Chronic Neck Pain : Postural Causes and A Unique Fix
— Bookspan, Dr. Jolie."How to Fix Neck Pain, Upper Back Pain, Shoulder
Pain, Rotator Cuff and Tightness"
"After years of squashing the discs in your neck with a forward head posture...so that the weight of your head unevenly presses the vertebrae and the disc between them, the discs start to be pressed outward toward the back. They break down and bulge in the direction you've been pushing them."
"...it is not a matter of strengthening muscles to stop pain. Strength does not make you sit or move in healthy ways. Many people do strengthening exercises and become stronger people who still slouch."
She mentions that a degenerating disc can heal with proper posture. But discs and cartilage are notorious for slow healing. Bony changes also are unlikely to reverse. I did look for a reference about the healing of intervertebral discs, and apparently herniated and torn discs can somewhat heal. See the next reference.
— Eveleigh, Janice PT. Stretching-Exercises-Guide
A comprehensive guide to stretching. Includes the science, the how to's, when not to stretch, and precautions. Includes types of stetching, and stretches for specific areas of the body, for muscular conditions and injuries, and specific sports. And a section for posture and posture improvement exercises.
—Fitzgerald, Matt. "Balance Your Blades: 3 Corrective Shoulder Exercises"
"Healthy shoulder blades are a rarity in our society. The problem is the amount of time we spend sitting in front of computers and steering wheels. The hunched position we tend to assume in these situations leads to a more or less permanent forward rounding of the upper spine, called kyphosis.'
"It doesn't stop there. In the keyboard-typing and steering-wheel-grasping positions because we hold our arms out in front of us, typing and driving etc, our shoulders are internally rotated and protracted (pushed forward) for long periods of time. This leads to laxity and weakness in the muscles that externally rotate and retract (pull back) the shoulders."
"This posture inhibits the ability of the scapula to tilt backward and create space for the rotator cuff in the shoulder joint when the arm is lifted overhead. As a result, the rotator cuff gets pinched, causing tissue damage."
— Eric Goodman. Foundation Training Program
He promotes strengthening the true core: the posterior chain muscles attached to the pelvis—the back extensors, gluts, and hamstrings; and stretching the front of body by lifting the chest, widening the rib cage, and lengthening the distance between bottom of ribcage and hips—to improve posture and lessen or eliminate back pain. Several videos on his website explain his reasoning and main exercise, the Founder, which is a type of squat with arms extended forward and upward. His book, Foundation Training, also includes variants of "good mornings," planks, and a prone back extension exercise similar to one shown in this video. Also foam roller exercises, discussions of interval training, training zones and nutrition. See Dr. Mercola's comprehensive article on Foundation Training. [I strongly agree with Goodman's approach to tackling back pain by strengthening the posterior of the body, which naturally improves posture. He does not mention stabilizing the shoulder blades, but then his concern is not with neck pain, but with lower back pain.]
— Todd Hargrove's blog at BetterMovement.org
Many interesting and thoughtful articles that challenge accepted beliefs about exercise, posture, spine pain and the way we move in general. Also he cites and explains academic research studies to support his "arguments". Two good blog entries are: "Fatigue is an Emotion" where he cites an article by Timothy Noakes "Fatigue is a Brain-Derived Emotion that Regulates the Exercise Behavior to Ensure the Protection of Whole Body Homeostasis" and "Is "Efficient" Movement Unsafe" (Poor movement, posture etc may "...reduce energy demands on local muscles because they transfer the work of stabilization to ligaments and other connective tissues. This saves on energy expended by local musculature but creates mechanical stress because body weight is just “hanging” passively off the ligaments and connective tissues. ... [Poor, lazy movement and posture] are not actually energy efficient at all, because they sacrifice the stabilization and proper bony alignment that is the key to efficient movement and posture," and avoidance of acute and chronic musculo-skeletal damage)
—Jull, Gwendolen et al. "A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache" Spine 2002:27:1835–45.
