eMedicine Specialties > Physical Medicine and Rehabilitation > Cervical Spine Disorders

Cervical Sprain and Strain: Treatment & Medication

Author: Oregon K Hunter Jr, MD, Physiatrist, Southeastern Rehabilitation Medicine, SIMED
Coauthor(s): Michael D Freeman, PhD, MPH, DC, Clinical Associate Professor of Epidemiology, Department of Public Health and Preventive Medicine, Oregon Health Sciences University; Adjunct Associate Professor of Forensic Medicine and Epidemiology, Institute of Forensic Medicine, Faculty of Health Sciences at Aarhus University, Denmark
Contributor Information and Disclosures

Updated: Jul 15, 2009

Treatment

Rehabilitation Program

Physical Therapy

Early rehabilitation helps to prevent chronic pain and disability. Passive modalities include the application of heat, ice, electrical stimulation, massage, myofascial release, and traction. Passive modalities are often used to decrease pain or inflammation and to facilitate participation in an active rehabilitation program, which often involves stretching and strengthening. Extended use of passive modalities without a more active program is generally inappropriate.

Active treatment refers to therapeutic exercises that are aimed at improving the patient's strength, endurance, flexibility, posture, and body mechanics. The goal is to obtain an independent home program or community fitness program at the conclusion of formal physical therapy. The typical therapy prescription is recommended 3 times per week for 4-8 weeks.

Scientific evidence for the physiotherapeutic management of whiplash is sparse. An early, active strategy is recommended to improve functions, increase activity, and prevent chronicity.52 In patients with whiplash-associated disorders caused by a motor vehicle collision, treatment with frequently repeated active submaximal movements combined with mechanical diagnosis and therapy is more effective in reducing pain than is a standard program of initial rest, use of a soft collar, and gradual self-mobilization.53

In patients with whiplash-associated disorders, active intervention is more effective than standard intervention in reducing pain intensity and sick leave, as well as in retaining/regaining total ROM. Appropriately trained healthcare professionals can start and support active intervention, that is, frequently repeated, active cervical rotation, which can be followed, if needed, by assessment and intervention according to the McKenzie protocol.54 Strength and endurance training for 12 months are effective for decreasing pain and disability in women with chronic, nonspecific neck pain. Stretching and fitness training are commonly advised for patients with chronic neck pain, but stretching and aerobic exercising alone are less effective than strength training.55

Specific neck exercises for the management of chronic neck pain, including active activation of the deep neck muscles and dynamic strengthening, may significantly improve disability scores.56 Consistent evidence (from 2 randomized, controlled trials) supports mobilization as an effective, noninvasive intervention for acute whiplash-associated disorders.57,58

In examining the costs and consequences of 2 types of intervention after whiplash trauma in automobile crashes, active intervention using physical therapy was found to be less costly and more effective than short-term immobilization using a cervical collar followed by a gradual self-exercise program taught by a leaflet.59

Another study questioned the efficacy of therapeutic interventions. The report found that 1 year after whiplash injury, a strategy employing immobilization, "act-as-usual," or mobilization had a similar effect to the other 2 methods in terms of pain prevention, disability, and work capability.60

Occupational Therapy

Occupational therapy may be indicated unless a concurrent problem involves a distal upper-extremity function or ergonomic factors in causation. A workstation ergonomic evaluation may be indicated if biomechanical stresses of work activity are factors in the causation or exacerbation of the condition.

