A cervical strain occurs when muscles around the neck stretch or tear. A sprain occurs when the ligaments stretch or tear. The terms “cervical acceleration-deceleration injury,” “CAD,” or “whiplash” may also be used to describe the clinical findings of neck pain, particularly after a motor vehicle collision.
Cervical strain/sprain injuries may occur as a result of trauma from a fall or, most commonly, from motor vehicle collisions. These injuries can happen as a result of collisions from any direction and often occur when the individual's car is hit from behind. The sudden acceleration thrusts the individual's body forward, with the head rapidly whipping backward and then forward (acceleration-deceleration). That movement can injury many different tissues and structures of the neck, including bones, facet joints, muscles, blood vessels, ligaments, nerves, the esophagus, and intervertebral discs. Almost all cervical spine injuries result in some degree of muscle injury. Muscles in the cervical area stabilize the spine and produce motion, and significant injury can adversely affect these functions.
In severe trauma, concussion may also occur. Injuries to the brainstem, bruising of the brain (subdural hematomas), and bleeding (hemorrhage) on the surface of the brain may occur. These multiple injuries may give rise to a myriad of symptoms.
Chronic pain develops in some patients who have experienced a cervical strain/sprain injury. It may be associated with injuries to the joints in the back of the cervical spine (facet joints), discs, and upper cervical ligaments. There is no direct correlation between the magnitude of impact and the degree of injury, although immediate onset of neck pain may be a predictor for chronic pain.
Other causes of cervical sprains and strains include a contact sports injury, a fall, or a blow to the head from a falling object.Risk: Individuals at risk of cervical sprain and strain are those who have sustained a motor vehicle accident or fall, lift or pull heavy objects, sleep in awkward positions, engage in contact sports (e.g. football, wrestling) or high-speed sports (e.g., skiing, diving), or work overhead or in prolonged static positions. Chronic neck pain is present in 13.5% of women and 9.5% of men; the average age at injury is the late 40s (Hunter). Incidence and Prevalence: Over 1 million cervical strain and sprain injuries due to whiplash are reported annually in the US; the incidence of whiplash injury is estimated at 3.8 individuals per 1,000 annually, and about 15.5 million individuals suffer late effects from whiplash (Hunter). Forty percent of individuals involved in rear-end collisions report neck pain (Petropoulos). The incidence of cervical sprain and strain is significantly higher in women and is a major cause of work absenteeism among young women (Hunter). Cervical spine injury occurs in 10% to 15% of football players, and 17.2% are re-injuries (Malanga). |
Source: Medical Disability Advisor
History: The individual may report a history of trauma or accident, most commonly a motor vehicle accident. The individual may have had a contact sports injury or blow to the head from a falling object. A history of previous neck or spinal injury is obtained.
In mild to moderate strains, pain is mostly located in the cervical muscles. The pain intensifies over several hours and is followed by stiffness and spasm. Individuals may hold their necks rigidly or keep their head tilted to one side because of spasm or to relieve discomfort. Headache, pain radiating into the shoulders, pain in the upper chest and back, and changes in sensation in the upper extremity or face are common in moderate to severe strains and sprains.
Other common symptoms may include headache, dizziness (vertigo), nausea, blurred or double vision, ringing in the ears (tinnitus), fatigue, restlessness, loss of libido, insomnia, pain in the jaw or temporomandibular joint (TMJ), and difficulty swallowing (dysphagia). More severe sprains and strains have similar symptoms but may not respond to the usual interventions. In the most severe cases, symptoms of pain and spasm are intense, and signs of instability may be present. The individual may be unable to support his or her head. Severe sprains and strains with associated spinal cord injury can occur in sports-related injuries and in elderly individuals with severe degenerative changes. Physical exam: In any individual with suspected acute neck sprain or strain, care must be taken during the examination to evaluate for possible instability. Lateral cervical spine x-rays are often taken to rule out a fracture or dislocation before any neck motion is tested. Once those are ruled out, range of motion may be tested by having the individual actively move the neck. Pain, swelling, and tenderness may be noted if local bleeding has occurred at the site of the strain injury. Pain may be referred to the shoulder or occipital area. The presence, location, and duration of any neurological symptoms (e.g. weakness, sensory changes, reflex changes) are noted. A neurological assessment of the upper and lower extremities is performed to assess possible nerve damage. Tests: Cervical spine x-rays are taken to rule out more serious injury, but sprains and strains do not have findings on x-ray. Imaging studies (CT and/or MRI) may be warranted to evaluate soft tissue damage and to check for a cervical disc herniation. Tests may need to be repeated in 6 months if symptoms do not resolve. Objective findings on routine imaging studies are usually limited. Facet joint injections may be indicated after the individual has failed other conservative care, to determine whether there is facet joint involvement. |
Source: Medical Disability Advisor
Early introduction of movement has been shown to be superior to immobilization (Malanga). Passive therapies should be limited to the acute phase of recovery, and then the physician or physical therapist should progress individuals to activity as soon as possible. Conservative treatment may include a soft support collar worn for short periods of time over the course of the recovery. Rigid cervical collars are used infrequently. Medication to control pain is usually prescribed and may include analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants.
Physical therapy modalities for pain relief are appropriate for treatment of acute sprain/strain. Traction may be used for symptoms of arm pain or radiculopathy resulting from the injury. Trigger point injections of anesthetics or steroids may be performed on a selective basis. Pain-induced depression may be treated with antidepressants and psychotherapy. In a small percentage (fewer than 10%) of individuals, surgery may be appropriate, particularly in the presence of radiculopathy. Radiofrequency medial branch rhizotomy to disrupt the nerves associated with the facet joints may be used, usually after facet joint injections have demonstrated effectiveness in relief of pain. |
Source: Medical Disability Advisor
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| ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.* |
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| Neck and Upper Back Disorders |
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| * The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence. |
Source: ACOEM Practice Guidelines
Healing of soft tissue is expected within a few weeks. Most individuals can return to work immediately or within 6 weeks. Symptoms may still be present in 20% to 40% of individuals 6 months after injury, but the prognosis is good for these individuals, and their symptoms eventually resolve (Petropoulos).
One-third of individuals report persistent symptoms of neck pain 10 years after the injury (Hunter). Persistent neck pain is more common in women. Other prolonged symptoms include headache, neck ache, neck stiffness, fatigue, and anxiety (late whiplash syndrome). Older individuals tend to have more persistent symptoms than younger individuals, and older women have a worse prognosis than either younger women or men of any age. Individuals who experience severe initial neck pain, upper back pain, multiple symptoms, reduced range of motion, neurological deficit, and/or headaches at the back of the head (occipital region) have a poorer prognosis than individuals without these symptoms. |
Source: Medical Disability Advisor
A careful assessment for serious pathologies (fractures, spinal cord compromise, nerve compression, and head injury) must be performed prior to rehabilitation for a neck sprain and strain. It is important for the therapist to identify the underlying etiology of the neck symptoms, and if trauma is involved, then to identify the impact of the trauma. The primary focus of rehabilitation is to decrease pain, increase function, and teach individuals how to manage their symptoms.
The first goal in treating sprains and strains of the cervical spine is to decrease pain. In combination with pharmacological management, modalities such as heat and cold may be used. Immobilization with a soft collar is rarely indicated; however, with significant soft tissue damage, it might be necessary for a short period of time (up to 3 days) (Verhagen).
While managing pain, therapists may instruct individuals in gentle exercises. Because of variability in individual response, the treating practitioner must pay careful attention to the individual's tolerance to treatment. Initial exercises may include isometrics, accompanied by stretching or gentle range of motion of the cervical spine. Once the acute phase has subsided, spinal manual therapy may help reduce symptoms when combined with active treatment. Postural training should be initiated as soon as tolerated by the individual.
Once range of motion is restored, therapy should progress to strengthening and stabilization exercises of the neck, shoulders, and upper trunk (Weinhardt). In addition to undergoing supervised rehabilitation, the individual should be instructed in a home exercise program to be practiced daily and continued independently after the completion of rehabilitation. Individuals should also be instructed how to care for and protect the neck from recurrence of symptoms.
If symptoms persist, further treatment is best addressed by a multidisciplinary team. An ergonomic evaluation can provide information regarding the avoidance or modification of activities and positions at work that may aggravate the symptoms. Psychological intervention such as cognitive and behavioral pain management may be indicated to support the individual and identify associated factors that may be contributing to symptoms (Sterner). |
FREQUENCY OF REHABILITATION VISITS | | Nonsurgical | |
| Physical or Occupational Therapist | | Up to 12 visits within 6 weeks | |
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| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
Fractures, instability, nerve stretch or traction injuries, or disc disruption (herniation) can complicate treatment. Disc herniation occurs in up to 33% of individuals within two years after they’ve had whiplash injury (Hunter). Headaches and referred pain are part of the expected ongoing problems of a cervical sprain but may complicate or prolong treatment. Complications of cervical strains and sprains include instability, nerve damage, headache, stiffness, and referred pain. Individuals with underlying spondylosis may develop cervical myeloradiculopathy as a complication of cervical flexion/extension injury.
