Cervical collars – why do they help some people and not others?
Ross Hauser, MD and Brian Hutcheson, DC
Many patients we see have a long history of neck pain treatment. One of the treatments or therapies that they have been prescribed is the use of a cervical collar or cervical traction in an attempt to alleviate the patient’s symptoms by stretching the spinal vertebrae to relieve pressure and pain on the nerves that transverse the cervical vertebrae. For many patients, this will provide relief of symptoms. For some patients, the cervical collar may cause more problems than it was designed to help. The automatic prescription of a cervical collar in instances of neck pain should not be automatic, but, carefully considered in each patient’s situation to maximize benefit and minimalize complication.
When should a cervical collar be used to treat neck pain?
The above question was asked by a team lead by Harvard Medical School researchers in a 2008 paper appearing in the journal Current Reviews in Musculoskeletal Medicine.(1)
Let’s look at what this paper says:
“Although cervical collars are a seemingly benign intervention, they can have adverse effects, especially when used for longer periods of time. It is feared that a long period of immobilization, can result in atrophy-related secondary damage. Many physicians cite anecdotal evidence of their clinical utility and soft cervical collars are often prescribed by convention for patients complaining of neck pain. The use of cervical collars to treat neck pain is an area of controversy.
Comment: Below we discuss the challenges and problems a patient may face in prolonged cervical spine immobilization.
“In whiplash patients, most studies suggest that early mobilization and activity is superior to immobilization and soft cervical collar use. However, more recent studies have not found any long-term benefits of early aggressive treatment as compared to immobilization. Therefore, no definite conclusion can be drawn about the efficacy of cervical collars in this population. Our conclusions are that cervical collars should not be universally recommended to all whiplash patients. However, for patients who find it useful for symptom relief, a soft cervical collar for 10 days or less has not been shown to have any adverse impact.
Rigid cervical collars have a well-established role in the acute management of trauma patients to prevent instability of the cervical spine. They also may play a role in the conservative treatment of certain types of cervical fractures such as nondisplaced axis fractures and C2 body fractures. However, since most of the studies done in patients with fractures, were case series and lacked an adequate control group, no specific recommendations can be made in this population.
Several studies suggest that hard cervical collars may play a role in the conservative management of cervical radiculopathy. However, sufficient evidence is lacking to advocate its routine usage. Further studies are needed for patients with non-traumatic axial neck pain, and radicular pain with or without trauma to understand the role that cervical collars may play in their management.”
That of course was a 2008 study. Have recommendations changed in the 12 years since? No
Here are the observations of an April 2020 study published in the Yeungnam University Journal of Medicine.(2)
- Citing the 2008 Harvard research, these researchers noted no reported side effects (e.g., muscle weakness) associated with the use of soft cervical collars for fewer than 10 days.
- Further research was cited to suggest that in patients with acute cervical whiplash injuries who used a soft cervical collar for 2 weeks reported a higher reduction in both the intensity of pain and range of motion of the cervical spine than similar patients who did not use a soft collar. Yet another study did not offer similar findings and found little added benefit to soft collar use.
In examining the Philadelphia collar, a more rigid plastic molded collar, the researchers noted that the “Philadelphia collar slightly reduces the load on the spine by promoting the correct posture at the cervical spine and plays a role in limiting the cervical flexion/extension, lateral flexions and rotation. Nonetheless, some pressure may be applied on the clavicle by the Philadelphia collar. Considering that excessive pressure can cause discomfort or pressure sores, special attention is required for users with sensitive skin. The Philadelphia collar can be used to treat injuries of the bones and ligaments in the mid-cervical spine region and for postsurgical stabilization. In addition, it can be used instead of the halo orthosis to stabilize upper cervical fractures (Jefferson and hangman’s fractures) and fractures of the odontoid process.”
So the conclusion we arrive at again is: For some patients, a soft or rigid collar can be helpful when used appropriately. But it should not be used always.
Is my collar too tight? Is it making my symptoms worse?
An April 2020 randomized controlled trial study published in the journal Medicine (3) measured the effect of different cervical collars on optic nerve sheath diameter. Optic nerve sheath diameter was used as a compression measurement to see if the collars caused determintal effects of venous compression which would develop into intracranial pressure.
Learning points of this research were:
- There is considerable evidence that prolonged use of cervical collars could potentially cause detrimental effects including increase in optic nerve sheath diameter among healthy volunteers.
- Different types of cervical collars immobilize cervical spine differently and may cause different effects of venous compression and intracranial pressure.
- Results in sixty healthy volunteers showed there was significant increase of optic nerve sheath diameter from the start of wearing a poorly fitting or not appropriate collar for that patient. Measurements taken at 5 and 20 minutes revealed the compression. The researchers noted: “Clinicians should take proactive steps to assess the actual need of cervical collar case by case basis.”