The degree of neck pain or dysfunction can be evaluated by using standardized scales. The choice of a scale should be tailored according to the target population and the purpose of evaluation. The Neck Disability Index is useful for evaluating groups of patients, and the Patient Specific Scale is an effective tool for assessing individual patients.61

Medical Issues/Complications

  • Pain complaints may escalate during the rehabilitation program.
  • Pain must be treated aggressively and appropriately.
  • Underlying medical conditions may need to be evaluated and treated to facilitate rehabilitation.
  • The goal of therapy is functional rehabilitation and restoration with an emphasis on improving the patient's strength, endurance, and flexibility.
  • When the patient reaches a plateau, as determined by using objective measurements, therapy progresses to an independent home program or a community fitness program.
  • In a Toronto study, early, aggressive treatment of whiplash injury did not promote faster recovery, and a combination of chiropractic and general practitioner care was found to significantly reduce the patient recovery rate.62

Surgical Intervention

  • Cervical strain without myeloradiculopathy or instability is not a condition requiring surgical intervention.
  • Cervical myeloradiculopathy or instability, a possible complication of cervical strain, may require surgical intervention (eg, fusion).
  • According to Sampath and colleagues, cervical radiculopathy has a better outcome with surgical intervention than with medical treatment. However, in clinical practice, many physicians believe that most patients respond well to nonsurgical treatment.63
  • In one study of patients with cervical spondylotic myeloradiculopathy, the short-term effects of surgery (eg, pain, weakness, sensory loss) were superior. However, at 1 year, no significant differences between surgically and nonsurgically treated groups were found.64
  • Severe sprains of the cervical spine may result in a traumatic rupture of the intervertebral disk and ligaments, which, if not surgically treated, can lead to a significant kyphotic deformity.65

Consultations

  • A board-certified electrodiagnostic medicine specialist may be consulted for EMG and/or an NCS if radiculopathy or peripheral nerve involvement (eg, carpal tunnel syndrome) is suspected. For additional information, contact the American Association of Neuromuscular and Electrodiagnostic Medicine (formerly the American Association of Electrodiagnostic Medicine).
  • Surgical consultation with a neurosurgeon or orthopedic spinal surgeon may be appropriate if surgical intervention is being considered.
  • Psychological or psychiatric consultation may be indicated if secondary depression, anxiety, or adjustment disorder needs evaluation and treatment.
    • Patients who achieve complete relief from chronic neck pain resolve all of their psychological distress. Patients with persistent neck pain also have persistent anxiety, depression, and other forms of psychological distress.
    • Findings from a study of patients with whiplash-associated disorders suggested that psychosocial problems of these patients are more pronounced than their physical problems. Coping strategies seem to be a significant predictor of psychological well-being.66
  • A functional capacity evaluation (FCE) may be required if objective evaluation of the level of ability/disability needs to be documented for litigation or for determining the patient's readiness to return to work. The degree of neck pain or dysfunction can be evaluated by using standardized scales. The choice of scale should be tailored according to the target population and the purpose of evaluation. The Neck Disability Index is useful for evaluating groups of patients, and the Patient Specific Scale is effective for assessing individual patients.61

Other Treatment

Upon review of several randomized, controlled trials and epidemiologic studies regarding medical and surgical interventions, published since 1993, moderate evidence exists in support of radiofrequency neurotomy. Evidence for steroid injections, botulinum treatments, and cervical diskectomy is conflicting or unclear.57,58

