What is the recommended treatment for an adult patient with neck pain and no underlying severe medical conditions, considering physiotherapy (physical therapy) as a primary intervention?

Physiotherapy for Neck Pain

For adults with nonspecific neck pain, implement a structured exercise program of cervical and scapulothoracic strengthening and stretching 2-3 times per week, combined with manual therapy techniques, as this approach provides superior pain relief and functional improvement compared to continued general practitioner care or passive modalities alone. 1, 2

Primary Treatment Algorithm

First-Line Exercise Therapy

• Prescribe cervical and scapulothoracic strengthening exercises performed 2-3 times per week on non-consecutive days, as specific neck strengthening demonstrates superior short- to medium-term pain relief compared to general exercise programs 1
• Include scapular stabilization exercises targeting rotator cuff and posterior shoulder girdle muscles, since scapular dysfunction frequently accompanies neck pain 1
• Start with low resistance (40-60% of 1-repetition maximum) for 10-15 repetitions, performing 1 set of 8-12 reps 1
• Execute exercises at moderate to slow controlled speed through full range of motion, exhaling during contraction and inhaling during relaxation to prevent Valsalva maneuver 1

Manual Therapy Integration

• Add manual therapy (specific mobilization techniques) once per week for 6 weeks, as this achieves 68.3% success rates compared to 50.8% for exercise therapy alone and 35.9% for continued general practitioner care 2
• Manual therapy produces statistically significant pain intensity reductions of 0.9 to 1.5 points on a 0-10 scale compared to other interventions 2
• Low-level laser therapy provides moderate effect sizes for short-term function and pain improvement 3
• Massage therapy demonstrates small but meaningful improvements in short-term function and pain 3

Adjunctive Modalities

• Apply local heat before exercise sessions to improve tissue elasticity and reduce pain, as heat has higher strength of recommendation than ultrasound 1
• Consider acupuncture for small improvements in short- and intermediate-term function, though pain benefits versus sham acupuncture are not consistently demonstrated 3

Critical Contraindications

Avoid these harmful interventions:

• Never prescribe overhead pulley exercises, as these encourage uncontrolled abduction and have the highest incidence of developing shoulder pain 1
• Do not use vigorous, repetitive exercises or explosive movements that stress cervical structures 1
• Avoid passive range-of-motion exercises performed aggressively or improperly, as these cause more harm than benefit 1
• Do not offer interventional procedures including facet joint radiofrequency ablation, epidural injections, or intramuscular injections for chronic neck pain 4

Pain Threshold Monitoring

• Use pain as the intensity guide: discontinue exercises if pain persists more than one hour after completion 1
• This represents a practical safety parameter that prevents overtraining and tissue damage 1

Home Program Components

• Provide education on load reduction strategies during daily activities and proper positioning 1
• Incorporate cognitive behavioral therapy, distraction, mindfulness, relaxation, and guided imagery as adjunctive psychological interventions 1

When Physiotherapy Alone Is Insufficient

Red Flag Assessment

Before initiating physiotherapy, screen for serious pathology requiring imaging or specialist referral: history of cancer, unexplained weight loss, fever, immunosuppression, IV drug use, elevated inflammatory markers (WBC, ESR, CRP), myelopathy signs, progressive weakness, or bowel/bladder dysfunction 5, 4

Pharmacological Adjuncts

• Add acetaminophen 1000 mg every 6 hours (maximum 4 grams daily) for continuous pain control if exercise therapy alone provides inadequate relief 4
• Consider topical NSAIDs for localized pain before systemic NSAIDs, given cardiovascular and renal risks 4
• Reserve opioids strictly for breakthrough pain when non-opioid strategies fail, using shortest duration and lowest effective dose 4

Evidence Quality Considerations

The recommendation for exercise therapy is supported by consistent findings across multiple high-quality guidelines 3, 1. Manual therapy demonstrates the strongest single-study evidence with a well-designed randomized controlled trial showing clear superiority over both physical therapy alone and continued general practitioner care 2. The combination approach leverages both active patient participation through exercise and passive manual techniques, addressing both muscular dysfunction and joint mobility restrictions that characterize mechanical neck disorders 6.