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Basics ⬇

Author(s): Jeffrey M.Mjaanes, MD, CAQSM, FAAP, FACSM and Ryan P.Cole, MD, CAQSM

Description

  • Cervical strain refers to a stretch-type injury within the muscle substance or at the myotendinous junction of the cervical and upper back muscles. In addition to the muscle and tendons, injury may involve the ligamentous structures of the cervical spine.
  • Synonym(s): cervical sprain; whiplash (whiplash-associated disorders)

Epidemiology

  • Most frequently caused by whiplash injury, that is, hyperextension of the cervical spine from a rear-end motor vehicle collision
  • >1 million cases per year are reported in the United States; more common in urban areas with a greater number of motor vehicles
  • Higher incidence seen in females
  • More common in adults than children (especially persons ages 30 to 50 yr)
  • Incidence associated with sports is unknown.
  • In general, collision sports are responsible for a high number of injuries to the head and neck.

Etiology and Pathophysiology

  • In sports, cervical strain often occurs as the result of a blow to the head or neck during muscular contraction. In motor vehicle accidents, the causative force is usually a rear-end collision leading to a hyperextension then hyperflexion of the neck. The applied force often creates an eccentric contraction causing microscopic or gross tensile failure, most often at the myotendinous junction and in ligamentous structures.
  • Muscles with high ratios of type II or fast-twitch muscle fibers demonstrate a higher risk for strains or shearing-type injuries.
  • Cervical strains can also be chronic in nature and related to repetitive stress or abnormal postural biomechanics.

Risk-Factors

Speculated: age, level of conditioning, prior history of neck injury, cervical degenerative disc disease, head position at time of impact, mechanism of injury, personality traits, and psychosocial factors

Diagnosis ⬆ ⬇

History

  • When taking the history, it is essential to determine the mechanism of injury. For example, if the injury is the result of a motor vehicle accident, important information includes the approximate speed of the vehicles, the location of the patient within the vehicle (driver, front seat passenger, etc.), and whether the patient was restrained.
  • Onset, time course, and location of symptoms (Anatomical pain drawings may be helpful in providing an overview of the pain pattern.)
  • Presence of any neurologic symptoms and course: upper or lower extremity sensory changes, pain radiating into the arms past the elbows, or weakness in upper extremities
  • Activities and head positions that aggravate or alleviate symptoms
  • Prior episodes of similar symptoms, previous neck injury or surgery
  • Previous treatment, including modalities, medications, physical therapy, traction, manipulation, injection, and surgical treatments
  • Social history, including level of physical activity, occupation, job satisfaction, ongoing litigation, and use of nicotine, alcohol, and/or other substances
  • Pain is the most common presenting complaint in cervical strains. Frequently, patients may have minimal pain immediately after the injury but have increasing pain severity several hours to days later. Pain may be referred to the shoulder, upper limb, and occipital or temporal regions of the head.
  • Soft tissue swelling may be present.
  • Muscle spasm or tightness
  • Limitation in range of motion at the neck
  • Neck fatigue, stiffness, pain at rest and/or with movement
  • Other symptoms may include unusual skin sensations at head/face, dizziness, lightheadedness, concentration and memory deficits, tinnitus, blurred vision, hearing difficulties, and other cranial nerve deficit complaints.

Physical Exam

  • Observation: head and neck posture, movement during normal conversation, weak or stiff movement
  • Range of motion: active range of motion, usually reduced, particularly in directions stretching the injured muscles
  • Palpation: tenderness, usually noted along the cervical paraspinal muscles; may be present along muscles where symptoms are referred, muscles with associated hypertonicity, or “spasm”
  • Generally normal neurologic examination, although subjective sensory deficits may be present
  • Careful manual muscle testing for evidence of deficits in myotomal distribution
  • Sensory examination for dermatomal deficits in sensation, hyperesthesia, inconsistent or “nonanatomical” pattern
  • Deep tendon reflexes/muscle stretch reflexes and Hoffman or Babinski signs helpful in identifying myelopathy, radiculopathy, and brachial plexopathy
  • By definition, all provocative tests are negative in an isolated soft-tissue strain.
  • Spurling test is performed by extending the neck and rotating the head, and then applying downward pressure on the head. Considered positive if pain radiates into the limb ipsilateral to the side the head is rotated; specific but not sensitive in diagnosing acute radiculopathy
  • Lhermitte sign is performed by passively flexing the neck. Considered positive if “electric-like” sensation radiates down the spine; positive with cervical stenosis, myelopathy, spinal cord injury due to tumor, multiple sclerosis, and other conditions
  • Axial compression test is performed by gently applying an axially directed pressure on top of the seated patient’s head. The patient’s neck is in neutral. Pain radiating distal to the elbow is considered positive for likely radicular origin. Manual distraction often greatly reduces neck and limb symptoms in patients with radiculopathy.

