What is the recommended treatment for a patient presenting with neck strain?

Treatment of Neck Strain

For acute neck strain, patients should remain active with early mobilization and exercise combined with NSAIDs (ibuprofen 400mg) for pain control, while avoiding prolonged immobilization that leads to muscle weakness and delayed recovery. 1

Initial Assessment and Red Flags

Before initiating treatment, clinicians must rule out serious pathology by evaluating for:

• Constitutional symptoms including fever >101°F or unexplained weight loss, which suggest infection or malignancy 2, 1
• Neurological deficits such as radiculopathy, myelopathy, or new focal neurologic symptoms requiring urgent MRI 3, 1, 4
• Recent bloodstream infection particularly with Staphylococcus aureus, which raises concern for vertebral osteomyelitis 3
• Persistent pain >2 weeks without improvement, which warrants further evaluation 2

If any red flags are present, obtain MRI without contrast immediately rather than proceeding with conservative management. 1

Pharmacologic Management

NSAIDs are first-line therapy for acute neck strain:

• Ibuprofen 400mg orally provides effective analgesia and should be initiated immediately 5
• Muscle relaxants may be added for short-term use (3-7 days) when muscle spasm is prominent, though evidence is limited 6, 4
• Avoid routine antibiotic prescription unless clear signs of bacterial infection are present (purulence, fever, elevated inflammatory markers with infectious source) 3, 1

The evidence shows that NSAIDs provide the primary pain relief, with adjunctive therapies offering modest additional benefit. 5

Physical Therapy and Exercise

Active mobilization is superior to immobilization:

• Early mobilization and exercise should begin immediately rather than rest, as activity promotes healing and prevents stiffness 2, 1, 4
• Referral to physiotherapy for individually tailored graded exercise is recommended if pain persists beyond initial treatment 2, 1
• Avoid prolonged immobilization which causes muscle weakness, stiffness, and delayed recovery 2, 1

Exercise therapy has the strongest evidence base among conservative treatments for neck pain. 4

Adjunctive Therapies

Heat or cold application (patient preference):

• 30 minutes of heating pad or cold pack provides mild additional pain relief when combined with NSAIDs 5
• Low-level continuous heat between physical therapy sessions may improve compliance with home exercises and modestly reduce pain 7
• Choice between heat versus cold should be based on patient preference, as efficacy is equivalent 5

Soft collar use (limited duration only):

• Short-term use (days, not weeks) may provide symptom relief initially 2, 1
• Long-term use must be avoided as it causes muscle weakness and dependence 2, 1

Patient Education and Self-Monitoring

Patients must be educated on:

• Weekly self-monitoring of pain intensity and functional limitations 2
• Warning signs requiring immediate evaluation: difficulty swallowing, fever >101°F, progressive neurologic symptoms, or unexplained weight loss 2, 1
• Expected timeline: Most acute strains improve within 2-4 weeks, but nearly 50% experience recurrent or persistent symptoms requiring ongoing self-management 1, 4
• Ergonomic modifications at work and home to reduce ongoing strain 2, 1

Follow-Up Protocol

Structured follow-up is essential:

• Document a clear follow-up plan to assess resolution or determine if additional evaluation is needed 3, 2
• Re-evaluate at 2 weeks if symptoms persist or worsen 2, 1
• Consider imaging (MRI) only if red flags develop or pain is refractory to 4-6 weeks of conservative treatment 1, 4

Critical Pitfalls to Avoid

• Do not order imaging without red flags - unnecessary MRI in acute neck strain does not improve outcomes and reveals high rates of asymptomatic abnormalities that complicate management 1, 4
• Do not prescribe antibiotics empirically - most neck pain is mechanical, not infectious, and inappropriate antibiotics delay proper diagnosis 3, 1
• Do not recommend prolonged rest - immobilization worsens outcomes compared to early mobilization 2, 1
• Do not rely on passive treatments alone - heat, cold, and manual therapy must be combined with active exercise for optimal outcomes 2, 1