Cervical collars – why they help some people and not others?
In this video, Ross Hauser, MD and Brian Hutcheson, DC discuss the use of cervical collars in patients with cervical neck instability. Specifically when the collars help, and, when the collars do not help. Below the video is a summary transcript and explanatory notes and references.
Dr. Hauser: Over the years we have kept track and studied why some of our patients did not respond well to treatment. In over 27 years of helping patients, we have continuously used these observations to change, develop, and advance our treatment protocols to adjust for our findings and to maximize treatment benefits.
This helps us understand why two patients with similar DMX findings (digital motion x-ray) and symptoms take different healing paths where one patient will show excellent results after 3 – 4 visits, and another patient will be on their sixth visit and be struggling.
A case history: Young female patient with cervical spine instability and a collar comparison
We took a young female patient who had cervical spine instability, very loose neck ligaments. We did DMX imaging (displayed and explained in the image below).
- The patient has significant left side C1-C2 instability. When wearing one type of collar, the instability was not helped.
- Then we put her in a normal (over the counter type) cervical collar, something you would get at the CVS or the Walgreens or online. Sometimes, in some patients, this type of collar is enough to limit motion and provide patient benefit. HOWEVER, when we repeated the DMX Imaging, with the patient wearing the collar, you could see that she still had C1 C2 instability, it wasn’t stabilizing her.
- We then put her in a Hauser-Hatto collar which we offer to some patients to provide added support to the collar immobilization. This was the right collar for this patient because as she tried to bend or flex her neck, the collar held her in proper alignment. This helps us demonstrate that while we treat the cervical ligaments to strengthen them and bring stability into the cervical spine, we need good, temporary immobilization to allow our treatments to achieve maximum benefit.
In this image we have a patient who had DMX imaging done: 1) Without a collar 2) With a standard over the counter type collar 3) With a Hauser Hatto collar or a collar that had more stability to it. (Similar collars can be recommended by your doctors or researched online.) This collar is not necessary in all patients.
At 2:30 of the video, Dr. Hutcheson explains immobilization of the cervical spine as a temporary help
- We are not proponents of telling somebody that we want you to be immobilized for long periods of time or “forever.” This is definitely not the right route. However when you have a lot of instability sometimes you need periods of immobilization to allow our treatments to do their job in strengthening and regenerating the soft tissue of the ligaments and supportive connective tissue in the neck.
“Do a collar check”
- Dr. Hauser will often tell me to do a “collar check,” on a patient who is now on their second, third, or fourth visit so we can make sure that when they have a collar on that it is on correctly and it’s preserving and helping the joint function.
- We want to make sure that while the patient is wearing their collar which could be depending on your individual case could be for as short as a week and could be for a couple of months, but, while the patient is wearing the collar we want to make sure that the neck has stability and integrity and to allow our treatments to have maximum effect.
Static and Dynamic imaging and checking the collar
Dr: Hauser (4:00 of the video) we do static and dynamic (motion) imaging to test and check the collar in some patients and depending on their case.
- Sometimes the collar can give you too much motion which can inhibit the healing by not allowing the ligaments time to repair. Sometimes the collar can compress the internal jugular vein. The collar is too tight. In one patient, we saw compression of the jugular vein that was causing pressure on their optic nerve. We had to get them into a collar that not only supported their chin but did not compress the jugular vein which can increase intracranial pressure which we were seeing in this patient by optic nerve sheath diameter swelling.
C1-C2 position while the collar is on
Dr. Hutcheson (5:53) of the video
- Sometimes people have their collar on and we will see that their C1 posterior arch is unstable, hypermobile, and jamming into the occiput or the C1 will be moving in the other direction and touching on the C2 spinous process. So we’ll make sure not only that the collar is not compressing the internal jugular vein, but also that the C1-C2 and occiput will have good spacing.
Understanding the proper collar can be pretty comprehensive.
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1 Muzin S, Isaac Z, Walker J, El Abd O, Baima J. When should a cervical collar be used to treat neck pain?. Current Reviews in Musculoskeletal Medicine. 2008 Jun;1(2):114. [Google Scholar]
2 Choo YJ, Chang MC. Effectiveness of orthoses for treatment in patients with spinal pain. Yeungnam University Journal of Medicine. 2020 Apr;37(2):84. [Google Scholar]
3 Ladny M, Smereka J, Ahuja S, Szarpak L, Ruetzler K, Ladny JR. Effect of 5 different cervical collars on optic nerve sheath diameter: A randomized crossover trial. Medicine. 2020 Apr 1;99(16):e19740. [Google Scholar]
This page was updated January 21, 2021