Neck pain often appears to arise out of nowhere, but this is never the case. Pain can originate as a result of an injury or trauma, but it is generally due to repeated and prolonged postures and positions, resulting in cumulative microtrauma. Because of this, when your neck finally starts to hurt, there is no obvious cause. Neck pain or injury is also closely linked with shoulder or low back injuries or dysfunction.
How We Treat Neck Pain, and Why:
At Absolute PT we screen for each and every aggravating factor. There is always a cause for neck pain, and eliminating the source of injury is the first step to recovery. We treat both acute and chronic neck pain with an early emphasis on removing the cause of pain and aggravating factors:
- With acute trauma, early emphasis is on minimizing pain and stresses during normal daily activity as we gradually restore strength and function in a pain-free manner.
- For chronic neck pain, we work to find and eliminate the cause(s) of the discomfort while gradually restoring strength and function in a pain-free manner.
For both causes we stress patient education and real world postural modifications that are designed to lessen damaging stress to the spine, and that require little to no effort. Keeping a neutral posture requires a degree of awareness and also some muscular strength and endurance.
In a randomized control trial measuring the effect of long term neck muscle training on pressure pain threshold, it was seen that both strength and endurance training improved pain and ROM better than stretching alone. This study found a significant decrease in tender points in both the strength and endurance groups as compared to the stretching only control group. The strength group was a little better off than the endurance group. I found it interesting that this is the first study to show an increase in pressure pain thresholds as a result of long-term muscle training. A decrease in neck pain was associated with reduced pressure pain sensitivity in neck muscles, showing that the pressure pain threshold may be a useful outcome measure of the effectiveness of neck muscle rehabilitation
Check out my blog to read more about Strength Restoration and Neck Pain
Strength and Postural Exercises
Static posture is an important factor that McKenzie does address in his books. Though in my opinion, his recommended lumbar supports are on the extreme side, resulting in an extended rather than a neutral spine. Lumbar supports can be as simple as a couple throw pillows on a couch, perhaps adding a thin lumbar support to your car seat (but not so much as to push your spine into extension beyond neutral), and adjusting the seat position so its close enough and upright enough that when your shoulders are back in the seat you can still rest your wrist over the top of the steering wheel. For cyclists, I would maybe suggest a higher handlebar position or to keep your elbows extended.
Check out my blog to read more about Decreasing Neck Pain With Static Posture
Supine Chin Tucks and Flexion Holds
When I treat my physical therapy patients for neck pain with a largely exercise-based approach, they often report their pain levels decreasing from the beginning to the end of the workout. This decrease in pain happens before the application of EMS, which is my preferred modality for pain.
In a study examining the specific therapeutic exercise of the neck and induction of immediate local hypoalgesia, a supine neck flexion hold, where you lay on your back and hold your head no more than 2 cm off the table (which is an exercise I like), along with a supine (lying on your back) chin tuck, where you attempted to bring your chin toward the chest while keeping the back of your head flat on the mat both decreased neck pain were used as the exercise protocols. They did three sets of 10 reps, each rep with a three second hold and two second rest with 30 seconds between for the flexion holds, and the chin tuck was held for 10 seconds with 10 seconds rest in between for 10 reps.
This study showed an immediate local mechanical hypoalgesic response to specific exercise of the cervical spine. Although both exercises decreased participant’s neck pain, it was shown that the supine shin tuck exercise worked better. I imagine the difference might be due to the chin tuck increasing space for the spinal cord and nerves exiting the cervical spine, and perhaps it having a more immediate effect on improving posture once completed. The improved posture also increases space for the spinal cord and nerves exiting the cervical spine after the exercise so it’s win-win. The other exercise would do more to increase cervical flexor strength and endurance, which would likely lead to gains further down the road; however, it does not immediately lessen stresses on cervical structures in the same way the chin tuck does.
Check out my blog to read more about Decreasing Neck Pain With Supine Chin Tucks
Strength Training and EMS
While neck strength training has been shown to be effective in improving neck muscle strength and reducing neck pain, it has also been shown to increase a patient’s health-related quality of life. The study was a randomized- controlled one-year follow up study that looked at the effect of neck strength training and health-related quality of life in females with chronic neck pain. Subjects were divided into an endurance training group, a strength training group, and a controlled training group. The strength training group improved significantly in five of 15 dimensions, giving further confirmation that strength training for women with chronic neck pain is beneficial.
While this is another study showing that strengthening is more effective than stretch for the treatment of chronic neck pain, the improvements were significant but not exceptional. The reason for this is that with spine injuries in particular, exercise, while beneficial, is not the entire answer. Motor control, ergonomics, and postural alignment are all part of recovery, and part of my physical therapy programs for neck pain. In addition, I find electric muscle stimulation very effective at acutely decreasing pain while further increasing muscle strength and endurance just as well as it does with low back pain, thus complementing the active exercise, motor control, and postural improvements.
Check out my blog to read more about Strength Training and EMS
Successfully treating neck pain in the long term requires addressing:
- Posture and ergonomics at home and workplace
- Motor control
- Immediate pain reduction
- Establishing a long term fitness program
Chad has noticed considerably faster reductions in pain in his physical therapy programs when exercises are combined with specific postural exercises, biomechanical counseling, and ergonomic adjustments at home and in the work place. EMS helps a lot to decrease pain and increase strength in the near term, while the patient is waiting for the exercises and ergonomic changes to take effect. While treatment is provided in the clinic, a lot of what Chad Reilly PT, MPT and his Technicians do is help patients decide what kind of EMS/TENS machine and accessories they need, help them program the machine, and teach them how to set up the electrodes for home use.
