Tension
at the base of the neck, or maybe you feel it across your shoulders but the
sensation is one most of us have experienced; Heavy pressure, squeezing and
tightness that translates as pain somewhere in the upper or middle back or
shoulder. Often there is radiation up
toward the head or down along one or both arms.
You may feel burning or tingling.
You no longer remember the freedom of fluid soft tissue mobility that
once existed among the individual structures in the neck region. Years ago, each vertebra, both collar bones,
each shoulder blade moved on its own without disturbing surrounding
structures. Now, when you tilt your
head, or raise an arm, it’s as if half of your chest rises.
Everything we do is done in front of us.
We use our arms and our hands and watch with our eyes. Our heads are usually bent forwards. Our shoulders are rounded, sitting in front
of where they should be. And once we
have finished whatever activity we have just completed, we rarely resume a
“proper” posture but maintain this forward rounded one. Gravity and habit brought us to this
shape. Until we feel pain, we have no
stimulus to change. Unless we happen to
catch a glimpse of ourselves in a mirror or a photograph and notice how we actually
look so hunched.
Figure 1
A main muscle that supports the head in
its upright posture is the trapezius ( Fig 2). When the head is bent forward, the trapezius
is in essence turned off. We then
recruit muscles nearby to hold the head up instead. But these muscles are not intended to do this
job. Their fibers are not oriented to
create the upward force needed to support our 14 to 20 pound skulls. The thin strap muscles that surround the neck
twist and turn the head sideways, upwards and downwards. When we clench these muscles to use them as a
head support, they fatigue, their fibers shorten, and their metabolic processes
are altered causing a build-up of noxious substances. The soft tissue surrounding these muscles are
altered by the changes in the muscles’ function and the entire area becomes
dysfunctional. The neck area changes
shape becoming rounder and thicker.There is less motion, so there is less blood flow with less oxygenation and impaired tissue metabolism. Eventually we experience discomfort and then pain.
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| Figure 2 |
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| Figure 3 |
The muscles most often affected are the semispinalis, splenius cervicus and capitus and the scalenes, especially the posterior scalene (figure 3). There is not much motion within the fibers of these muscles, even when they work at their maximum potential.
When the local environment is healthful, circulation is sufficient to clear any toxic byproducts of normal reactions. In a setting of chronic, unhealthy behaviors, in the presence of soft tissue damage there is a build up of noxious stimuli. The local circulation becomes overloaded and cannot clear the area. The tissue becomes further damaged and scar forms. The process is self propelled to escalate. We perceive an increase in pain with no additional obvious cause for injury. We develop neck, shoulder and head pain.
Referred
pain:
This is pain felt in a part of the body
other than its actual source. A network
of interconnecting sensory nerves supplies many different tissues. When there is an injury at one place in the
network, this pain can be interpreted in the brain to radiate to nerves and can
give pain elsewhere in the related areas of the network. If this does not make
sense, think of it this was. Embryologically
we start with a single cell that divides into two cells, and then those two
into four, those four into eight and so on.
The cells differentiate into all of our different structures, and
migrate away from each other to their proper places. As we get more cells, they take up more space
and each are located further away from each other. But cells that were originally linked
maintain some connection despite physical distance, perhaps chemical, perhaps
neurological. When one structure is
affected by a stimulus or injury, all related structures may be affected and
this is a referred response or referred pain.
Referred pain is an important component
of neck pain and headaches. Much of the
pain experienced is a result of pain referred from original sources of injury. Treatments need to be directed at the injury
and not necessarily at the sites of symptoms.
Treatment should be aimed at restoring healthy tissue. The best way to achieve this is to restore
posture and normal motion to the area.
This will take some time. To
retrain any body takes time and effort. Exercise to strengthen the middle and
upper back is a long term solution.
Physical therapies including modalities with soft tissue manipulation,
transcutaneous nerve stimulation, ultrasound, the application of ice and heat
will promote soft tissue health and healing.
For very focal tissue repair, trigger point injections may help disrupt
stubborn tissue damage and then promote muscle tissue repair more rapidly than
manual work and exercise alone. Trigger
point injections are performed by a specialty trained physician. This may be a Physiatrist, Orthopedist, Neurologist
or Rheumatologist. They can be repeated
often if necessary, or done once. The
success depends on a number of factors; how long the soft tissue injury has
existed, the accuracy of the diagnosis for the trigger point injection, the
skill of the clinician.
The success of therapy will also be
dependent on numerous factors. Therapy
requires patient participation. It is an
interactive modality that requires homework.
Our soft tissues (our muscles,
nerves, ligaments, tendons) have memory and need to be trained and reminded of
the proper positions to hold and the proper ways to move. We must practice good posture and proper
kinetics to maintain them. If we move
our shoulder blades regularly they remain loose. If not, they become stiff and locked within
the back muscles (for example). But this
is an important example, because so many of the muscles that control head and
neck motion are attached to the shoulder blades, so if they are not moving
freely, the head and neck will feel stiff.
Now, this is not something we wish to think about. We just want to live, and move, freely,
without pain. But, and forgive the cliché, use it or lose it. It is important that people do not
underestimate the importance of some form of “exercise” in their rehabilitation
when they have neck pain and/or headaches.
I have purposely delayed discussing
medications as treatment. There is a list
of medications used to treat neck pain.
The pain arises from numerous sources: mechanical, muscular,
neurological and centrally mediated – especially once the pain becomes
chronic. Medications should be used to
help enable one to endure the pain while participating in the mobilization
phase of a rehabilitation program. For
the small percent of people with chronic, incurable conditions, medications are
used to manage pain appropriately. What
is an incurable neck condition?
Osteoarthritis, yes. Herniated
disc, no. But even those with osteoarthritis do not necessarily require
lifelong medication. Anti-inflammatory
medications treat the pain caused from inflammation. This is pain induced by tissue damage, when
there is underlying tissue disease, whether systemic or induced by strain. These include ibuprofen (motrin) or
naproxsyn(aleve). Analgesics treat
mechanical pain caused by things such as joint disease and degenerative
conditions or traumas. Acetaminophen (Tylenol)
is an example. The best class of
medication for muscle pain is the muscle relaxing drug and the most popular is cyclobenzaprine
(Flexeril) though the one I like best is tizanidine (xanaflex) since this is
less sedating. Finally drugs used to
address central pain, that is pain arising from the central nervous system,
what is often called “nerve” pain can be varied. These medications are a bit more complicated. They are drugs whose main use are to treat
psychiatric and neurologic conditions but also have been shown to also temper
pain. Gabapentin (Neurontin) is a
popular example. I am not suggesting a
medication regimen here but only explaining how medications might be used. Every medication plan would be tailored
specifically for any individual based on their specific needs. And usually patients find medications unsatisfactory
in treating their musculoskeletal pain.
The
topic of neck pain is vast. This article
just touches on a small component, specifically common musculoskeletal
pain. And even this topic can be
expanded. But we have to start
somewhere. The take home message, if you
have neck pain for more than a couple of weeks, mention it to a physician. Seek assistance in resolving the issue while
it is easy to fix. Chronic neck pain is
much harder to get rid of and can lead to significant debility. 