This information is for those of you with chronic or recurring neck pain. If you had a serious accident, have serious neurological symptoms like complete loss of sensation, pain down one side of the body, incessant headache that is getting worse, difficulty with speech, crushing pain in the chest, or if you have a fever associated with this pain, please call or see a Medical Doctor immediately as these may indicate very serious conditions.
The majority of neck pain is mechanical in nature. That means the moveable soft tissue components of the spine are normally the things that get injured. Things like the ligaments that provide support and prevent the spine from moving into damaging ranges of motion; the discs between each vertebra that provide shock absorption and mobility of the spine; the joint capsules that surround the facet joints and give it mobility and support; the tendons that attach muscle to bone to move our spine but also to stabilize it against forces like gravity; and the fascia that covers every muscle fiber giving it shape, elasticity, and strength.
The cervical spine should have a natural inward curve and when this is maintained there is equal distribution along the entire vertebral disc and facet joints with no strain to the ligaments, tendons, and myofascia. First try this experiment: Pull your index finger back just before it hurts and hold it there for 1 minute. When you release it, you will probably feel stiffness and maybe even pain as you bend it back. You have strained the soft tissue components of the joints and deformed them slightly registering as pain. When you maintain a flexed posture for prolonged periods it’s the same thing for your neck. The muscles and associated fascia become over lengthened, stiff, and weak. The ligaments and joint capsules become overstretched making them fragile and inelastic. There is more pressure on the front of the disc causing the jelly-like nucleus to bulge back towards the spinal cord eventually causing spinal or nerve impingement.
The average human head weighs 10 pounds and one of the main functions of the cervical spine is to hold that bowling ball upright. When everything is stacked properly there is no tension in the spine.
For every inch your head protrudes forward you add about 10 lbs of tension to your spine.
Imagine holding a bowling ball in your hand and your arm is right under the ball. It wouldn’t take a lot of effort to hold the ball up. But if you let your head tilt forward at a 60 degree angle for hours at time you would fatigue very quickly. What I find is that the muscles and fascia in the upper back and neck get locked into a lengthened position. They harden and stiffen and turn into leather straps. They don’t stretch well and they really don’t shorten/contract well acting like a wedge blocking you from straightening up.
What am I doing during the day to cause this?
This always reminds me of the movie Baby Mama, when Amy Poehler yells at Tina Fey, “I don’t know your life!” I still come across new things that people are doing but here are some of the most frequent ways we injure our spine. The most common cause of neck pain is stress from prolonged awkward positions like poor posture. There are lots of different names for it like Anterior Head Carriage, Forward Head Posture, and Upper Cross Syndrome.In Upper Cross Syndrome, you have weak and locked long cervical flexors in the front and rhomboids, mid and lower trapezius muscles in the back. Not only are they weak but they will resist shortening until broken up myofascially. The pectorals in the front cross over to the upper trapezius, levator scapula and suboccipitals in the back. These muscles are locked short and resist lengthening. Half of rotation and lateral bending in the cervical spine happens at the upper two vertebrae. The other 50% is spread out along the last 5 vertebrae so if you have pain in the lower neck it’s probably because you don’t have at the range of motion in the upper neck.
In our modern world, technology is the main culprit for bad posture. For the adult it’s usually sitting at a computer or the car with poor posture It actually starts with proper lumbar support. If you are sitting for 8 hours at your computer desk and you don’t have good lumbar support, your head is going to lean forward. You can’t fix your neck if the supporting structures below aren’t properly aligned. See my article on low back pain for advice on proper lumbar support. Cell phones and tablets are especially damaging for our youth but adults as well. Keeping the phone down around our midsection causes a forward flexed posture. If you are a back sleeper, having too many pillows also keeps you in a flexed posture for hours at a time. If you are a side sleeper, too thin of a pillow causes compression of the shoulder and neck. Stomach sleepers cause your head to be turned to the side for hours and strains the soft tissue. Lying on the couch in a slouched position rounds the low back and puts the neck in a forward head posture.
If your low back is rounded when you sit, then it is near impossible to get your head in a neutral spine position. When you sit down, take a second to lift and tilt your pelvis to a neutral position after you scoot all the way against the backrest. If you’re not sure how to do this, then reach under your buttocks one at a time and pull the sit bones toward the backrest. Typically when we plop into a chair or booth our pelvis is tilted backwards making it even more difficult to sit up straight. If you can add a lumbar support to your chair to put the curve in your low back it will help significantly. Make sure your chair is close enough so that you don’t have to reach for the keyboard/mouse/steering wheel. Keep your shoulders pinned to the seat back.
For short term mobile device use bring the phone up to your eyes. If you are reading or texting a lot, your shoulders might get fatigued. Another option is tuck your chin and rotate your head down while keeping the spine in a neutral position. Think of a bowling ball spinning down but not changing its position. The muscles that do this are the deep cervical neck flexors which are typically very weak. The suboccipitals, which we’ve seen are tight in the Upper Cross Syndrome, will restrict that motion. You’ll see later how to strengthen and stretch those muscles respectively.
Time to Move
I’ve known patients who can sit and work at their desk with no restroom, drink, or food breaks for 8 hours. It almost seemed like they were bragging but mentally I was shaking my head. We are designed to move. Movement nourishes our muscles and joints and stimulates our brain as well as decreases pain. Think about how often we bend our head to the side or rotate during the day. Not much at all. At minimum, you should take a break and move every hour. Do the exercises for the appropriate level of care, acute pain or maintenance, in the next section.
I am a big fan of the McKenzie Cervical Pillow. Tuck it into your pillowcase at the bottom of your pillow so it keeps the curve in your neck and supports your head at the same time. Putting it in your pillowcase also stops it from getting away from you in the night if you switch from back to side. But no matter how you sleep, it will maintain the natural curve of your neck.
There is one movement that has herniated more cervical discs than any other. It’s the forward head thrust while working out. You see this in sprinting, situps, planks, but especially in overhead movements like push press, snatch, and handstand pushups. Keep your chin tucked and pulled back as your thrust overhead.
If you have pain radiating down the back, shoulder, elbow, or hand you probably have a herniated disc that is putting pressure on a nerve root. The goal for these exercises is centralization which is the movement of the pain to a more midline location. If your back pain worsens, but the pain down your arm starts moving up towards the neck, then this is a positive indication that the pressure on the nerve root is being diminished. The neck pain is likely due to the reformation of the soft tissues that have been deformed for so long. The longer you’ve had your pain the longer this may take, but you can speed the process up dramatically with a few visits to my clinic. I have treated many patients in these McKenzie positions and they show dramatic improvement over a few visits. Depending on the severity and length of injury it may take weeks to find significant relief with just the McKenzie exercises.
<em>When you are in acute pain, you should start with Exercises 1 and 2; if the pain is too severe start with Exercises 3 and 4; Perform 10 reps of each every 2 hours. If pain is going down one side of your body and is not responding, do Exercise 5 first then Exercise 1 and 2. Once you are out of acute pain, do exercises 5 -7 to improve mobility of the neck followed by Exercise 1 and 2. At the first sign of recurrence, check your posture and resume Exercise 1 and 2 every 2 hours 10 times each. back in the future,</em>
Exercise 1: Neck Retraction in Sitting
• Sitting upright with proper lumbar support, keeping your elbows at your side, relax your head and let your chin jut forward
• Now, slowly move your head straight backwards keeping your chin tucked. Your jaw line should remain parallel to the floor
• You should feel activation of the deep neck flexors in the front and a stretch of the suboccipitals at the base of your head.
• Each time you retract your head try to go as far as you can.
• If you aren’t feeling much, it could be the deep neck flexors are really weak, or the upper neck muscles are really tight. You can add overpressure by pushing your chin back with your fingers after you’ve gone as far as you can.
• I am guilty of the following: Make sure you don’t engage your pectorals and round your shoulders as you retract your head. That will pull the traps tighter and act like a yoke around your neck. Keep those elbows at your side or try to pin your shoulders against the backrest.
• Perform 10 repetitions 6-8 times per day.
Exercise 2: Neck Extension in Sitting
• Repeat Exercise 1 then tilt your head backwards as you look up.
• Keep the neck retracted as you look up and do not let the chin jut forward.
• Go as far as you can, then wiggle your head left and right about a half inch while you try to go a little farther into extension.
• Perform 10 repetitions 6-8 times per day
Exercise 3: Head Retraction in Lying
• If the pain is so severe that you can’t perform Exercise 1 and 2, start with Exercise 3
• Lie face up at the foot of your bed completely flat with no pillow
• Push the back of your head into the mattress keeping your chin tucked and hold for several seconds
• Relax and repeat 10 times
• Important: Evaluate your pain and if it has centralized or decreased in pain you can continue this exercise and move on to Exercise 4. If the pain increases considerably, moves farther away from the spine, or you experience numbness/pins and needles stop immediately and contact a medical professional.
Exercise 4: Neck Extension in Lying
• Still lying on the bed, hold your head with one hand while you move to the end of the bed. Stop after the tops of your shoulders have cleared the edge
• Slowly lower your head with the support of your hand as far as it will go, then remove your hand slowly.
• Try to tilt your head backwards as far as it will go, then wiggle your head left and right about a half inch as you try to go a little farther.
• Lie here for about 30 seconds then using one of your hands lift your head up slowly and move down the bed so your head is resting on the mattress again.
• Important: do not get up right away. Just lay there for a few minutes.
• 1 repetition for 30 seconds after Exercise 3. Once you no longer have severe pain, replace with Exercise 1 and 2.
Exercise 5: Neck Sidebending
• This is best done in front of a mirror until you are familiar with how it should feel.
• Perform Exercise 1 a few times while seated to warm up the neck and then hold in the retracted position
• Hold your index finger in front of your nose and watch your finger and nose In the mirror as you bend your head side to side. Think of your nose as the axis you are pivoting around so don’t let your nose go to the left or right of your finger.
• If your head looks like a metronome going side to side, you are only moving from the lower cervical vertebrae and not the entire cervical spine. As you bend right your neck should look
like a ‘C’ and a backwards ‘C’ when you bend to the left.
• You can add some overpressure after you get to the end range by pulling your head with the opposite hand.
• Make sure the head stays retracted, shoulders are back, and you try to go farther every time.
Exercise 6: Neck Rotation
• Perform Exercise 1 a few times while seated to warm up the neck and then hold in the retracted position while you perform rotations.
• Turn your head as far to the right as possible and then to the left. That is 1 repetition. Keep your shoulders back, don’t let your neck pull your shoulders and rotate your body.
• If there is pain in one direction, continue the exercise turning into the painful side. If it doesn’t centralize or decrease in intensity after 10 repetitions; perform 10 reps to the least painful side. Once the pain on each side equalizes or just turns into stiffness perform rotations in both directions.
• You can increase range of motion by adding some pressure and using your hands to push you a little past end range. Again make sure you are activating the muscles at all times and not just
using your hands to stretch.
• Perform 10 repetitions each way Exercise
7: Neck Flexion in Sitting
• This is to release tension in the upper trapezius, levator scapula, and suboccipitals as well as great for relieving headaches.
• Sit in a chair with proper lumbar support, look down with your eyes and tuck your chin trying to put it on your sternum/breastbone. Think of the bowling ball spinning again as you feel the
deep neck flexors turn on and a good stretch at the top of your neck.
• Don’t let the upper back or low back round forward or you mobilize the wrong areas.
• Add some pressure at end range by tucking your chin and pushing your head back into your hands. Feel the stretch and the head-spinning forward while keeping the neck fairly neutral
• You can do the same thing with a 45 degree turn to the left, tuck chin, and overpressure. Then go to the right.
• Perform 5 reps each to the middle, left, and right.