Getting neck pain at the computer, join the club, it’s frustrating, it’s annoying, you are trying to get your work done and it keeps popping back up. Or maybe you’ve recently had a car accident and you’ve suffered a little bit of whiplash. Neck pain is one of the most common presentations physiotherapists see and there is a huge range of different presentations from those driven by postural changes, to whiplash, nerve impingement/compression, to acute wry necks. For such a small region of the body, there are a lot of potential differential diagnoses that need to be worked through to determine an accurate diagnosis. Approximately 15% of adults will experience an episode of acute neck pain per year so let’s help make you not be one of them in the future and learn how to best manage your neck pain now, and help reduce your risk of future episodes of neck pain.
Neck pain can disrupt many normal parts of day-to-day life, one of the most common frustrations I hear from clients is simply the pain, tension, and stiffness build-up that they often experience with prolonged periods of sitting. A lot of clients blame this on their posture and it may play a role but often posture isn’t the be-all and end-all that some clients perceive it to be. There actually isn’t any research linking posture as a causative factor to pain, but it can certainly be part of the picture. Neck pain is clearly highly multifactorial with concerns potentially including muscle tightness or weakness, joint stiffness, postural elements, as well as contributing factors from either the shoulder joint or the thoracic spine.
As with just about any other presentation to me, I always like to first understand how the issue started. Now I wouldn’t say it’s uncommon for some people to not be able to recall a distinct moment when their neck pain started, there is a fair proportion of people who experience neck pain that has gradually come on over time. In those cases, it often becomes more of a what’s changed question rather than what happened. For example, you could have started a new job and that means that your desk is set up slightly differently, or perhaps you changed pillows and mattress recently, there could be any number of factors that could have resulted in it so often thinking about what is different can be a good place to start.
If you have suffered a whiplash injury following a motor vehicle accident we will want to have a good understanding of how the accident occurred including the direction that you were hit from, whether you saw the vehicle coming, what direction were you looking e.g. directly forwards, in the rearview mirror, over your shoulder, turned to the side etc.
Secondly, understanding your symptoms, what they were like when they started and how they have evolved and changed over time or with different activities or positions. This includes any other symptoms such as pain referring down the arm or to the shoulder, as well as any pins and needles, numbness, or areas of altered sensation. Understanding what makes your pain feel worse and what makes your pain feel better are key pieces of information, for example, you may say you really dislike sleeping on your left side, but sleeping on your right side feels great, it’s small information but can help fill in the clinical picture for us.
Lastly, understanding any previous history of neck symptoms you have suffered prior to this episode and whether you can find any common linkages between them can assist us in determining whether there is a preventable pattern to your symptoms.
As you are moving we will be observing your posture and positioning of your neck, thoracic spine and shoulder complex. I find it is very common for clients with neck pain to present rounded through the mid back, and with rounded and slouched shoulders, this isn’t a great position to be in as it puts a lot of the soft tissues through the shoulder and neck region on stretch and can create the illusion of something that feels “tight” but in reality, is a stretched and overworked muscle.
The next step is often to feel how the muscles and joints through the cervical and thoracic region “feel”. What I am often looking for here is areas of tightness through the muscles – some people often refer to these as knots. Through the joints, I am often assessing for irritability and pain to touch, as well as whether a joint feels stiff to move under the pressure of my thumb. Whilst this isn’t a wholly accurate assessment as multiple research papers have found, we are able to correlate areas of stiffness with your movement restrictions and then if we treat the corresponding area and have an improvement of symptoms it relatively concludes that there is a relationship between the two.
Lastly, we may need to perform a neurodynamic or even a neurological assessment depending on if you have presented with a nerve referral or symptoms of potential nerve compression. Neurodynamic tests are an assessment of the mobility of the neural system. There is a test for each of the three main nerve paths through the arm, the median, ulnar and radial nerve. Which assessment we choose will largely depend upon the area that your symptoms present in. A neurological examination on the other hand is a little different.
A neurological examination consists of three main components, an assessment of myotomes (muscle contraction), dermatomes (sensation), and reflexes. All of these assessments are designed to help narrow our diagnostic ideas, particularly if we are looking at an avenue of further imaging such as a CT scan or MRI, we don’t want to just go for an MRI and blindly follow what it shows us. The assessment is designed with different contractions and areas of sensation designated to different spinal levels of the cervical spine. Following your imaging, we will be looking to correlate the findings of a neurological examination and the findings on your scan to ensure they match and make clinical sense.