"In the presence of neck pain and headache, weakness has been identified in the deep neck flexor muscles (bend forward), and patients show increased activity in their superficial flexors, presumably as a compensation strategy."
"Atrophy has been shown in the suboccipital extensors (back neck muscles), and thus the deep muscle sleeve, important for active support of the cervical segments, becomes impaired."
"increased activity has been shown in muscles such as the upper trapezius (and levator scapula—shoulder girdle muscles) in patients with neck pain during functional tasks, which may cause unnecessary loading on cervical structures."
"One of the more commonly observed postural faults is the protracted (abducted or farther apart than normal) and downwardly rotated position of the scapula."
"Regaining control of scapular orientation is begun from the outset."
"Re-education of control of posture begins from the first treatment. Frequent correction to an upright neutral postural position serves 2 functions. It ensures a regular reduction of adverse loads on the cervical joints induced by poor spinal, cervical, and scapular postures. Most importantly, it trains the deep and postural stabilising muscles in their functional postural supporting role."
—Jull, G. Interview: Rehabilitation of the Cervical Spine. (No longer available)
(r.c.'s notes from interview) In the past, manipulative therapists gave little attention to muscle systems, but the recurrent nature of neck pain showed something was missing. Manipulation, strengthening and stretching exercise is not enough.
Deep neck flexors become deficient in neck pain. Neck pain patients try to use superficial neck flexors, which aren't adequate. Professor Jull noticed neck pain patients could not do exercises that normal people did easily (such as lifting the head off the pillow—neck flexion against gravity).
In rising to a standing position, neck pain patients don't use their postural stability muscles well. If they can't facilitate their spinal multifidus, they can't activate their deep neck flexors.
Downwardly rotated scapular position is common in neck pain. Patients may have scapular muscle strength but under low load (like sitting at the computer) they fatigue easily. Jull is looking at scapular control and orientation in further studies.
Painful neck joints that come from muscle overload (e.g. working on the computer for hours with the head craned forward, which stresses back neck extensors) won't be helped long term by manipulative joint therapy unless the muscle (postural) rehabilitation is addressed first to reduce load on joints.
60 - 80% of whiplash patients do well with Jull's program but at least 20% have an augmented pain process, are hypersensitive to cold, lightheaded, unsteady and have eye movement control problem, PTSD/anxiety symptoms. She is conducting further research.
—Jull, Gwendolen, Whiplash Injury Recovery: A Self-Management Guide—free download. Explains the neck flexor strengthening exercise and gives several other stretches and strengthening exercises. Also discusses and gives tips on maintaining good posture.
—Jull, Gwendolen et al., "Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash?" Pain 129 (2007)28-34. Study of whiplash pain patients. Jull's physiotherapy treatment helped patients but pain relief was marginal in the patients with widespread mechanical and cold hyperalgesia.
— Kaiser Permanente "Neck Pain, What You Can Do" (PDF)
A simple, comprehensive booklet that emphasizes correction of posture to improve neck pain. Gives great tips for improving posture in sitting and standing.
— Kelty, Dr. Robert, Complete Care Chiropractic and Massage
Includes helpful information on spine and health, by Dr. Kelty to help his patients in practicing exercises he has prescribed. Included are videos explaining with clarity and detail how to do low back, shoulder and neck exercises. Of particular note is a video with tips, references and a comprehensive video on improving sitting posture to avoid neck and shoulder pain due to prolonged desk work, computer and mobile device use; see Sitting At Your Computer. Another page, Yardwork without Pain, includes two videos, one showing how to avoid back pain from bending and twisting during yard work, and the other, an exercise and explanation of the importance of bending at the hips rather than bending at the "belt" to avoid strain to the lower back.
— King, Dr. Neil, King Chiropractic
Posture improvement videos: Stabilizing the Lower Back, Pull Shoulders Back, Strengthening the Legs and Hips (sacro-illiac exercise) and Back Extension and Abdominal Strengthening (However, he states that "posture is resting on the ligaments. [and that] It should not take any muscular involvement at all for you to stand up and look better and feel better...." Resting on the ligaments may apply to poor posture but not good posture. The point is to correctly align the joints by increasing muscle tension in some muscles and relieving it in others, and thereafter, muscle tension, which is mainly antagonist co-contraction maintains the improved posture. That muscle tension/work eventually becomes a habit, which is largely subconscious.
