What is the best course of treatment for a 24-year-old female patient with a history of cervicalgia (cervical pain) and muscle spasm, presenting with a stiff neck upon waking, who has previously been diagnosed with muscle spasm of the right sternocleidomastoid (SCM) and posterior scalenes muscles, and has been given a home exercise program (HEP) 8 months ago?

Management of Recurrent Neck Stiffness in a Young Adult

Reassess for red flags and reinitiate conservative physical therapy with a structured home exercise program, as most mechanical neck pain resolves with nonoperative management, but consider imaging if symptoms persist beyond 6-8 weeks or new concerning features emerge. 1

Immediate Assessment Priorities

Screen for Red Flags

Before proceeding with conservative management, you must exclude serious pathology:

• Constitutional symptoms (fever, unexplained weight loss, night sweats) 1
• Elevated inflammatory markers (if CRP or ESR were checked) 2
• History of malignancy or immunosuppression 1
• Neurological deficits (weakness, numbness, bowel/bladder dysfunction, gait disturbance) 1
• Intractable pain unresponsive to conservative measures 1
• Recent trauma or history of IV drug use 1

If any red flags are present, obtain MRI cervical spine without contrast immediately. 1 Given this patient has no documented red flags and her previous evaluation 8 months ago identified benign muscle spasm, she likely has mechanical neck pain.

Evaluate Treatment Adherence

Determine if she completed and maintained her home exercise program from 8 months ago. Approximately 50% of patients with neck pain have residual or recurrent symptoms up to 1 year after initial presentation, making recurrence common. 1, 3

Conservative Management Approach

Physical Therapy Referral

Refer back to physical therapy for a comprehensive treatment program, as 75-90% of cervical radiculopathy and mechanical neck pain cases resolve with conservative nonoperative therapy. 1

The physical therapy program should include:

• Posture training and ergonomic assessment (particularly sleep positioning, as symptoms occur upon waking) 4
• Dynamic shoulder/scapular strengthening to address muscle imbalances 4
• Cervical stabilization exercises 4
• Stretching of SCM and scalene muscles (the previously identified problem areas) 4
• Manual therapy techniques including muscle energy techniques, which show statistically significant improvement in cervical range of motion and pain 5
• Progressive home exercise program with clear instructions for daily compliance 4

Pharmacologic Management

For acute symptom relief during the initial treatment phase:

• NSAIDs (ibuprofen or naproxen) for pain and inflammation 2
• Short-term muscle relaxants may be considered if muscle spasm is prominent, as there is some evidence supporting their use in acute neck pain associated with muscle spasm 3

Avoid prolonged use of muscle relaxants beyond 1-2 weeks due to sedation and dependency risks.

Patient Education

Counsel the patient on:

• Expected timeline: Most acute neck pain improves within 4-6 weeks with conservative treatment 3
• Activity modification: Avoid prolonged static postures, particularly during sleep 4
• Compliance with home exercises: Critical for preventing recurrence 4
• Warning signs: Return immediately if she develops arm pain/numbness, weakness, or severe unrelenting pain 1

Follow-Up and Imaging Considerations

Short-Term Follow-Up

Schedule follow-up in 2-4 weeks to assess response to conservative therapy. 2

Imaging Indications

Do NOT order imaging at this visit unless red flags are present, as imaging has no additive diagnostic value for mechanical neck pain and degenerative changes are present in 53.9% of asymptomatic individuals. 1

Consider MRI cervical spine without contrast if:

• Symptoms persist beyond 6-8 weeks of appropriate conservative therapy 1
• New neurological symptoms develop (radicular pain, weakness, numbness) 1
• Red flags emerge during follow-up 1

MRI is superior for evaluating soft tissue abnormalities, disc herniation, nerve root impingement, and excluding serious pathology. 2, 1

Common Pitfalls to Avoid

• Premature imaging: Ordering MRI too early leads to overdiagnosis of incidental findings that don't correlate with symptoms and may lead to unnecessary interventions 1
• Assuming previous diagnosis still applies: While her prior PT notes identified SCM/scalene spasm, reassess for new pathology, particularly if presentation differs 1
• Inadequate home exercise program: Simply telling patients to "do exercises" without structured follow-up leads to poor compliance 4
• Missing sleep ergonomics: Since symptoms occur upon waking, specifically address pillow height, mattress support, and sleep positioning 4