The facet joints at C2-C3 are the most frequent source of referred pain in 60% of individuals with headache symptoms, and the C5-C6 vertebral level is the most common source of referred arm pain (Hunter).
Twenty to forty percent of individuals who sustain a whiplash injury will develop chronic whiplash syndrome, with persistent symptoms for up to 6 months (Petropoulos). |
Source: Medical Disability Advisor
Any activity that requires flexion or extension of the neck such as overhead work, lifting, or carrying a heavy object should be restricted in symptomatic individuals. Evaluation may be needed if the individual works at a desk or drafting table. Workstation ergonomics need to be addressed. An adjustable chair and proper height of the computer monitor allow for optimal posture and neck positioning. Individuals who spend a great deal of time on the telephone would benefit from a headset.
A worksite evaluation helps to assess risk factors that might aggravate symptoms during recovery, which can be slow. The use of a soft support collar may restrict dexterity. Safety and policy drug issues must be evaluated if medication is needed during work time. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has degenerative spondylosis or acute torticollis been ruled out?
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If pain and/or stiffness persist after adequate treatment, has MRI been done to rule out disc herniation?
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Has neurologic evaluation ruled out a pinched nerve (radiculopathy)?
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Was individual involved in a motor vehicle accident recently or in the past?
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Did individual sustain a sports injury or blow to the head from a falling object?
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Does individual hold the neck rigid or the head tilted to one side?
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Does individual exhibit symptoms such as headache, pain in upper chest and back, changes in sensation, dizziness (vertigo), nausea, blurred or double vision, ringing in ears (tinnitus), fatigue, restlessness, loss of libido, insomnia, pain in the jaw or temporomandibular joint (TMJ), and difficulty swallowing (dysphagia)?
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Does individual have symptoms characteristic of a cervical sprain or strain?
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Is there evidence of symptom magnification behavior?
Regarding treatment:
- Have all aspects of conservative treatment been utilized?
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Has individual worn a soft support collar for several days?
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Were pain medications (analgesics, NSAIDs, antidepressants, anticonvulsants, and cortisone) prescribed?
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Were trigger points injected with anesthetics or steroids?
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Has individual participated in a comprehensive, appropriate rehabilitation program?
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Did individual require surgical interventions?
Regarding prognosis:
- How severe was initial injury?
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Was individual able to return to work?
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To what degree do symptoms affect the individual’s ability to work?
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Has individual experienced complications such as fracture, instability, nerve stretch or traction injuries, disc disruption, nerve damage, headache, or referred pain?
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Does individual have an underlying condition that may affect recovery?
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What symptoms persist?
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To what degree do symptoms impact individual's ability to perform daily activities?
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Is a psychological evaluation warranted?
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Source: Medical Disability Advisor
| CitedHunter, Oregon K. "Cervical Sprain and Strain." eMedicine. Eds. Martin K. Childers, et al. 29 May. 2008. Medscape. 18 Mar. 2009 <http://emedicine.medscape.com/article/306176-overview>.Petropoulos, P. "Whiplash Injury (PTG)." Ferri's Clinical Advisor: Instant Diagnosis and Treatment. Ed. Fred Ferri. 2004 ed. St. Louis: Mosby, Inc., 2004. 927-928. MD Consult. Elsevier, Inc. 28 Oct. 2004 <http://home.mdconsult.com/das/book/41010365-2/view/1161?sid=300920724>. Malanga, Gerard A. "Cervical Spine Sprain/Strain Injury." eMedicine. Eds. Janos P. Ertl, et al. 31 May. 2008. Medscape. 18 Mar. 2009 <http://emedicine.medscape.com/article/94387-overview>. |
| RehabilitationSterner, Y., et al. "Early Interdisciplinary Rehabilitation Programme for Whiplash Associated Disorders." Disability Rehabilitation 23 10 (2001): 422-429. National Center for Biotechnology Information. National Library of Medicine. 18 Mar. 2009 <PMID: 11400904>.Verhagen, A. P., et al. "Conservative Treatments for Whiplash." Cochrane Database System Review 1 (2004): CD003338. National Center for Biotechnology Information. National Library of Medicine. 18 Mar. 2009 <PMID: 14974013>. Weinhardt, C., and K. D. Heller. "A Systematic of the Value of Physical Therapy in Whiplash Neck Injury." Z Orthop Ihre Grenzgeb. 140 5 (2002): 499-502. National Center for Biotechnology Information. National Library of Medicine. 18 Feb. 2009 <PMID: 12226772>. |
Source: Medical Disability Advisor
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