What is the treatment for cervical muscle strain?

Treatment for Cervical Muscle Strain

For acute cervical muscle strain, initiate activity modification with short-term cervical collar immobilization (up to 2-3 weeks), combined with NSAIDs as first-line pharmacotherapy, while muscle relaxants like cyclobenzaprine offer no additional benefit over NSAIDs alone. 1, 2, 3

Initial Conservative Management

Activity modification and cervical collar use are the cornerstone of initial treatment for mild cervical strain with axial neck pain. 1 The collar should be used for short periods only—up to 2-3 weeks maximum—as prolonged immobilization can lead to muscle deconditioning. 4 This approach is particularly important when cervical strain occurs in the context of concussion, where the injury mechanism involves both head trauma and neck structures. 5

Clinical Presentation to Recognize

Cervical strain manifests as: 5

• Neck pain and stiffness
• Neck or upper extremity weakness
• Persistent headache (often occipital/suboccipital location)
• Pain/tenderness on cervical spine palpation (midline, paraspinal, and suboccipital muscles)
• Limitation of cervical motion with pain on movement
• Possible paresthesia in upper extremities or occipital region

Pharmacologic Treatment Algorithm

First-Line: NSAIDs Monotherapy

NSAIDs are the recommended first-line drug treatment, showing large improvements in spinal pain and function with Level Ib evidence. 2 Prescribe NSAIDs for up to 6 weeks for short-term pain relief. 2

For patients with gastrointestinal risk factors, use either: 2

• Non-selective NSAIDs plus a gastroprotective agent, OR
• Selective COX-2 inhibitor

Muscle Relaxants: Not Recommended as Add-On Therapy

Cyclobenzaprine, while FDA-approved as an adjunct to rest and physical therapy for acute painful musculoskeletal conditions, provides no additional benefit when combined with NSAIDs for cervical strain. 4, 3, 6

The evidence is clear on this point:

• A randomized controlled trial found no significant differences in pain scores, time to resumption of activities, or adverse events between ibuprofen alone, cyclobenzaprine alone, or combination therapy. 3
• A larger multicenter trial (867 patients) demonstrated that cyclobenzaprine 5mg TID plus ibuprofen was not superior to cyclobenzaprine monotherapy for acute neck pain with muscle spasm. 6
• If muscle relaxants are used, they should only be prescribed for 2-3 weeks maximum, as adequate evidence for longer use is not available. 4

There is some evidence supporting muscle relaxants specifically for acute neck pain associated with muscle spasm, but this evidence is conflicting and does not support routine combination therapy. 7

Physical Therapy and Exercise

Physical therapy should be initiated early, focusing specifically on posture correction and ergonomic modifications. 1 Home exercise programs improve function in the short term compared to no intervention (Level Ib evidence). 2

Group physical therapy demonstrates significantly better patient global assessment compared to home exercise alone. 2 The combination of non-pharmacological and pharmacological treatments is complementary and both are valuable in initial and continuing treatment. 2

Duration of Conservative Treatment

For uncomplicated cervical strain: 1, 4

• Cervical collar: up to 2-3 weeks
• NSAIDs: up to 6 weeks
• Physical therapy: ongoing as needed

For cervical strain associated with concussion, nonoperative therapy including immobilization, activity modification, and anti-inflammatory medications may be appropriate for up to 3 years. 1

Red Flags Requiring Further Evaluation

If symptoms persist beyond 4-6 weeks or neurological symptoms develop, MRI should be considered to rule out: 2

• Cervical spondylotic myelopathy with progressive neurological deficits
• Spinal cord compression
• Radiculopathy requiring surgical intervention

Nearly 50% of patients may continue to have residual or recurrent episodes of pain up to 1 year after initial presentation. 2, 7 Factors associated with poor prognosis include female gender, older age, coexisting psychosocial pathology, and radicular symptoms. 2

Critical Pitfalls to Avoid

• Do not routinely combine muscle relaxants with NSAIDs—the evidence shows no additional benefit and increases medication burden and side effects. 3, 6
• Do not use cervical collars for prolonged periods beyond 2-3 weeks, as this can lead to muscle deconditioning. 4
• Do not rely solely on imaging findings for treatment decisions, as spondylotic changes correlate poorly with the presence of neck pain in patients over 30 years. 2
• Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy. 2