  • Injection may be indicated for patients with chronic, persistent neck pain. Injection is indicated for severe neck pain with functional impairment, particularly cervical radiculopathy.
    • An anesthesiologist, interventional physiatrist, neuroradiologist, or other appropriately trained pain specialist may perform the injection.
    • Types of injection include epidural, selective nerve root, or facet block injections.
    • Intramuscular injections of lidocaine for chronic mechanical neck disorders (MNDs) and intravenous injections of methylprednisolone for acute whiplash are effective (a single trial). Evidence of the effectiveness of epidural injections of methylprednisolone and lidocaine for chronic MND with radicular findings is limited.67,68
  • Percutaneous radiofrequency neurotomy of medial branch nerve to facet joint is effective for chronic neck pain due to cervical zygapophysial joint pain.
    • In one study of the efficacy of radiofrequency medial branch neurotomy to treat cervical zygapophysial joint pain from whiplash injury, the potential for secondary gain did not influence the response to treatment.69
    • Using cervical zygapophysial joint pain as a model of chronic pain, investigators studied the effect of percutaneous radiofrequency neurotomy. In all patients who achieved complete pain relief, their preoperative psychological distress also resolved.70
    • Medical branch blocks of the dorsal rami of the spinal nerves supplying the facet joints are recommended by Schofferman and colleagues. If significant relief occurs on 2 occasions, radiofrequency neurotomy is recommended, providing relief for up to 8-12 months.71
  • Whiplash-associated headache pain may be reduced with the injection of botulinum toxin A in cervical trigger points.72 Moderate evidence has shown that intramuscular injections of BOTOX ® A for chronic MND were no better than saline injections.
  • Traction may be helpful.
    • A physical therapist can provide a trial of manual and/or mechanical cervical traction within the clinic. If patients achieve positive results, the physical therapist then may offer instruction in the use of a home overhead cervical traction unit, which must be prescribed by the physician.
    • A home cervical traction unit is most useful for patients with cervical radiculopathy.
  • Manipulation or manual therapy may offer some benefit in patients with acute or chronic neck pain.73
    • This therapy may be provided by an osteopathic physician (DO), a chiropractic physician (DC), or an allopathic physician (MD) with appropriate training.73
    • According to a study by the RAND Institute, the estimated rate of complication as a result of cervical manipulative procedures is 1 case per 1 million manipulations.74
  • Acupuncture may be beneficial for pain control and should be administered by an appropriately trained and certified provider.
  • Bracing with a soft cervical collar may provide symptomatic relief. The collar does not immobilize the spine; it only reminds the patient not to move his/her neck. If use of a soft cervical collar is prolonged, it may result in worsening of strength, flexibility, and function.
  • In a review of conservative treatments for whiplash, Verhagen concluded that "the current literature is of poor methodological quality and is insufficiently homogeneous to allow the pooling of results. Therefore, clearly effective treatments are not supported at this time for the treatment of acute, subacute or chronic symptoms of whiplash-associated disorders."75  The clinician is then left with trying to do the right thing for management of whiplash injury in the face of uncertainty in the scientific community.

Medication

Early and appropriate treatment with analgesics for pain relief, with anti-inflammatory agents for inflammation, with muscle relaxants for spasms, and with aids for sleep disturbance, are the mainstay pharmaceutical therapies for cervical sprain/strain injuries.

Nonopioid analgesics

Pain control is essential to high-quality patient care. Nonnarcotic analgesics ensure patient comfort and promote pulmonary toilet. These medications have sedating properties, which are beneficial for patients who have traumatic injuries.


Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or in patients with upper GI disease or who are taking oral anticoagulants

Adult

1000 mg PO qid

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h

Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity can occur in patients with chronic alcoholism, with various dose levels of acetaminophen; severe or recurrent pain or high or continued fever may indicate serious illness

Opioid analgesics

These agents are indicated for the medical treatment of moderate to severe pain.


Hydrocodone/acetaminophen (Lortab)

For relief of moderate to severe pain. Dose available with 2.5, 5, 7.5, 10 mg of hydrocodone. Total daily dose of acetaminophen should be considered; not to exceed 4 g/d. Individualize dose from qd to q4h, depending on degree of pain, effect of pain on patient's lifestyle, and need to keep blood levels of analgesic at therapeutic dose consistently or only intermittently.

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

Do not exceed the following doses of hydrocodone bitartrate:
<2 years: 1.25 mg PO q4-6h prn
2-12 years: 5 mg PO q4-6h prn
>12 years: 10 mg PO q4-6h prn

Phenothiazines may decrease analgesic effects; toxicity can increase with concurrent CNS depressants or tricyclic antidepressants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates (substitution may result in acute opiate-withdrawal symptoms); caution in severe renal or hepatic dysfunction; alcohol intake may result in excessive sedation or liver toxicity; dependency may occur with use of hydrocodone

Cyclooxygenase-2 (COX-2) inhibitors

Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional nonsteroidal anti-inflammatory drugs (NSAIDs). Ongoing analysis of cost avoidance of GI bleeds will further define the populations for whom COX-2 inhibitors are most beneficial.