Differential Diagnosis

  • In evaluation of the patient with acute and subacute neck pain, it is essential to rule out more serious conditions, such as fractures, dislocations, instability, and spinal cord injury. In chronic neck pain, other diagnoses, such as neoplasia, must be considered.
  • Differential diagnosis includes:
    • Cervical fracture.
    • Cervical instability, subluxation, or dislocation.
    • Disc annulus fibrosis injury.
    • Facet joint injury.
    • Myofascial pain.
    • Cervical radiculopathy.
    • Myelopathy.
    • Brachial plexus injury.
    • Thoracic outlet syndrome.
    • Peripheral nerve entrapment (e.g., suprascapular nerve).

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

  • In the management of cervical strain, radiographs are usually not necessary. In trauma patients, however, plain radiographs are used to rule out other potentially serious conditions, such as fractures or dislocations.
  • Minimum views include anteroposterior, lateral, and oblique cervical spine views for evidence of acute fracture or subluxation with trauma.
  • Open mouth view for evidence of atlantoaxial instability and odontoid fractures. Flexion and extension lateral views are helpful to look for evidence of spinal instability.
  • According to the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria, cervical spine radiography is indicated for patients with trauma unless they meet all of the following five criteria:
    • No posterior midline cervical spine tenderness
    • No evidence of intoxication
    • A normal level of alertness
    • No focal neurologic deficit
    • No painful distracting injuries
  • Computed tomography (CT) offers superior sensitivity for detection of acute fractures than plain radiographs. When combined with myelography, CT has significant sensitivity and specificity for radiculopathy and stenosis.
  • Magnetic resonance imaging (MRI) is the study of choice to detect soft tissue pathology including disc or ligament disruption, nerve root or spinal cord compression/injury.
  • MRI is also indicated for patients with deterioration in neurologic findings in order to detect spinal cord changes.

Diagnostic Procedures/Other

  • Electrodiagnostic studies used to diagnose nerve root dysfunction when the diagnosis is uncertain or to distinguish a cervical radiculopathy from other lesions that are unclear on physical examination
  • Ideally performed 3 or more weeks after injury because diagnostic abnormalities will first be seen 18 to 21 days after the onset of radiculopathy

