What therapy is recommended for a stiff neck or locked neck?

Treatment for Stiff Neck or Locked Neck

For acute stiff neck or locked neck, initiate self-management strategies with supervised neck exercises and stretching, combined with NSAIDs (such as ibuprofen) and heat or cold application as first-line therapy. 1

Initial Assessment: Rule Out Red Flags

Before proceeding with conservative management, screen for serious pathology requiring urgent evaluation:

• Constitutional symptoms (fever, weight loss, night sweats) 1, 2
• Neurological deficits (weakness, numbness, bowel/bladder dysfunction) 3, 1
• History of cancer or immunosuppression 1, 2
• History of IV drug use (raises concern for infection) 2
• Severe intractable pain or vertebral body tenderness on palpation 3, 2
• Trauma with high-risk features 3

If any red flags are present, obtain MRI cervical spine without contrast immediately to evaluate for vertebral osteomyelitis, discitis, metastatic disease, cervical myelopathy, or primary spinal tumors. 2

If no red flags are present, imaging is not indicated and conservative management should proceed. 3, 1, 2

First-Line Non-Pharmacological Treatment

Active Exercise (Cornerstone of Therapy)

• Supervised neck exercises and stretching provide significant pain relief and functional improvement and should be initiated immediately. 1
• Graded physical exercise is recommended, particularly for patients with autonomic instability or physical deconditioning. 4
• Self-management strategies should be offered as the cornerstone of treatment, emphasizing active participation rather than passive therapies. 1

Heat or Cold Application

• Low-level continuous heat (LLCH) significantly reduces pain and improves range of motion when used as adjunct therapy between physical therapy sessions. 5
• Heat application increases blood flow and promotes healing in affected tissues. 5
• Both heat and cold application are recommended as first-line interventions. 1

Manual Therapy

• Manual treatment of the neck including mobilization, manipulation, and trigger point therapy can provide substantial pain reduction. 4, 1
• Manual therapy should address cervical and thoracic spine dysfunction. 4
• This intervention is particularly beneficial when combined with exercise. 4

First-Line Pharmacological Treatment

• NSAIDs (such as ibuprofen) are recommended as first-line medication for pain relief. 1
• The combination of LLCH with ibuprofen as adjunct to physical therapy significantly improves pain attenuation and increases compliance with home exercise programs. 5
• Muscle relaxants (such as cyclobenzaprine) are effective for acute neck pain associated with muscle spasm. 6, 7
• For elderly patients or those with hepatic impairment, cyclobenzaprine should be initiated at 5 mg and titrated slowly upward. 8

Physical Therapy Referral

Physical therapy is indicated for persistent symptoms beyond initial self-management attempts. 1

Physical therapy should include:

• Vestibular rehabilitation if balance or dizziness symptoms are present 4
• Manual treatment of cervical and thoracic spine 4
• Progressive exercise programs 4

Timeline and Escalation

• Most acute cervical strain improves within 7-8 weeks with conservative management, though approximately 50% may have residual or recurrent symptoms at one year. 3, 7
• If symptoms persist beyond 4-6 weeks despite conservative management, imaging may be warranted. 1
• If symptoms persist beyond 6-8 weeks of conservative therapy, consider MRI cervical spine without contrast to evaluate for nerve root compression, disc herniation, or facet joint arthropathy. 2

Common Pitfalls to Avoid

• Do not proceed to invasive procedures or imaging before exhausting conservative options in the absence of red flags. 1
• Do not rely solely on passive treatments without incorporating active exercises, as this reduces treatment effectiveness. 1
• Do not use cervical collars, as international consensus guidelines recommend against their use due to growing evidence of complications and lack of benefit. 3
• Avoid opioids for chronic neck pain due to limited evidence of benefit and risk of adverse effects. 1
• Do not neglect patient education about the condition and self-management strategies, as this is essential for optimal outcomes. 1

Special Considerations

• For neuropathic components of neck pain (radiating pain, numbness, tingling), gabapentin may be considered. 1
• Acupuncture may be considered, though evidence is moderate. 1, 6
• Cognitive behavioral therapy is beneficial for chronic neck pain management if symptoms persist beyond the acute phase. 1
• 75-90% of cervical radiculopathy cases resolve with conservative nonoperative therapy, so surgical referral should be reserved for refractory cases. 2