Patients with neck pain often complain of headaches. A cervicogenic headache is one that originates from tissues in the neck, as opposed, for instance, to a migraine. These headaches are frequently the result of holding the neck and head in stressful daily postures, looking down (cervical flexion) or a forward head posture (lower cervical flexion combined with upper cervical extension). Both postures increase muscular strain and strain on cervical joints, ligaments, discs, and nerve roots as the exit the vertebral foramen much more so than a neutral cervical posture with the head level and centered (front to back) over the shoulders. EMS also works for immediate headache relief in both research and FDA approval.
The end result of visiting Absolute Physical therapy for neck pain generally leaves you with eliminated or significantly reduced pain levels, improved range of motion, improved strength and endurance, and a spine safe exercise program that can be performed in your home or at your fitness center.
How I DON’T Treat Neck Pain, and Why:
Kinesio Tape is that colorful tape you see applied to people’s body parts, often in fancy patterns, with an intent to make them heal better. In a systematic review of randomized trials to test the effectiveness of Kinesio Taping of patients with musculoskeletal conditions, results showed that Kinesio Taping was no better than sham taping/placebo and active comparison groups. In all comparisons where Kinesio Taping was better than an active or a sham control group, the effect sizes were small and probably not clinically significant, or the trials were of low quality. The current evidence of this study does not support the use of this intervention in these clinical populations.
Nonetheless, it doesn’t surprise me in the least that researchers are only now concluding that it has no clinical benefit. Kinesio tape has been around for years, and this paper says it was first created by a Japanese chiropractor in the 1970s. I noticed it really got popular in and after the 2012 Summer Olympics, where Kinesio Tape was prominently displayed on a number of beach volleyball players. Sure enough, a quote from this paper is: “It seems that the growing use of Kinesio Taping is due to massive marketing campaigns (such as the ones used during the London 2012 Olympic Games) rather than high-quality, scientific evidence with clinically relevant outcomes.” So in other words, Kinesio Tape is popular because of good marketing and poor researchers. I think another problem is just a lack of critical thinking skills on the part of medical practitioners (which sadly includes a lot of physical therapists) who should know better.
Check out my blog to read more about Kinesio Tape and Neck Pain
On my blog, I read and posted a study conducted in 2013, specifically intended to raise awareness of the effect of strenuous yoga flexion exercises on osteopenic or osteoporotic spines. It was concluded that the development of pain and complications with some flexion yoga positions in the patients with osteopenia leads to concern that fracture risk would increase even further in osteoporosis. This finding suggests that factors other than bone mass should be considered for exercise counseling in patients with bone loss.
The author noted he had seen, but not reported, other compression fractures in women with yoga flexion stretches before, and said they were considered incidental until other yoga related vertebral fractures were reported; at which point, he decided to do this paper. With a lot of vertebral compression fractures going unreported, I expect the incidence is greater than this paper suggests. The author did a good job of defining which yoga stretches are the problematic ones, which are those in which the person flexes their back or neck as they bend forward to touch the floor/their feet, or flexes their neck as they bring their chin forward towards their chest. These flexion stretches mimic the direction that causes lumbar discs to herniate. Also worth noting is that extension strengthening, contrary to flexion stretching, has been shown to be protective against vertebral compression fractures and squats with accelerating progressive resistance has been shown to increase both hip and lumbar bone mineral density.
The right exercises are good, the wrong exercises are bad, and physical therapists need to differentiate what exercises are going into their programs to maximize rewards and minimize risks.
Check out my blog to read more about Negative Impact of Flexion Exercises On the Neck and Back
Psychology and Neck Pain
So does psychology have anything to add to physical therapy treatment for neck, back, and other disorders?
The research thus far would indicate no for both low back and neck pain, but I think the research thus far has been based on utilization of poor psychological methods that don’t understand the causes of spine injury. With neck pain in particular, I often notice that anxiety has a significant effect on correlation with pain. It also tends to make patients very apprehensive with regards to beneficial strength-based exercise programs, which research shows are very effective. I notice this tendency much less so with back pain but I don’t doubt some effect. Active exercise programs that increase strength, ability and confidence as the patient’s see themselves get stronger is psychologically empowering. Proper lifting techniques (using a neutral spine) teaches the neck or back pain sufferer that they can complete difficult tasks without pain and injury, resulting in lessening anxiety with such activities. Lessening anxiety also helps to reduce pain. The improved fitness of the exercise program contributes to improved feelings of well being, such that a negative spiral of damage, pain, and disability is turned around.
Psychological principles of adopting optimistic as opposed to pessimistic attitudes also increases hope, decreases discomfort, and all that is a lot easier to achieve when you teach the patient how they can lessen or eliminate pain, rather than tell them that pain is normal. So I don’t think the biopsychosocial model of low back and neck pain in physical therapy needs to be thrown out but it certainly needs a complete overhaul, needs to take into account environmental factors contributing to low back pain; it needs to understand that some activities and exercises are more damaging than others, and needs to stay up to date with new psychological techniques including much coming out in the new field of positive psychology.
Check out my blog to read more about the Biopsychosocial Model and Neck Pain