— Jill McNitt-Gray,PhD and Witaya Mathiyakom, PT, PhD, "Preventing Shoulder Injuries: Recognizing muscle tightness and reducing muscle imbalance through exercise can
keep your shoulders healthy" in Dimensions of Dental Hygiene.
Excellent article directed toward Dental Professionals with advice about upper body posture, how to test for muscle imbalance and therapeutic exercises. Good illustrations of the exercises.
— Mullen, G. John, DPT, Pain in the Neck: Fixing the Problem at its Root
Symptoms, tests and treatment of postural neck pain. Instructions for a deep neck flexor test. Also included is a corner stretch for tight front shoulder (pectoralis) muscles and a shoulder blade/scapular squeeze exercise. However, the armpit sniffer, scalene stretch, upper trapezius stretch would have flared my neck pain in the past, and are still impossible for me. But still, I wish I'd had him as my physical therapist 7 years ago. Also tips for holding proper posture while at the computer or sitting down.
— Osar, Dr. Evan – Fitness Education Seminars:
a wide range of free videos devoted to the reasoning behind and proper performance of many important exercises including strengthening/stabilization of core, spine, hip, shoulder and foot.
—Pashman, Robert M.D, eSpine: Flatback Syndrome
"In many individuals, lack of lumbar lordosis does not produce symptoms. Those patients who are symptomatic however, can be treated ...initially with physical therapy. The emphasis of therapy should be on strengthening of the gluteal, low back, abdominal and hamstring musculature (hip flexors too?)....When conservative methods fail and the patient is symptomatic to the point of dysfunction due to the pain, surgery is indicated....Flat back occurs most commonly in patients who have had previous spinal fusions. To recreate balance, it is necessary to break the fusion mass (osteotomy) and re-fuse the spine in a more balanced position.(rc. restore lordosis)"
— Paula Moore at Posturevideos.com:
All you'd ever want to know about Intervertebral Disc Degeneration, also known as Degenerative Disc Disease (DDD)
— BrainandSpinalCord.org Blog: News stories and articles about brain and spinal cord injuries, diseases, research and treatments. Four years of posts on topics such as Alzheimer's and chronic head trauma, promising therapies, rehabilitation and injury prevention.
— Medical News Today: Hourly health news from well regarded medical journals and articles written by staff members.
— Medscape: News and valuable medical reference articles. You can arrange for email alerts on new articles in specific subjects to be sent to your inbox.
— Science Daily: The latest research news in Health & Medicine, Mind & Brain, Plants & Animals, Earth & Climate, Space & Time, Matter & Energy, Computers & Math, Fossils & Ruins.
— Today's Dietitian Article Archive: Complete articles from previous issues of the magazine. Cites current research and easy to read.
— Psyblog, Understand your mind: What recent psychology research tells us about how our minds work. Interesting posts by Jeremy Dean on the shortcuts our minds use, how we can persuade others or others persuade us, changing habits, dealing with stress etc etc. (I enjoyed his new book, Making Habits, Breaking Habits: How to Make Changes that Stick)
—Cailliet, Rene, Neck And Arm Pain, 3rd edition, 1991—Part of a series on pain, injury and disability. Delves into the complexities of all the varieties of neck pain: spinal, muscular, nerve impingement, whiplash, cervicogenic headaches and myelopathy etc. One chapter is devoted to posture. His commentary on degenerative disc disease is an eye-opener. Makes a complex subject readable and understandable. Many illustrations. Available used (as low as 1¢) on Amazon—see link above. Discusses Posture Extensively! (Also see an article by Rene Cailliet with free access to the complete article, Pain in the Neck and Arm—Diagnosis by History and Examination.