Treatment ⬆ ⬇

  • Early discussion involving reassurance, treatment, recovery, and maintaining daily activity as tolerated are important in the initial management.
  • A multimodal treatment approach (medications, soft tissue treatment, stretching, exercises as tolerated) has been shown to be superior to a minimal intervention approach (advice and medications only) (1)[A].
  • Acute treatment directed at reducing pain and inflammation. Therapies include local icing, nonsteroidal anti-inflammatory drugs (NSAIDs), and avoidance of positions that increase symptoms. Patient should be encouraged to be as active as pain allows; bed rest is discouraged.
  • In addition to NSAIDs, other pharmacologic therapies include muscle relaxants to decrease spasm and tonicity and other analgesics such as acetaminophen. Narcotic analgesics are often used for pain relief, but in general, their use should be limited due to the potential of opioid-associated side effects.
  • Consider myofascial trigger point injections or modalities such as electrical stimulation if pain not controlled by initial therapies in the acute phase.
  • Gentle stretching; first passive mobilization and then active to begin to reestablish nonpainful range of motion
  • Gentle strengthening: isometric cervical strengthening in a single plane (flexion, extension, lateral flexion, rotation), scapular stabilization, and cervicothoracic stabilization programs. All exercises should be performed without pain.
  • If unable to engage cervicothoracic region due to persistent pain, consider isometric strengthening of uninvolved musculature (i.e., quadriceps). This has been shown to help decrease pain in chronic whiplash-associated disorders (2)[C].
  • Low-level aerobic cross-training (e.g., stationary bike, stair stepper, treadmill, aquatic running, etc.) begun as soon as tolerated to avoid deconditioning.
  • Use of soft and rigid collars for cervical strain management is controversial and has not been proven effective. Several randomized studies, including one by Kongsted et al. in 2007, showed no significant difference in outcomes (headache and neck pain intensity, disability, and work capability) between those treated with immobilization and those treated with an “act-as-usual” approach (3)[A].
  • Recover phase directed toward normalizing active range of motion, neuromuscular control, strength, and posture
  • Progressive passive and active stretching, mobilization, and manipulation as appropriate
  • Progressive strengthening (isometric to isotonic) with independent single-plane and complex multiple-plane coordinated motions to include cervicothoracic, scapulothoracic, and scapulohumeral stabilization activities
  • Maintenance phase directed toward sport/activity-specific training
  • Guidelines for returning to competition: no pain at rest, full pain-free range of motion, normal posture, normal strength, and normal physical examination; athletes should not return to competition until they can perform at the level of their preinjury abilities.
  • Prehospital:
    • Any victim of blunt cervical trauma who is unconscious, or conscious and complaining of neck pain or extremity paresthesias/paralysis should be assumed to have a cervical spine injury. The cervical spine must be stabilized and the patient transported to the emergency department (ED) on a backboard and with a semirigid cervical collar in place (4)[B].
  • ED treatment:
    • All posttrauma patients with cervical pain should be “clinically cleared” using NEXUS low-risk criteria or the Canadian C-spine rule to guide the use of cervical spine radiography.
    • Initial treatments for cervical strain include:
      • Ice, analgesics or NSAIDs, muscle relaxants.

Medication

  • Analgesics, such as acetaminophen, can be used in the acute phase for pain relief.
  • NSAIDs have anti-inflammatory as well as analgesic effects and are often used successfully in the management of cervicalgia. Examples include ibuprofen and naproxen.
  • Muscle relaxants are often prescribed acutely as adjunct therapy to decrease the spasm and hypertonicity experienced in acute muscle strain.

Additional Therapies

  • Follow-up is recommended to ensure there has been no deterioration in symptoms or exam findings. Ideally, patients should follow up with their primary care physician within 1 wk.
  • Often, referral to physical therapy may be necessary, especially in patients who have significant spasm and decreased cervical motion.
  • For chronic pain, consider adding supervised exercise programs such as tai chi, qigong, or yoga (5)[A].
  • Therapy focusing on progressive motion, stretching, and finally strengthening is often beneficial. Vassiliou et al. demonstrated in a randomized controlled trial involving 200 patients with whiplash injury that those who participated in a consistent physical therapy regimen had decreased pain intensity scores after 6 wk and 6 mo compared to controls (4,6)[A].
  • Osteopathic manipulation may be helpful in treating cervical strains. Avoid manipulation in the following scenarios: focal neurologic deficits, severe cervical spasm or pain, advanced age, rheumatoid arthritis, point tenderness over bone, cervical fusion or fracture, osteoporosis, and cervical laxity.
  • Acupuncture
  • Ultrasound
  • Topical analgesic creams

Ongoing Care ⬆ ⬇

Complications

Neck strain can result in stiffening in the cervical region with resultant decreased motion. The prolonged muscle spasm itself can become a source of long-term pain and disability. Morbidity from cervical strains comes from disuse, weakness, and spasm. Cervical strain can lead to chronic pain syndromes in certain patients.

Additional Reading ⬆ ⬇

  • Bogduk N, Teasell R. Whiplash: the evidence for an organic etiology. Arch Neurol. 2000;57(4):590–591.
  • Cantu R, Bailes J, Wilberger JE Jr. Guidelines for return to contact or collision sport after a cervical spine injury. Clin Sports Med. 1998;17(1):137–146.
  • Cole AJ, Farrell FP, Stratton SA, et al. Cervical spine athletic injuries: a pain in the neck. Phys Med Rehabil Clin N Am. 1994;5(1):37–68.
  • Eyre A. Overview and comparison of NEXUS and Canadian C-spine rules. Am J Med. 2006;3(4):12–15.
  • Johnson G. Hyperextension soft tissue injuries of the cervical spine—a review. J Accid Emerg Med. 1996;13(1):3–8.
  • Jónsson H Jr, Cesarini K, Sahlstedt B, et al. Findings and outcome in whiplash-type neck distortions. Spine (Phila Pa 1976). 1994;19(24):2733–2743.
  • Lagattuta FP, Falco FJE. Assessment and treatment of cervical spine disorders. In: BraddomRL, ed. Physical Medicine Rehabilitation. 1st ed. Philadelphia, PA: WB Saunders; 1996:747–748.
  • Malanga GA. The diagnosis and treatment of cervical radiculopathy. Med Sci Sports Exerc. 1997;29(Suppl 7):S236–S245.
  • Maujean A, Sterling J, Sterling M. What information do patients need to know following a whiplash injury?The perspectives of patients and physiotherapists. Disabil Rehabil. 2018;40(10):1135–1141.
  • Panjabi M, Vasavada A, White AA III, et al. Cervical spine biomechanics. Semin Spine Surg. 1993;5:10–16.
  • Pettersson K, Hildingsson C, Toolanen G, et al. Disc pathology after whiplash injury. A prospective magnetic resonance imaging and clinical investigation. Spine (Phila Pa 1976). 1997;22(3):283–288.
  • Ronnen HR, de Korte PJ, Brink PR, et al. Acute whiplash injury: is there a role for MR imaging?—a prospective study of 100 patients. Radiology. 1996;201(1):93–96.
  • Squires B, Gargan MF, Bannister GC. Soft-tissue injuries of the cervical spine. 15-year follow-up. J Bone Joint Surg Br. 1996;78(6):955–957.
  • Sturzenegger M, DiStefano G, Radanov BP, et al. Presenting symptoms and signs after whiplash injury: the influence of accident mechanisms. Neurology. 1994;44(4):688–693.
  • Torg JS, Glasgow SG. Criteria for return to contact activities following cervical spine injury. Clin J Sports Med. 1991;1:12–26.
  • Zmurko M, Tannoury T, Tannoury C, et al. Cervical sprains, disc herniations, minor fractures, and other cervical injuries in the athlete. Clin Sports Med. 2003;22(3):513–521.

References ⬆ ⬇

  1. Sutton DA, Côté P, Wong JJ, et al. Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders?A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Spine J. 2016;16(12):1541–1565.
  2. Smith A, Ritchie C, Pedler A, et al. Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders. Scand J Pain. 2017;15:14–21.
  3. Kongsted A, Qerama E, Kasch H, et al. Neck collar, “act-as-usual” or active mobilization for whiplash injury?A randomized parallel-group trial. Spine (Phila Pa 1976). 2007;32(6):618–626.
  4. Vassiliou T, Kaluza G, Putzke C, et al. Physical therapy and active exercises—an adequate treatment for prevention of late whiplash syndrome?Randomized controlled trial in 200 patients. Pain. 2006;124(1–2):69–76.
  5. Southerst D, Nordin MC, Côté P, et al. Is exercise effective for the management of neck pain and associated disorders or whiplash-associated disorders?A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Spine J. 2016;16(12):1503–1523.
  6. Dorshimer GW, Kelly M. Cervical pain in the athlete: common conditions and treatment. Prim Care. 2005;32(1):231–243.

Clinical Pearls ⬆

  • Cervical strain is common and is usually a benign, self-limited condition.
  • Management should be multimodal including analgesics, muscle relaxers, soft tissue massage/mobilization, and various exercises.
  • Care must be taken not to miss more serious conditions such as fractures or dislocations, especially in patients with acute neck pain.
  • Victims of trauma with neck pain or tenderness and unconscious victims need to be treated with cervical stabilization until the spine can be fully evaluated with imaging.
  • At 1 to 10 yr after whiplash injury associated with motor vehicle trauma, 60–80% of patients are asymptomatic and only 5–15% are severely symptomatic. Prognosis associated with sports activities is believed to be excellent, although no data are available.