Cervical Spine Sprain/Strain Injuries Treatment & Management

Rehabilitation Program

Physical Therapy

The tissue injury and clinical signs and symptoms of cervical spine strain/sprain injuries are treated during the acute phase of rehabilitation. ^{[17, 18, 19, 20, 21, 22]} The goals of this phase are the following:

• Decrease pain and control inflammation

• Reestablish nonpainful ROM

• Improve neuromuscular cervical spine postural control

• Prevent the development of any muscular atrophy of the cervical spine muscle groups and postural muscles

• Facilitate primary tissue healing

Therapeutic activities during the acute phase of rehabilitation include the following:

• Relative rest

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Physical therapy modalities

• Manual therapy approaches

• Protected ROM and stabilization

• Isometric muscle strengthening

• Conditioning of other areas

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. ^[23]

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:

• Resolution of significant cervical pain

• Significant improvement in passive ROM (PROM), AROM, and neuromuscular control

• Decreased muscle spasms

• Improvement in the muscles and other tissue that maintain the postural adaptive changes

Related Medscape Reference topics:

• Superficial Heat and Cold

• Transcutaneous Electrical Nerve Stimulation

Medical Issues/Complications

The clinician should always rule out a significant bony or ligamentous injury, as missing such an injury could result in neurologic injury. ^{[24, 25]}

Consultations

Consult a spinal surgeon for any patient with suspected ligamentous spinal instability.

Other Treatment

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.

Rehabilitation Program

Physical Therapy

During the recovery phase of rehabilitation, the tissue overload and functional biomechanical deficit complexes are addressed. ^{[17, 18, 19, 20, 21, 22]} The goals of this phase are the following:

• Completely eliminate the patient's pain

• Improve and normalize cervical PROM and AROM

• Improve and normalize cervical strength and neuromuscular control

• Continue to improve posture

• Initiate sport-training progressions

Therapeutic activities during this phase include the following:

• Protected ROM

• Appropriate loading

• Resistive exercise

• Functional exercises

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:

• Fully pain-free cervical PROM and AROM

• Significantly improved cervical spine posture

• Normal neuromuscular control

• Significantly improved strength and flexibility of the supporting muscles and joints

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.

Rehabilitation Program

Physical Therapy

During the maintenance phase of rehabilitation, the functional biomechanical deficit and subclinical adaptation complexes are addressed. ^{[17, 18, 19, 20, 21, 22]} The goals of this final phase of rehabilitation are the following:

• Increase and improve balance, power, and endurance of the cervical muscles as well as other muscles in the kinetic chain

• Normalize posture

• Normalize multiplane-coupled neuromuscular control to eliminate subclinical adaptations

• Enable the patient to return to unrestricted sport-specific activities

Therapeutic activities during this phase include the following:

• Activities emphasizing endurance, strength, flexibility, and balance

• Functional sport-specific progressions

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.