— Carey, Anthony B., The Pain-Free Program: A Proven Method to Relieve Back, Neck, Shoulder, and Joint Pain, 2005 - One of the best books I've found on treatment of chronic musculo-skeletal pain. Carey definitely puts posture and alignment first, and the exercise regimes he recommends are based on the specific type of faulty posture present.
— Goodman, Eric, Foundation Training: Redefine Your Core, Conquer Back Pain, and Move with Confidence - Flashy book with lots of photos. Not a lot of info and mostly variations on a few well-known exercises such as squats, good–mornings, prone back extensions, and planks, but if done correctly these should greatly improve strength in the true core - the posterior chain of muscles that hold us upright. See above entry with videos from his website.
—Jemmett, Rick, Spinal Stabilization: The New Science of Back Pain, 2011—Jemmett, a Canadian physical therapist explains the importance of strengthening specific spinal stabilizing muscles when spinal joints loosen and become more unstable with age and arthritic degeneration. The Australian Approach theorizes that positional information from nerve endings in discs and ligaments is compromised in various spine pathologies, causing poor activation of protective spinal stabilizing muscles. These small, deep muscles are supposed to tense just before trunk movement takes place, but since they may not (especially with a painful back) more superficial muscles are recruited to stabilize the spine; not being well-suited to that role, they end up tightening in spasm, which does stabilize the spine, but not in a healthy way...it's just too darn painful to move. Waking up the positional sense nerves is done with off–balance type exercises such as standing on one leg with eyes closed etc. And the Multifidus and Transversus muscles are re-educated in their primary roles as spinal stabilizers by deliberately learning to contract them. (R.C.—The exercise to activate the transversus abdominis was doable, but activating the multifidus just by willing it to would have been very difficult if I hadn't already been practicing using Jim Johnson's instructions in The Multifidus Back Pain Solution book.) Spinal Stabilization is a short, easy to read book (124 pages). About half is devoted to explaining the concepts, and half to a program of familiar exercises done while activating the Multifidus and Transversus. Several are position sense exercises: such as standing on one leg with eyes closed, sitting/kneeling on a Swiss Ball, bridges, and then there are knee and leg lifts — all strengthening-the-core-type exercises. The more advanced exercises (some shown on the cover) are not designed for an older person with thinning bones (such as myself). And No Mention of Posture at all! Strengthening spinal stabilizing muscles helps hold the spine erect, but if postural imbalances remain, such as tight hamstring group muscles, there will still be flat back/sway back, and if tight quadriceps then there'd still be lordotic back (which is a strong lower back already) and etc. Back pain worsened by poor posture, won't be addressed by these exercises.
—Johnson, Jim, The Multifidus Back Pain Solution, 2002—Johnson, a physical therapist, explains that weakness in the Multifidus, many small muscles that extend the length of the spine and interconnect the vertebra, is hypothesized to lead to back pain. The book includes several good multifidous strengthening exercises. The last one in particular can be done by anyone able to sit or stand. (This exercise(#6), in spite of neck and back pain, I could always do.) Also good discussion of how some degree of nerve compression doesn't necessarily result in pain unless the nerve is inflamed. Extensive references. No Mention of Posture Here, either! (See comments for Jemmett's book, above)
—Kendall et al., Muscles: Testing and Function with Posture and Pain, 5th edition, 2005—A classic text, which covers muscle testing, and the evaluation and treatment of postural conditions.
— Rick Olderman, MSPT, CPT; Fixing You: Neck Pain and Headaches. Mainly devoted to Droopy/Depressed shoulder, where neck and shoulder pain are accompanied by horizontal collar bones and low set shoulder blades. However, I believe that more commonly, shoulders are not depressed but even held a little higher because of upper trapezius dominance, weak lower trapezius and lower serratus anterior. Unless one specifically has depressed shoulders, his book won't be as much help. Though there are some interesting discussions about how shoulder blades are supposed to move and function.
—Sahrmann, Shirley: Diagnosis and Treatment of Movement Impariment Syndromes, 2001. A classic physical therapy text—Includes evaluation, treatment and detailed descriptions of exercises.