Wellness Articles

Rehabilitating Neck Injuries

Neck Pain Treated by Vancouver Chiropractor

Most non-traumatic conditions that produce neck pain can be managed by chiropractors, with physical/sports therapy to augment rehabilitation.  One key role the chiropractor can often play is to reassure the patient that the injury is not serious.  After, the goal of immediate treatment is to minimize pain and inflammation with recommendations of natural anti-inflammatory supplements, natural muscle relaxants, application of TENS, interferential current (IFC), icing, and in some cases immediate manipulation.  The chiropractor will perform an examination to determine if manipulation is clinically warranted at the onset of treatment.  Rehabilitation to recover lost function should address the entire kinetic chain and include an aerobic component.  Return to play must be gradual.  Some injured or aging patients may have to cut back on activity or cross-train to maintain an active lifestyle.

The primary care practitioner must have a rational approach to non-traumatic neck and associated upper-limb pain during all phases of rehabilitation management: acute, recovery, and maintenance.  Early pain control combined with appropriate rehabilitation techniques and followed by a gradual return to activity is the key in safely putting patients where they want to be: back in action.

Immediate Treatment

General guidelines  A specific diagnosis of non-traumatic neck pain is sometimes difficult to make, especially if the pain is localized.  Therefore, the chiropractor’s key role can be in assuring the athlete  the problem is not serious.  If the patient has normal strength and reflexes and a history consistent with mechanical pain, he or she can be told with confidence that no significant herniated disk or nerve injury exists, and that resolution or control of symptoms is expected without surgery or other invasive techniques.  Even in the setting of a herniated intervertebral disk with radiculopathy, aggressive conservative care frequently prevents the need for surgical intervention (5).

Management of neck pain is divided into three phases: acute (immediate), recovery/correction (manipulation/rehabilitation), and maintenance (return to play) (6.)  In the acute phase, the goal is to minimize pain and inflammation.  Initial treatment of acute injuries consists of manipulation, hydrotherapy, electrotherapy, and a 4- to 6-week course of anti-inflammatory drugs, most preferably natural sources, such as Nature’s Relief, or similar compilations consisting of Bromelain, Boswelia, Devil’s Claw, Tumeric, and/or Ginger.  Further, frequent self-administered ice packs to the painful area for 10 to 15 minutes, and home stretching within the “vulnerable ROM.”  The patient should discontinue activities that aggravate symptoms.

Manual therapy is a valuable empiric adjunct to other measures during both the acute and recovery phases of treatment.  Whether high-velocity manipulation, passive mobilization, muscle energy technique, or fascial release is used, the athlete may find that pain decreases and range of motion improves faster with manual therapy, above all else.

A patient who recovers full and painless range of motion within a few days to a week can return to sports without limitations or further treatment.

Radiculopathy.  In the athlete who has a cervical radiculopathy, a more prompt referral to physical therapy is warranted, in addition to the measures described above.  Cervical traction, postural exercises, gentle cervical mobilization, and education are a few of the early measures a therapist might employ to help diminish radicular pain.

If the patient does not have any resolution of symptoms within 2 to 4 days of rest, ice, anti-inflammatory supplements, or if the pain prevents participation in physical therapy, referral to another health care practitioner may be warranted.

Chronic injury.  In degenerative cervical pain syndromes, the initial treatment for exacerbations has some similarities to the acute pain treatment.  Cervical manipulations and a short course of anti-inflammatory supplements may be used for periodic flares.  In addition, moist heat applied before activity and ice packs after may also provide symptomatic relief.

Some athletes acknowledge their chronic condition and merely seek suggestions about modifying their activity.  A 60-year-old male swimmer who has a degenerative disease, for example, can turn his head to the uninjured side during the crawl or switch to the back stroke to prolong the “life” of his neck.  Education about mechanics such as proper form, posture, and exercises is greatly enhanced by a knowledgeable chiropractor, especially one who also specializes in sports therapy.

Rehab and Recovery

As pain and inflammation are being controlled, the athlete is advanced to the recovery phase of rehabilitation, where the goal is to recover lost function.  Physical therapy is appropriate for any athlete who has acute neck pain and is slow to recover, or for a patient who has chronic neck symptoms but has never had a thorough physical therapy evaluation and treatment.  The primary principle that the chiropractor and/or therapist should understand when treating neck pain is that of the kinetic chain (6.)  The essence of this principle is that a functional and/or biomechanical deficit or injury anywhere in the musculoskeletal system can lead to injury elsewhere in the system.

For example, a tennis player who has poor thoracic and lumbar mobility and abnormal scapulothoracic and glenohumeral (shoulder) mechanics will stress her cervical spine more often during serving and overhead shots as she tries to maximize her reach and power.  This can result in a cervical overuse syndrome.  Thus, the physical therapist must address rehabilitation at all appropriate levels of the kinetic chain for a successful outcome.  Cole et al (8) provide a more detailed description of kinetic chain rehabilitation in sports-related cervical spine injuries.

The patient should also work on aerobic conditioning during the acute and recovery phases because maintaining overall fitness will facilitate return to activities.  Aerobic exercise can include stationary biking, brisk walking, using a stair-climbing machine, or some other non-impact activity.  Upper and lower extremity strengthening and stretching should also be maintained, provided the exercises do not exacerbate the cervical condition.  If at any time during the acute or recovery phases the athlete does not respond as expected, he or she should be referred to a specialist for further evaluation.

