletal muscle relaxants fail to adequately symptoms, we either add a small dose of tramadol to their regimen or substitute tramadol for the skeletal muscle relaxant. (See 'If NSAID or acetaminophen and muscle relaxants are insufficient' above.)

Management of persistent neck pain – For all patients with moderate to severe pain that persists beyond six weeks, and which interferes with daily functioning despite initial treatment, we perform imaging and suggest referral for physical therapy (Grade 2C). (See "Evaluation of the adult patient with neck pain", section on 'Indications' and 'Physical therapy for all patients' above.)

Treatments which may be used concurrently with physical therapy in patients with subacute and chronic neck pain include trigger point injections, for those with taut bands or significant muscle tightness, and manual therapy and joint mobilization for patients with whiplash injury. The use of acupuncture and massage therapy may also provide short-term pain relief. Spinal manipulation may be appropriate adjunctive treatment for patients with subacute or chronic neck pain without myelopathy, radiculopathy, or evidence of central spinal stenosis. (See 'Additional treatments for subacute pain' above.)

CBT and exercise for chronic neck pain – For all patients with neck pain that persists beyond 12 weeks despite the above treatments, we refer for CBT if they have not yet been referred. In addition, patients are encouraged to continue exercise, through a physical therapy provider or other appropriate exercise program such as Tai Chi, Qigong, or yoga. (See 'Multimodal care for chronic neck pain' above and 'Physical and movement-based therapies' above.)

Pharmacotherapy for chronic neck pain – Some patients with subacute and chronic neck pain are unable to discontinue pharmacologic therapy due to significant discomfort despite nonpharmacologic treatments. (See 'Adjunctive pharmacotherapy for subacute and chronic neck pain' above.)

For patients with adequate pain relief on an NSAID or acetaminophen, we continue the medication, use the lowest effective dose, and encourage use only for "flare-ups" (episodes of more severe pain) if possible. (See 'Patients with adequate pain relief on current pharmacotherapy' above.)

For patients who have been taking a skeletal muscle relaxant with adequate symptom control, we continue the medication at the lowest effective dose and frequency, and we discontinue as soon as symptoms permit. (See 'Patients with adequate pain relief on current pharmacotherapy' above.)

For patients on tramadol who have had a good response with sufficient pain control, we may consider continuing long-term therapy in some patients. We engage in shared decision-making, reviewing the risks and benefits of chronic opioid therapy. If appropriate, we prescribe the lowest effective dose, perform appropriate patient monitoring, and attempt to discontinue the drug at regular intervals. (See 'Patients with adequate pain relief on current pharmacotherapy' above.)

For patients with neck pain that persists beyond six weeks, and who have had inadequate pain relief with tramadol (or if chronic tramadol therapy is not a consideration), we initiate therapy with duloxetine or a tricyclic antidepressant. We typically prefer duloxetine over a tricyclic antidepressant in older patients and in patients with a coexisting mood disorder. In patients for whom sleep is significantly impacted by pain symptoms, a tricyclic antidepressant may be preferred. (See 'Second-line pharmacotherapy' above.)

For patients who continue to have neck pain that causes significant pain and functional impairment despite the medical and pharmacologic therapies reviewed above, we discontinue antidepressants and tramadol and begin treatment with gabapentin. (See 'Third-line pharmacotherapy' above.)

Interventional treatments for chronic neck pain – For some patients with chronic neck pain, certain interventional treatments may be beneficial (eg, dry needling and trigger point injections for those with prominent myofascial pain and taut bands; and cervical medial branch block or percutaneous radiofrequency neurotomy for severe or persistent neck pain due to whiplash injury, cervical facet arthropathy, or cervicogenic headaches). (See 'Interventional treatments' above.)

Therapies we do not routinely recommend – We do not routinely recommend the use of cervical collars, low-level laser light therapy (LLLT), cervical traction, botulinum toxin injections, transcutaneous electrical nerve stimulation (TENS), electromagnetic therapy, or surgery for the treatment of nonradicular neck pain. (See 'Therapies that we do not routinely recommend' above.)

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References

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