Overcoming Chronic Neck Pain

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Posture Topics

1. Hunched Posture: Restricted Breathing and Risk of Back Strain
2. Poor Sitting Posture
3. Effect of Faulty Lower Back Posture on Vertebra
4. Effect of Extension and Flexion on Intervertebral Discs
5. The Aging Disc
6. Poor Posture into Old Age
7. Straightening of the neck's lordotic curve
8. Methods for re–orienting/re-stabilizing the shoulder blades
9. Sustained correction of poor posture
10. Mobile devices, laptops and reading material

1 a. Hunched posture "caves" in the chest and restricts breathing. Taking a deep breath stretches the front chest muscles that have shortened and tightened, and helps reduce the hunched upper and mid thoracic spine, and the lower back to straighten.

    b. Hunched posture with forward head leads to the tendency of the entire body to lean forward, stressing the lower back and making back strain harder to heal. The pelvis tries to compensate by rotating backward, almost as if trying to pull back on the trunk to keep it erect. And in the process, thru the SacroIliac (SI) joint connection, pulls the lumbar spine flat and stretches back extensors and posterior spine ligaments. In addition, the butt/glut muscles shorten and tuck under, and the back thigh muscles shorten and tighten (both muscle groups attach to the back of the pelvis and shorten as pelvis tilts backward). The front of the thigh and other anterior hip muscles or hip flexors elongate and weaken as the pelvis tilts backward. With loss of the normal lumbar lordotic curve ("Flat–Back Syndrome") the body tends to lean forward when sitting, walking or standing. As with forward neck/head, the added weight of the out–of–balance upper body requires more force applied by the back extensors to keep the upper body from falling forward—causing them to be in a constant state of tightness. Both being tight and stretched, which weakens the muscle, makes spasm more likely. Under this double stress, acute back strain would not heal easily. See Fix the Posture

2. Poor Sitting Posture: Many of us spend more time sitting than standing. Some of us work leaning forward, our heads craned toward the computer screen. Some of us curve our backs into a big "C" so that we sit on our lower backs with pelvis rotated back, and lower back rounded into kyphosis, rather than a normal lordotic curve.
For the sake of keeping the neck and head erect, neutral sitting posture in a chair with lumbar support is best. Interestingly, Dr. Bashir et al did a study using a positional MRI machine to image the spinal discs of subjects in three sitting postures:
1. Hunched forward (kyphotic lower back)
2. Upright at a back–thigh 90 degree angle with knees bent and feet flat on the floor,
3. Upright at a 135 degrees back–thigh angle (pelvis boosted up with a wedge–shaped bolster) and feet flat on the floor (tilts pelvis forward increasing lumbar lordosis).
    The authors found that intervertebral discs showed less compression with increasing lumbar lordosis. "Slouched posture" showed the most disc compression. The 135 degree "position was shown to cause the least 'strain' on the lumbar spine, most significantly when compared with an upright 90 degree sitting posture." (But how do you stay in the chair without sliding off? You'd have to be strapped in.) They do not make clear if the 90 degree sitting position was with a lumbar support, which helps maintain the lumbar lordotic curve effectively as long as one sits back in the chair against the lumbar support.

It is difficult to avoid hunching forward when sitting for prolonged periods, especially when concentrating on work. Try pulling the chair close to the desk with abdomen against the front of the desk, and one's back pressed against the back of the chair. One way to remind oneself to straighten up is to place a chair pad between one's back around shoulder blade level, and the back of the chair. If the chair pad slips down, this is a signal to straighten the back.


3. Effect of Faulty Lower Back Posture on Vertebra:
— If the pelvis tilts forward, the low back is brought into excessive extension or hyper-lordosis, which shifts more of upper body weight onto the relatively delicate rear vertebral joints making them prone to damage. Also the excessive curve crowds the rear vertebral joints together, and the spaces (foramina) through which nerve roots travel become narrowed (see middle picture of illustration below); nerve impingement is risked if pre-existing disc degeneration has caused loss of disc height, bone spurring and stenosis (narrowing) of foramina through which nerve roots leave the spine. The large central canal containing the Cauda Equina, the bundle of nerve roots that hangs down from the spinal cord that ends above the lumbar spine may also be narrowed. Illustration 4. Effect of Extension and Flexion of Lumbar Spine on Vertebral Anatomy

4. Effect of Extension and Flexion on Intervertebral Discs: If the pelvis tilts backward, pulling the lumbar spine flat, as in flat and kyphotic back, weight is borne more by the discs—a good thing up to a point—but as the forward curve (flexion, see right picture of illus. 4 above) increases, such as when bending forward, slouched sitting, or any sit-up type exercises, all the weight of the upper body is borne on the discs, increasing their internal pressure up to two-fold (during sit-ups). The worst movement for increasing intradiscal pressure and also increasing the risk of a disc tear or herniation, is to lift weight with a curved forward/flexed spine. Direct measurements of intradiscal pressure showed 2.75 times the pressure compared to standing in neutral posture. And the heavier the weight, the greater the load on the disc. See "The Lumbar Spine: An Orthopaedic Challenge" by Alf L. Nachemson. (However, bending forward enlarges the nerve root foramina, which is the reason patients with severe nerve root compression may get relief walking or sitting with their backs rounded in flexion.)

(Roef, 1960. A Study of the Mechanics of Spinal Injuries), Mechanical stress tests done on spinal sections from human cadavers, both young and old.
— The disc of normal height and fluid content is very resistant to compression. The nucleus does not alter in shape or position on compression or flexion. The annulus bulges very little. On increasing compression the vertebral body breaks before the disc does.
— If the nucleus pulposus has lost fluid pressure, as in the aged spine, there is abnormal mobility between vertebral bodies. On gentle compression or flexion the annulus protrudes on the concave side—not on the convex side as is commonly thought.
— Disc prolapse consists mainly of the outer layer (annulus); and occurs only if the nucleus pulposus has lower fluid pressure and the annulus is lax and protrudes easily.
— In the normal disc, hyperextension or hyperflexion do not easily cause rupture of spinal ligaments but rotation forces can easily cause ligament rupture and dislocation.
— A combination of rotation and compression can produce almost every kind of spinal injury.

5. The Aging Disc: Even a lifetime of balanced posture and moving in posturally healthy ways will result in normal wear and tear of the spine over time. The shock absorbers of the spine, the intervertebral discs, lose water content, going from 90% down to 65% water, which causes loss of disc height. Body weight becomes increasingly borne by the more delicate rear vertebral facet joints, which over-stresses them and leads to new bone growth (bone-spurs, arthritic changes) in the body's attempt to thicken and stabilize them. Acceleration of this spinal aging process may occur from an acute injury as in a car accident or from the many small stresses of poor posture. Chronic hyperextension (hyperlordosis) or hyperflexion (round backed), eventually accelerate arthritic degeneration of the spine. "Repeated eccentric* (Force in a direction the spine is not designed to accept) and torsional (twisting) loading and recurrent microtrauma result in tears in the annular fibers" (tough outer layer of the disc) and lead to the gel-like nucleus losing water content faster. See E-medicine article: Low Back Pain and Sciatica

6. Poor Posture into Old Age: With time and arthritic degeneration, spinal flexibility is lost and all the varieties of poor posture result in fixed spinal changes—becoming permanent deformities.
— A fixed, hyper-kyphotic thoracic curve can't be changed without serious surgery. The resulting forward head and neck can only be minimally improved by standing as erect as possible and maintaining optimal lumbar lordosis. But even a little improvement is better than slouching, which over time causes progression of the curvature.
— Forward head posture causes the head's weight to press unevenly on the cervical spine. Uneven pressure hastens disc degeneration as one side of the containment structure wears out (cracking, thinning, allowing moisture loss) more than the other. The bulge worsens, eventually desiccating and hardening. See link to Dr. Bookspan's article.
— Straightening of the cervical lordotic curve may become permanent with time; see below: "Loss of normal lordotic curve in the cervical spine." (At first, I thought that my cervical spine had minimal flexibility because of arthritic degeneration. I could not bend my neck to either side and my lordotic curve was almost nonexistent. Thankfully my upper back was still flexible. so reducing the thoracic kyphosis allowed my neck to be in a more stable position over my shoulders.) In 2013, I discovered that part of my cervical inflexibility was from weakness of supporting muscles. Weak muscles that support a critical structure such as the neck tighten to compensate for weakness. As those muscles strengthen, they can relax. Thus as my neck muscles strengthened from improved posture alignment, my neck became more flexible, though not as flexible as I'd like, but much better than a year ago.
— In the lower back also, loss of the normal lumbar lordotic curve may become permanent. (I had believed my lumbar lordotic curve was lost to arthritic degeneration, which in an MRI looked almost as bad as my cervical spine, but then discovered that my pelvis was "locked" in a back-tilted position due to tightness of back hip extensors (hamstrings). Doing a "dead lift hamstring stretch" during chores helped me regain a somewhat normal lumbar curve. Definitely there's lack of flexibility as I can't "overextend" my lower back, but that may be due to my pelvic anatomy. Luckily a more extreme lumbar lordosis is not necessary for balanced posture.)
— If lower back surgery is ever considered, preservation and/or return of the normal lordotic curve should be insured. Back surgeries often fail without this step. See Flat Back Syndrome — Dr. Justin Paquette Interview.
— Same goes for cervical spine surgery. Outcomes are much better with preservation and/or return of the normal cervical lordotic curve, depending on an individuals normal thoracic alignment.

7. Straightening of the neck's lordotic curve is not necessarily related to neck pain. The degree of the normal neck's lordotic curve is dependent on at least 5 factors:
T-1 slope and cervical lordosis1. Slope of the first thoracic vertebra's upper endplate (which depends on upper thoracic kyphosis): A smaller slope and less kyphosis of the upper thoracic spine results in straighter cervical lordotic curve; a steeper slope and greater kyphosis of the upper thoracic spine/hunched back results in a greater cervical lordotic curve. (See illustration)

2. How the neck is used. When the neck bends downward to bring the head and eyes closer to something, a cell phone screen, for instance, the neck's lordotic curve is reversed into kyphosis; if habitual, the rear neck extensors (that maintain the lordotic curve) stretch and weaken. And the cervical discs—especially of the middle, most mobile segments (C4 thru C6)—are exposed to unbalanced forces that prematurely wear the front edges of the discs, and hastening degenerative disc and joint disease.

3. Flexibility of the cervical spine: Even if the upper thoracic spine is highly kyphotic, the cervical spine may lack the flexibility in spinal ligaments or some other anatomical element, and can't increase lordosis enough to bring the head back over the shoulders. Thus, the head will be forward of the shoulders. (Flexibility of spinal ligaments decreases with age perhaps due to calcification.)

4. Strength of neck extensors: If too weak from injury or overuse atrophy, neck extensors may not be able to bend the neck into extension (lordosis) to return the head over the shoulders.

5. Anatomical changes including i) cervical vertebrae out of alignment due to laxity of spinal ligaments when discs loose height from injury, or shrinkage in the course of degenerative disc disease (see my MRI images); ii) Wedging of the vertebral body from loss of bone density or as a result of compression fracture of the cervical spine; iii) Cervical spine surgery such as laminectomy or a fusion that has not healed.

Long term forward head posture aggravates all the preceding, and "the (off-balance) weight of the head can cause progression of the curvature." (See "A Patient's Guide to Cervical Kyphosis" from U. Maryland Spine Program.) Without a cervical lordotic curve, the only alternative to reducing posterior neck pain from forward head, is to maintain a posture where the neck is as straight as possible. This entails reducing thoracic kyphosis and maintaining a normal lumbar lordotic curve.

8. Methods for re–orienting/re-stabilizing the shoulder blades: for those with neck spasm, pain and inflammation that worsens with arm use, re-stabilizing the shoulder blades is difficult. The usual therapeutic exercises for shoulders, such as seated rows and pull downs that use the arms in pulling or lifting weights, can be painful unless there's already some degree of shoulder blade stabilization. Otherwise, spasm and pain prevents the effort from going into strengthening the middle and lower traps, instead of the over-worked default muscles—upper traps and levator scapula. (I wasn't able to activate the correct muscles during my 4 plus courses of Physical Therapy for neck and shoulders. I knew the effort was supposed to be coming from the shoulder blades area and not the arms, but that was next to impossible when one's back and shoulder blades are like an unknown territory). Without a good way to see what should be activated, there is lack of innate body feel for what's really happening back there. It was much later that I discovered that it was possible to learn to contract and strengthen the muscles that control shoulder blade movements without using the arms, but mirrors were needed for visual feedback. And thus the "Fix the Shoulder Blades" exercise is done with a swivel mirror and another larger mirror to provide visual feedback. (Turns out that many of these muscles are only innervated with motor nerves, not sensory nerves, so controlling the shoulder blades would be tough for a lot of people.)   Eventually when the problem of neck spasm with arm use is minimized, the usual therapeutic exercises are better tolerated and useful for further strengthening.     See... Fix The Shoulder Blades Exercise.

"Fix the Shoulder Blades" may help to reduce excessive kyphotic curve of the upper back (but only if the curve is still flexible). Modify Fix the Shoulder Blades for hyper-kyphosis of upper to mid-back by doing the exercise while lying on the back without a pillow on a firm surface. If thoracic kyphosis is not flattened or the back of the head does not touch the floor, Fix the Shoulder Blades Exercise may not help. Please talk to a doctor first.

9. Sustained correction of slouched posture also depends on reminding oneself to straighten the mid-back and lift the chest throughout the day. This also applies to sitting, where slouching seems almost automatic. Sit straight on the butt, not on the lower back, and maintain the lumbar curve by sitting back in a chair with a lumbar support and pull chair close to desk. Keep chest high, relax shoulders and rest elbows on the desk top.

As an exercise to do during the day, standing or sitting: try to lift the chest straight up when breathing, imagine it filling the top of the chest.

Learning to stand straight is a challenge. But the challenge is unmet unless you've noticed that you don't stand straight. To test, try standing against a wall—with butt, shoulders/upper back, head** touching and knees slightly bent. When I did this, I was leaning forward. To straighten myself, I had to unbend at the waist. but still I couldn't get my head back to touch the wall without tilting my chin up. It took time to figure out that all I had to do was take a deep breath, lift my chest, and voilà, my head was against the wall. Then I realized I'd been leaning forward most of my adult life, and that was part of the reason my arthritic right toe always hurt so much—I was bearing much of my weight on my forefoot, not the middle of my foot. (**if the back of the head doesn't touch, do not force and do not tilt it back. Try to straighten excessive thoracic kyphosis, if still flexible, by lifting the chest with a breath that fills the top of the lungs, and that will help bring the head back, so will the pulldown part of the Fix the Shoulder Blades Exercise)

The longer good posture is maintained, the more natural it feels and the stronger the postural stabilizing muscles. Maintaining good posture is difficult; but doing it strengthens postural stabilizing muscles (the Core) and in itself is legitimate exercise. See Fix the Posture.

10. Mobile devices, laptops and reading material: Don't hunch over the device or reading material. Anchor your elbows to your ribs and hold cell phones and reading material up to your face and roll your eyes downward to see. For laptops try to have the screen closer to your face. Without a detachable screen, that's difficult, but do the best you can.

 

 

 

 

 

© 2017 Rochelle Cocco