Returning to Activity

Few things are more frustrating for an athlete than to be out of sports because of an injury, but one of them is re-injury as a result of a premature return.  To minimize the chance of re-injury, the athlete is promoted to the maintenance phase of rehabilitation only after certain criteria have been met.  The goal in this phase is to ensure a graduated return to sports while maintaining the gains made during the recovery phase.

For the athlete who periodically has neck pain only in connection with an acute injury, one goal is pain-free cervical range of motion before full return to sports.  On the other hand, an athlete who has a chronic cervical pain syndrome, such as degenerative disk disease, and who sustains a flare-up or superimposed neck injury, will return to full activities when he or she reaches the “familiar” level of pain.  Cervical rotation and lateral bending should approach symmetry, with right and left values within about 10% of one another.  The range of cervical flexion and extension cannot be compared with values from an uninjured side, so clinical judgment based on normal ranges of motion must be used.

Motor strength of the neck muscles, another return-to-play criterion, is difficult to quantify in the clinician’s office, but a good qualitative attempt should be made.  The patient should offer strong, pain-free cervical resistance to the examiner’s hand in flexion, extension, lateral bending, and rotation.  Rotation and lateral bending should be relatively symmetrical side to side.  Extension should be more powerful than flexion.  Return to full athletic participation should be delayed if a gross side-to-side discrepancy is noted.

In patients who have cervical radiculopathy, the examiner should note side-to-side differences in extremity range of motion and strength.  The involved limb should be pain-free in motion with no further dysesthesias, and have at least 80% to 85% of the range of the uninvolved side.  Motor strength in the myotome of the affected limb should have recovered to at least 75% of that of the opposite side before the patient begins a gradual return to sports (6).

The athlete should resume his or her sport at a level or intensity that allows pain-free participation, then increase the time, distance, weight, number of throws, etc, by approximately 10% each week.  For example, if the 60-year-old swimmer mentioned previously had swum 30 laps per session prior to a flare of his symptoms, he might start at 15 laps and increase by 1.5 to 2 laps each week until he reached his previous level.  If the patient’s symptoms return at any point, he or she must drop back to the previous pain-free level and continue working on strength, flexibility, and good mechanics before attempting to advance.  A qualified coach can be invaluable in helping many athletes develop proper technique, which will facilitate injury-free participation.

Modifying Behaviours

Whether the patient is a recreational or professional athlete, at some point aging may dictate an alteration in activity.  Some patients by the age of 30 or 40, many by the age of 50, and most by the age of 60 will have to spend more and more time working to maintain neck flexibility and strength for sports that require significant cervical movement.

For the young athlete who finds cervical injuries occurring more frequently, or the older athlete who has chronic cervical pain, the chiropractor must ensure that appropriate radiologic studies (usually plain radiographs) have ruled out a serious problem, and that the rehabilitation program has been pushed to its maximum benefit.  If a complete and well-rounded exercise program is not preventing or minimizing neck pain during sports, the athlete must consider other options.  These may include tolerating a certain amount of discomfort or taking periodic breaks of 1 to 3 months from a sport to allow the neck to recover, much as a professional athlete does during the off-season.

Maintenance cervical adjustments, sports massage, IMS and/or acupuncture are a valuable adjunct to control pain for most patients.  These treatments, however, should serve to compliment an active rehabilitation program, not replace it.

Another reasonable approach would be to help the patient understand the ideas of conservation (cutting back intensity and/or frequency to improve longevity) and cross-training.  For example, our swimmer with chronic neck pain who swims freestyle 5 days a week for 30 minutes may benefit from mixing the backstroke into his routine, limiting sessions to 20 minutes 3 days a week, and working out on a cross-country ski machine the other 2 days.  The use of alternative training techniques will allow injured or aging patients to maintain an active lifestyle.

References
1. Cantu RC: Sports medicine aspects of cervical spinal stenosis. Exerc Sport Sci Rev 1995;23:399-409
2. Torg JS (ed): Athletic Injuries to the Head, Neck, and Face, ed 2. St Louis, Mosby Year Book, 1991
3. Torg JS: Cervical spinal stenosis with cord neurapraxia and transient quadriplegia. Clin Sports Med 1990;9(2):279-296
4. Wiesenfarth J, Briner W Jr: Neck injuries: urgent decisions and actions. Phys Sportsmed 1996;24(1):35-41
5. Saal JS, Saal JA, Yurth EF: Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine 1996;21(16):1877-1883
6. Kibler WB: A framework for sports medicine: evaluation and treatment. Phys Med Rehabil Clin North Am: Sports Medicine 1994;5(1):1-8
7. Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Williams & Wilkins, 1983
8. Cole AJ, Farrell JP, Stratton SA: Cervical spine athletic injuries: a pain in the neck. Phys Med Rehabil Clin North Am: Sports Medicine 1994;5(1):37-68

Have a great day,
Dr. Crysta Serné
Vancouver Chiropractor and owner of Vitality Clinic

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Sleeping Positions to Alleviate Neck Pain
Correcting Faulty Posture
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