Celecoxib (Celebrex)

COX-1 is important for platelet aggregation, regulation of blood flow in the kidney and stomach, and regulation of gastric acid secretion. Inhibition of COX-1 may contribute to NSAID GI toxicity. COX-2 is considered an inducible isoenzyme, being induced during pain and inflammatory stimuli. Celecoxib inhibits primarily COX-2. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose for each patient.

Adult

200 mg PO bid

Pediatric

Not established

Coadministration with fluconazole may increase plasma concentrations because of inhibition of celecoxib metabolism; coadministration with rifampin may decrease celecoxib plasma concentrations

Documented hypersensitivity to sulfonamides

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing patient to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction or abnormal liver laboratory results

Nonsteroidal anti-inflammatory agents

These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well; these include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell-membrane functions.


Nabumetone (Relafen)

Nonacidic NSAID rapidly metabolized after absorption to a major active metabolite that inhibits cyclooxygenase enzyme, which in turn inhibits inflammation.

Adult

1000-2000 mg PO qd

Pediatric

Not established

Probenecid may increase toxicity of NSAIDs; coadministration with ibuprofen may decrease effects of loop diuretics; coadministration with anticoagulants may prolong PT (watch for signs of bleeding); NSAIDs may increase serum lithium levels and risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)

Documented hypersensitivity; active peptic ulcer disease, hepatic impairment

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Elderly patients may require decreased doses; caution in hepatic and renal impairment

Muscle relaxants

These medications are indicated for the relaxation of increased muscle tone, spasm, and rigidity associated with cervical strain syndromes.


Tizanidine (Zanaflex)

Indicated for treating muscle spasm in patients with cervical strain. Centrally acting muscle relaxant metabolized in the liver and excreted in urine and feces.

Adult

2-8 mg PO tid; may give in small dose at night, eg, 2-4 mg, to help decrease spasms that interfere with sleep

Pediatric

Not established

May interact with alcohol (increase somnolence, stupor) and oral contraceptives (which decrease its clearance); can cause increased hypotensive effects with concurrent diuretics

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal impairment


Carisoprodol (Soma)

Short-acting medication that may have depressant effects at the spinal cord level.

Adult

350 mg PO tid/qid

Pediatric

Not established

Increases toxicity of alcohol, CNS depressants, MAOIs, clindamycin, phenothiazine

Documented hypersensitivity; acute intermittent porphyria

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal and hepatic impairment


Cyclobenzaprine (Flexeril)

Skeletal muscle relaxant that acts centrally and reduces motor activity of tonic somatic origins, influencing alpha and gamma motor neurons. Structurally related to tricyclic antidepressants and thus has some of their disadvantages.

Adult

20-40 mg/d PO divided bid/qid; not to exceed 60 mg/d

Pediatric

Not established

Coadministration with MAOIs and tricyclic antidepressants may increase toxicity; may have additive effect with concurrent anticholinergics; may enhance effects of alcohol, CNS depressants, and barbiturates

Documented hypersensitivity; patients who have taken MAOIs within last 14 d

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with angle-closure glaucoma, and urinary hesitance


Methocarbamol (Robaxin)

Reduces nerve impulse transmission from spinal cord to skeletal muscle.

Adult

1.5 g PO qid for 2-3 d and decrease to 4-4.5 g/d in 3-6 divided doses

Pediatric

Not established

Increases toxicity of CNS depressants

Documented hypersensitivity; renal impairment

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with history of seizures

Tricyclic antidepressants

Disturbed sleep is often a significant symptom with cervical strain. If analgesics and muscle relaxants do not provide enough relief, medications such as low-dose antidepressants can be used. These agents have central and peripheral anticholinergic effects, as well as sedative effects.


Amitriptyline (Elavil)

Analgesic for certain types of chronic and neuropathic pain.

Adult

10-40 mg PO qhs (50-150 mg may be necessary in some individuals)

Pediatric

Children: 0.1 mg/kg PO qhs; increase, as tolerated, over 2-3 wk to 0.5-2 mg/d qhs
Adolescents: 25-50 mg/d PO initially; increase gradually to 100 mg/d in divided doses

Phenobarbital may decrease effects; coadministration with inhibitors of CYP2D6 enzyme system (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Documented hypersensitivity; use of MAOIs in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention; acute recovery phase after MI; prostate enlargement with urinary retention

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in elderly patients with cardiac disease, arrhythmias, urinary retention (particularly due to prostate enlargement), angle-closure glaucoma; history of hyperthyroidism, and renal or hepatic impairment

Corticosteroids

These agents are used for severe inflammation (eg, radiculopathy) caused by the release of inflammatory chemicals from disk injury. These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, they modify the body's immune response to diverse stimuli.


Methylprednisolone (Solu-Medrol, Depo-Medrol)

Indicated for treatment of severe pain and/or radiculopathy if inflammation is suspected.

Adult

2-60 mg/d PO in 1-4 divided doses followed by gradual reduction to lowest level that can maintain clinical response

Pediatric

Loading dose: 2 mg/kg IV
Maintenance dose: 0.5-1 mg/kg/dose IV q6h for up to 5 d

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels (adjust dose); monitor for hypokalemia when used with concurrent diuretics

Documented hypersensitivity; viral, fungal or tubercular skin infections; labile diabetes, uncontrolled or severe hypertension, and active or recurrent PUD or gastritis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications

More on Cervical Sprain and Strain

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Treatment & Medication: Cervical Sprain and Strain
Follow-up: Cervical Sprain and Strain
Multimedia: Cervical Sprain and Strain
References
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Further Reading

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Keywords

C-spine sprain, C-spine strain, acceleration/deceleration injury, acceleration-deceleration injury, cervical myofascial pain, cervical soft-tissue pain syndrome, cervical sprain, cervicobrachial strain, chronic cervical sprain, chronic cervical strain, chronic neck sprain, chronic neck strain, extension-flexion injury, extension/flexion injury, flexion-extension injury, flexion/extension injury, hyperflexion-hyperextension injury, hyperflexion/hyperextension injury, neck/shoulder girdle soft-tissue injury, neck sprain, neck strain, regional soft-tissue pain syndrome, WAD, whiplash-associated disorders, whiplash syndrome

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Contributor Information and Disclosures

Author

Oregon K Hunter Jr, MD, Physiatrist, Southeastern Rehabilitation Medicine, SIMED
Oregon K Hunter Jr, MD is a member of the following medical societies: American Academy of Pain Management, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners, American College of Legal Medicine, American College of Occupational and Environmental Medicine, American Congress of Rehabilitation Medicine, American Medical Association, Florida Medical Association, Florida Society of Physical Medicine and Rehabilitation, International Association for the Study of Pain, International Society of Physical and Rehabilitation Medicine, National Association of Disability Evaluating Professionals, and North American Spine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Michael D Freeman, PhD, MPH, DC, Clinical Associate Professor of Epidemiology, Department of Public Health and Preventive Medicine, Oregon Health Sciences University; Adjunct Associate Professor of Forensic Medicine and Epidemiology, Institute of Forensic Medicine, Faculty of Health Sciences at Aarhus University, Denmark
Michael D Freeman, PhD, MPH, DC is a member of the following medical societies: American Academy of Forensic Sciences, American Academy of Pain Management, American College of Epidemiology, Association for the Advancement of Automotive Medicine, North American Spine Society, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Martin K Childers, DO, PhD, Associate Professor, Department of Neurology, Wake Forest University Health Services
Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology
Disclosure: Allergan pharma Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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