Neck Strain Acute (Cervical Spine) Rehabilitation Protocol

Pathophysiology

Acute neck strain, also known as cervical strain, commonly occurs due to sudden forced movements, whiplash injuries, poor posture, or overuse. It involves damage to the muscles, ligaments, and tendons of the cervical spine. This can lead to muscle spasms, inflammation, pain, and limited range of motion. The severity can range from mild discomfort to debilitating pain that significantly impacts daily activities. The primary muscles affected are often the upper trapezius, levator scapulae, sternocleidomastoid, and scalenes. Ligamentous involvement may include the nuchal ligament or the interspinous ligaments. Inflammation is a key component of the acute phase and contributes to pain and muscle guarding.

Phase I: Protection (Days 1-7)

The primary goals of Phase I are to reduce pain and inflammation, protect injured tissues, and promote early healing. This phase focuses on relative rest and gentle interventions.

• Goals:
• Pain reduction (VAS score < 4/10).
• Decreased muscle spasm and guarding.
• Initiate gentle range of motion (ROM) within pain-free limits.
• Patient education on posture and ergonomics.
• Interventions:
• Rest and Activity Modification: Avoid activities that exacerbate pain. Limit prolonged sitting or standing in static positions. Encourage frequent breaks to change positions.
• Cervical Collar (Optional): A soft cervical collar may be used for short periods (1-3 days) to provide support and limit movement, but prolonged use is discouraged due to potential for muscle weakness.
• Modalities:
• Ice/Cryotherapy: Apply ice packs for 15-20 minutes every 2-3 hours to reduce inflammation and pain.
• Heat: Moist heat may be used after the acute inflammatory phase subsides (after 72 hours) to promote muscle relaxation.
• Electrical Stimulation (TENS): Transcutaneous electrical nerve stimulation may be used to modulate pain.
• Ultrasound: Therapeutic ultrasound may be considered to promote tissue healing and reduce muscle spasm.
• Medications: Advise patient to consult with their physician regarding appropriate pain management, which may include NSAIDs or muscle relaxants.
• Gentle Range of Motion (ROM):
• Cervical Retraction (Chin Tucks): Perform gentle chin tucks in a pain-free range, holding for 5 seconds and repeating 10-15 times.
• Cervical Rotation: Slowly rotate the head to the right and left within a pain-free range, holding for 5 seconds and repeating 10-15 times.
• Lateral Flexion (Ear to Shoulder): Gently tilt the head to the right and left, bringing the ear towards the shoulder within a pain-free range, holding for 5 seconds and repeating 10-15 times.
• Patient Education: Educate the patient on proper posture, ergonomic principles for work and home activities, and techniques for managing pain and stress. Provide instructions on performing home exercises.
• Progression Criteria:
• Decreased pain (VAS < 4/10) at rest and with activity.
• Improved ROM within pain-free limits.
• Decreased muscle spasm and guarding.

Phase II: Loading (Days 7-21)

The primary goals of Phase II are to restore normal ROM, improve muscle strength and endurance, and begin functional activities. This phase focuses on gradually increasing the load on the cervical spine.

• Goals:
• Full, pain-free ROM.
• Improved cervical muscle strength and endurance.
• Normalization of posture.
• Initiation of light functional activities.
• Interventions:
• Continue ROM Exercises: Progress ROM exercises to include end-range stretching, holding for 15-30 seconds.
• Strengthening Exercises:
• Isometric Exercises: Perform isometric exercises for cervical flexion, extension, lateral flexion, and rotation, holding for 5-10 seconds and repeating 10-15 times. Apply gentle resistance with your hand or a theraband.
• Theraband Exercises: Use theraband to provide resistance for cervical flexion, extension, lateral flexion, and rotation. Start with a light resistance and gradually increase as tolerated.
• Scapular Retractions: Focus on strengthening the scapular retractors (rhomboids and middle trapezius) to improve posture.
• Postural Exercises:
• Chin Tucks: Continue chin tucks, focusing on maintaining proper alignment.
• Wall Slides: Stand with your back against a wall and perform arm raises, maintaining contact with the wall.
• Proprioceptive Exercises:
• Head Tracking: Slowly move your head in different directions, focusing on maintaining visual contact with a target.
• Balance Exercises: Incorporate balance exercises to improve proprioception and coordination.
• Manual Therapy: Soft tissue mobilization to address muscle spasm and trigger points. Joint mobilization may be considered if joint restrictions are present (performed by a qualified therapist).
• Ergonomic Assessment and Modification: Evaluate the patient's workstation and home environment and provide recommendations for ergonomic modifications to reduce strain on the neck.
• Progression Criteria:
• Full, pain-free ROM.
• Improved cervical muscle strength and endurance (able to perform strengthening exercises with minimal to no pain).
• Normalization of posture.

Phase III: Return to Function (Days 21+)

The primary goals of Phase III are to restore full functional capacity, prevent recurrence of injury, and return to pre-injury activity levels. This phase focuses on progressive loading and functional training.

• Goals:
• Return to pre-injury activity levels.
• Prevention of recurrence.
• Maintenance of optimal posture and ergonomic principles.
• Interventions:
• Progressive Strengthening Exercises: Gradually increase the resistance and intensity of strengthening exercises. Consider adding weight machines or free weights.
• Endurance Training: Perform endurance exercises, such as sustained cervical retraction or holding postural positions for longer periods.
• Functional Training: Simulate activities that the patient performs in their daily life or at work.
• Sport-Specific Training (if applicable): Gradually return to sport-specific activities, focusing on proper technique and mechanics.
• Maintenance Program: Develop a home exercise program to maintain strength, ROM, and proper posture.
• Education: Reinforce principles of posture, ergonomics, and injury prevention.
• Return to Activity Criteria:
• Full, pain-free ROM.
• Normal cervical muscle strength and endurance.
• Ability to perform functional activities without pain or limitations.
• Successful completion of sport-specific drills (if applicable).

Common Special Tests

• Spurling's Test (Cervical Compression Test): Assesses for cervical radiculopathy. Positive test indicates nerve root compression.
• Distraction Test: Assesses for pain relief with cervical distraction. Positive test indicates nerve root compression or facet joint pathology.
• Upper Limb Tension Tests (ULTT): Assess for neural tension in the upper extremity. A positive test may indicate cervical radiculopathy or thoracic outlet syndrome.
• Shoulder Abduction Relief Test (Bakody's Sign): Assesses for relief of radicular symptoms with shoulder abduction. A positive test suggests cervical radiculopathy.