Mobilisations are a technique aimed to reduce pain sensitivity of the joint structures as well as improve joint mobility. They can also help to reduce any neural symptoms by reducing potential nerve irritation at the level of the nerve root. Some physiotherapists may have a recipe approach to cervical mobilisations, in the sense that they will perform their glide in the same direction for each client. Instead, I prefer to look and find what is the stiffest direction for each joint to ensure that we can get the best bang for our buck with regard to treatment time.
Massage and soft tissue release are almost a given for clients with neck pain. Often shoulders are tense and some of the neck muscles may go into spasm in acute cases, or in longer-term cases, there may be longer-term muscle tightness present that we need to work through to ensure the best effect from our joint mobilisations.
Cervical traction can be a really nice technique that can have great effects on a wide range of presentations. Traction is the process of trying to open up the joint spaces and provide some stretch to some of the cervical musculature. This technique can work great in acute cases such as a wry neck, but also can have significant effects for clients who have neural irritation or compression through the cervical joints.
Following our comprehensive assessment, we may need to perform treatment in some other areas such as the shoulder complex or through the thoracic spine. It’s quite common to need treatment through one or both of these areas as there can be increased muscle tightness or increased joint stiffness either as a predisposing factor or as a secondary effect of the neck pain.
Now, for my favourite part, and most of my client’s least favourite part, the exercise program. Exercise is the best long-term treatment for pretty much any musculoskeletal complaint. Often for cases of neck pain, we are wanting to maximise mobility through the cervical and thoracic spine, improve strength through the back and shoulder complex, and improve muscular endurance. Some stretches may be needed, but often I find most clients need strengthening much more than they need stretching and it can often fix the tightness issue at the same time.
Meanwhile, adjunct treatments such as dry needling and taping can have great benefits for clients. Dry needling can be highly beneficial in reducing muscle tone as well as reducing pain sensitivity. Whilst taping is often used as a short-term de-loading technique so that we can reduce pain and irritability and can allow us to accelerate your road to rehabilitation.
Almost every client who I see who’s an office worker who complains of neck pain reports that “my problem is my posture”. But what is good posture, and why does posture seem to cause so many problems in so many people? I’d love to be able to agree with these people but I just can’t, currently, there isn’t any research that has been able to identify a link between certain postures creating pain, whether that be neck pain, shoulder pain, upper or lower back pain, there just isn’t a link yet. So why does the research say one thing but everyone else tells me different?
Here’s what I think the problem is. I agree with the research that certain postures don’t cause pain, but I also agree with my clients, but I think the answer isn’t the posture itself, it’s that we are always in the same posture, or we force ourselves to sit in an unnatural position because “my teacher in grade 4 told me to sit up straight”. As good as your teacher was, they probably didn’t quite grasp the complexities of posture. I believe humans are designed to adapt and move, the notion that there is a “correct posture” to sit in I think is incredibly outdated. We should be able to change postures throughout the day based on comfort and what we are doing. Why should I force myself to sit dead straight and be uncomfortable just to feel like I’m sitting in the correct position, it makes no sense to me. I encourage my clients to think of 3 questions when they think about their posture:
My second tip would be to get into a routine of some upper-body strengthening. This doesn’t have to be at the gym but the equipment can definitely come in handy. Otherwise, some light bodyweight exercises at home can help do the trick.
Thirdly, getting into a routine of some shoulder, thoracic spine, and neck mobility work. Making sure you have sufficient thoracic rotation and extension can help reduce pressure on the neck, and maintaining good shoulder mobility helps to reduce compensations as well. Keep everything moving freely and you’ll be on your way to keeping a pain-free neck.
Our 3-week program was designed for clients who have suffered an acute injury and want to get out of pain ASAP. This package could be suitable for clients who have suffered a wry neck, a recent onset of headaches or migraines, or who suffer from pain whilst in sustained positions.
Our 3-week program is inclusive of the following:
Package price: $770
Our 6-week program is designed for clients who have sustained a higher-grade injury. This could include clients who have a recurrent history of headaches, some whiplash presentations, some nerve pain presentations, or those who have suffered a long history of neck pain from prolonged positions and are interested in determining all of the predisposing factors.
Our 6-week program is inclusive of the following:
Package price: $1050
Our 12-week program is designed for clients who have sustained higher-grade whiplash injuries, or those with prolonged and chronic neck pain, or more severe presentations of nerve pain, some post-operative presentations could respond well to this treatment style too.
Our 12-week program is inclusive of the following: