The tissue injury and clinical signs and symptoms of cervical spine strain/sprain injuries are treated during the acute phase of rehabilitation. The goals of this phase are the following:
Therapeutic activities during the acute phase of rehabilitation include the following:
If no neurologic history or deficit is present in a patient with a cervical strain and/or sprain, the athlete should use ice packs for 15-20 minutes every 1-2 hours or have an ice massage for 5-10 minutes every 1-2 hours during the early management of the injury. This treatment aids in decreasing muscle spasms, decreasing pain, and promoting vasoconstriction.
Cold has a number of physiologic effects that are therapeutic. Local application of cold causes vasoconstriction, lowers cell metabolism, decreases extensibility of collagen tissue, decreases muscle contractility, decreases nerve conduction velocity, and increases the pain threshold. The spasticity of the muscle is reduced because local cold affects the muscle spindle’s responsiveness to stretching. Local cold also has a direct effect on the conduction velocities of the afferent and efferent fibers, which further decreases muscle spasm.
The relatively deep penetration of cryotherapy makes it an ideal form of treatment for tissues lying deep to superficial layers. The cooling agent must be utilized for a sufficient amount of time for effective deep-tissue cooling to occur. Subcutaneous fat is an effective thermal barrier to heat exchange. A duration of 15-30 minutes is a commonly accepted timeframe required for therapeutic results and physiologic changes to take place. Ice is far more penetrating than heat. Because the vasodilation responses of heat therapy increase tissue edema and may extend the injury or delay healing, heat is not recommended in the acute stage.
Starting active ROM (AROM) and isometric strengthening exercises as soon as possible is very important. After at least 24 hours of cryotherapy, most patients are able to start gentle, painless active-assistive range of motion (AAROM) or AROM. To aid in AROM, transcutaneous nerve stimulation (TENS) or cryokinetics (exercising while the musculature is numbed with ice) may also be used.
Isometric exercises are started in neutral positions and then progressed through the full ROM once the patient demonstrates that ROM has improved. Pain should not be exacerbated by these exercises. AROM and strengthening exercises are progressively increased until the athlete achieves full pain-free ROM and normal strength. Stretching exercises should not be instituted acutely because they may cause reactive paraspinal muscle spasm and tightness. Gentle passive stretching may begin after resolution of the acute inflammatory phase (usually within 72 h), which avoids eccentric muscle loads and stays within the painless arc of motion.
The reactive cervical spasm and tightness after an injury can produce a loss of ROM and chronic contractures if not corrected. Chronic contractures greatly increase the potential for reinjury because if a contracture exists, sudden motion at a moment of contact through that restricted ROM is likely to reproduce the injury and severe pain. A program of cervical stretching and ROM exercises can prevent contractures and restore a protective ROM.
While the athlete undergoes progressive rehabilitation for a cervical injury, stationary bicycling provides a way of maintaining aerobic fitness and an athlete’s competitive weight. Swimming also offers an acceptable aerobic exercise program in a semi-unweighted environment; however, a mask and snorkel should be used to avoid aggravation of the cervical muscles that is encountered as the neck is rotated during breathing when swimming.
Any aerobic exercise should be modified for the particular injury so that the activity does not exacerbate the patient’s symptoms. The repetitive impact encountered during running, in particular, can aggravate a cervical injury and should be avoided early on in the recovery period. Before workouts, light exercise and stretching should be performed to prepare the muscles for activity.
Criteria for advancement to the recovery phase of rehabilitation include the following:
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The clinician should always rule out a significant bony or ligamentous injury, as missing such an injury could result in neurologic injury. <http://emedicine.medscape.com/article/94387-treatment> 18 <http://emedicine.medscape.com/article/94387-treatment> ,19 <http://emedicine.medscape.com/article/94387-treatment>
Consult a spinal surgeon for any patient with suspected ligamentous spinal instability.
Athletes who have limited ROM and severe pain with a history of a collision can be placed in cervical immobilization in order to rest the musculature and assist with pain control. Careful instruction should be given to patients using cervical collars so that dependency does not occur. Patients should spend at least 1 of every 3 hours out of the cervical collar by the third day of use; this time can then be gradually increased. The patients should discontinue collar use by 1 week from their injury unless there is a significant bony/ligamentous injury.
Manual therapy techniques can also help to decrease pain and improve mobility and function to the point that the patient may begin to exercise in a painless manner. These techniques include soft-tissue massage, manually sustained or rhythmically applied muscle stretching, traction applied in the longitudinal axis of the spine, and passive joint mobilization.
To help decrease pain and spasm, a trained therapist may apply grade 1 or grade 2 mobilizations. Repetitive passive joint oscillations carried out at the limit of the joint’s available ROM can have a mechanical effect on joint mobility, thus improving a restriction of vertebral motion. Mechanically controlled passive or active movements of joints can improve remodeling of the local connective tissue, the rate of tendon repair, and the gliding function within tendon sheaths during the repair process.
If the patient’s pain is not significantly relieved during the acute phase of rehabilitation, trigger point injections, typically along the medial border of the scapula, may help decrease trigger zones and referred pain and help improve muscular flexibility. These injections may allow rehabilitation to progress more rapidly, but they should be used judiciously when the active rehabilitation has stalled. Repeated injections are not recommended.
During the recovery phase of rehabilitation, the tissue overload and functional biomechanical deficit complexes are addressed. <http://emedicine.medscape.com/article/94387-treatment> 12 <http://emedicine.medscape.com/article/94387-treatment> ,13 <http://emedicine.medscape.com/article/94387-treatment> ,14 <http://emedicine.medscape.com/article/94387-treatment> ,15 <http://emedicine.medscape.com/article/94387-treatment> ,16 <http://emedicine.medscape.com/article/94387-treatment> ,17 <http://emedicine.medscape.com/article/94387-treatment>
The goals of this phase are the following:
Therapeutic activities during this phase include the following:
NSAIDs are probably unnecessary in this phase, and these agents should be tapered. The improved ROM permits further normalization of the patient’s posture as muscular strength and balance are enhanced to help maintain the improved posture during daily activities as well as athletic training and competition. Strength training using independent single-plane and complex multiplane coordinated motions is performed using varying combinations of concentric and eccentric isotonic exercises. Thera-Band or Sportscord can be used to allow training at home. Criteria for advancement to the maintenance phase of rehabilitation include the following:
Other Treatment (Injection, manipulation, etc.)
Manual therapy, including soft-tissue and manipulative techniques, still may be needed to help eliminate vertebral motion restrictions and improve the flexibility and motion of the soft tissues so that cervical PROM and AROM are normalized.
Occasionally, trigger point injections may be used for recalcitrant, taut, hyperirritable muscles. Again, multiple and repeated injections are discouraged.
During the maintenance phase of rehabilitation, the functional biomechanical deficit and subclinical adaptation complexes are addressed. The goals of this final phase of rehabilitation are the following:
Therapeutic activities during this phase include the following:
Soft-tissue flexibility and proper balance of flexibility and strength are emphasized to allow the athlete to assume and maintain a biomechanically correct posture. Power and endurance training is focused on maintaining normal multiplane-coupled cervical motion.
Pain and inflammation can be reduced by the judicious use of NSAIDs. The antiprostaglandin effect of NSAIDs may control the inflammatory response to an injury and may provide pain relief. The duration of the analgesic effect of an NSAID may be different than the duration of its anti-inflammatory effect. Some investigators have expressed concern that NSAIDs may actually interfere with the later stages of tissue repair and remodeling in which prostaglandins still help mediate cleanup of debris. The dosage, timing, and potential side effects of NSAIDs should be evaluated.
Nonsteroidal anti-inflammatory drugs
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Naproxen (Naprosyn, Naprelan, Anaprox)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in the decrease of prostaglandin synthesis.
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Muscle relaxants are thought to work centrally by suppressing conduction in the vestibular cerebellar pathways. These agents may have an inhibitory effect on the parasympathetic nervous system.
Skeletal muscle relaxant that acts centrally and reduces motor activity of tonic somatic origins, influencing both alpha and gamma motor neurons. Structurally related to tricyclic antidepressants and thus carries some of their same liabilities.
20-40 mg/d PO divided bid/qid; not to exceed 60 mg/d
Long-term complications that may develop from cervical injuries include chronic pain <http://www.medscape.com/resource/painmgmt> , headaches <http://www.medscape.com/resource/headache> , depression <http://www.medscape.com/resource/depression> , permanent loss of cervical ROM, and disability. In patients with chronic symptoms that are unresponsive to a progressive rehabilitation approach, diagnostic zygapophyseal joint injections may help to identify a potentially treatable process, which may respond to radiofrequency denervation treatment in a properly selected patient group.
Author: Gerard A Malanga, MD, Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael’s Medical Center; Fellow, American College of Sports Medicine
Coauthor(s): Michael J Mehnert, MD, Volunteer Faculty, Department of Physical Medicine & Rehabilitation, Thomas Jefferson Medical School; Associate Physiatrist, Rothman Institute of Orthopedics; Graduate of Musculoskeletal/Pain Management Fellowship, New Jersey Medical School; Daniel Kim, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey