Neck Pain

Discussion

Neck pain is one of the most debilitating of everyday muscular annoyances humans experience. There are many causes of neck pain and care should be taken in determining exactly why you’re having it. A doctor’s diagnosis may be necessary before some types of work can be done to help eliminate neck pain, if it can be done at all. Sometimes, it’s as simple as having slept wrong and you may be back in the pink once you’ve been up and about for an hour or two.

For this discussion, we’ve broken down many causes of cervical conditions into categories. Sometimes, more than a single cause may need consideration. Not all cervical problems cause pain in every individual. However, each has the capacity to do so, some immediately, some gradually over time, some chronically.

Causal Categories

Skeletal

In this category, we find:

• Hyper/hypo-lordotic cervical curve (too much or not enough normal neck curve)
• Kyphotic cervical curve (reversed neck curve)
• Military neck (straight/no neck curve)
• Stuck vertebral facets

Structural

• Degenerated disc
• Bulging or herniated disc
• Fractured spinal segment
• Spinal spondylitis (inflammation of spine)
• Spinal spondylosis (degeneration or arthritis of vertebrae)
• Spinal spondylolysthesis (forward displacement of a single vertebra)
• Spinal retrolysthesis (backward displacement of a single vertebra)
• Cervical myelopathy (spinal cord compression in the neck)
• Osteoarthritis
• Spinal osteophytes (bone spurs)
• Spinal stenosis (narrowing of vertebral canal)
• Destabilized spinal ligaments
• Damaged spinal ligaments

Neural

While these may contribute more to pain as a symptom rather than cause, they are important considerations.

• Neuritis (inflammation and swelling of nerves in the cervical spine)
• Neuralgia – dysfunction or injury to cervical nerves within the spinal bones affecting whatever is innervated

  C1 and C2 nerves control the head. C3 and C4 help control the diaphragm. C5 controls upper arm muscles like the deltoids and biceps. C6 controls the wrist extensors and also part of the biceps. C7 controls the triceps. C8 controls the hands.

• Neural compression (pressure placed on nerve roots within or exiting spinal bones, or when coursing through, between, or beneath muscles, or between bone and muscle)
• Afferent/efferent miscommunication with brain
• Sensory (proprio- and nocieoception organ)

Muscular

• Muscle tension
• Muscle strain/sprain
• Muscle guarding/splinting
• Trigger points
• Physical damage (microtearing in muscle fibers, musculotendinous and tendoperiostial junctions)
• Sensory (proprio- and nocieoception organ)
• Muscular timing and activation
• Association with mechanical neck pain
• Muscle structure (concentration of fatty tissue within muscle and amount of type II, slow twitch, muscle fibers)
• Tendinitis (inflammation of tendon tissue)
• Tendinosis (degeneration of tendon tissue)

Metabolic

• Nutritional deficiencies/imbalances
• Dehydration
• Sensor receptor blockage
• Pharmaceutical affects

Systemic

• Infection
• Allergens
• Mental/emotional stress
• Organ dysfunction

Myoskeletal Neck Pain

In myoskeletal work, the practitioner uses specialized soft tissue manipulative techniques to address and directly affect change in the muscular category, and, indirectly, the skeletal and neural categories above.

The cervical column is a busy place. Within the neck, one will find about two dozen superficial muscles plus dozens more deep, intrinsic muscles (some start or end in the neck, some start and end here, and some are transient from the head to the thorax), eight cervical nerve complexes, some cranial nerves, several arteries and veins, many lymph nodes, scores of ligaments and segments of cartilage, fascia, seven or eight cervical vertebrae, and their associated joint capsular tissues, the esophagus, larynx, vocal cords, and other organ system components. When you think about it, it’s a wonder that everyone doesn’t have neck pain all the time.

If all the contents within the neck isn’t enough to consider, consider also that many of these are attached to and thus affect other structures. The largest configuration of attached structures is, of course, the musculoskeletal system, and this is why myoskeletal and remedial massage techniques are called for in neck work.

Myoskeletal massage work for neck pain, like all myoskeletal work, is intended to:

• relax tonic muscle tissue
• reset golgi tendon organ and muscle length nocieoception
• calm the parasympathetic nervous system
• break up adhesive quality of stuck connective tissue
• break up adhesions between normally separated scar tissue from fascia, connective tissue, muscles, ligaments, and tendons
• improve vertebral joint mobility and range of motion
• lubricate joints

Myoskeletal Concerned Cervical Pathologies, Conditions, & Dysfunction

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Whiplash & Whiplash Associated Disorders

Anytime the head and neck are suddenly forced in one direction, then another, a whiplash injury may occur. Whiplash is generally thought of as an injury involving a motor vehicle accident. However, they can occur after a severe fall, sport or occupational injury, or even amusement park rides. Essentially any type of repercussion injury can result in whiplash.

Velocity of movement where whiplash can occur does not have to be violent in nature. Even low-impact collisions may result in whiplash injury.

While whiplash usually results from forward/backward movement, injury can also result from a side-to-side pattern, too; particularly if the head and neck is turned at the time of impact.

Damage that occurs as a result of whiplash may include muscle and/or tendon and/or ligament strain and sprain, dislocation, break, or fracture of vertebral bodies, vertebral disc herniation, facet joint damage, neuromuscular inhibition, and possibly damage to peripheral nerve roots and/or the central nervous system.

Approximately 2/3 of people involved in auto accidents end up with whiplash symptoms and conditions. Presentation of symptoms may be delayed as long as 48 hours. Although many theories exist, no one is entirely certain what causes the delay. Physical symptoms of whiplash, in no particular order of occurrence, frequency, or magnitude, are:

• Headache
• Stiffness in neck and upper back
• Neck pain, jaw, lower back, and hip pain
• Dizziness (vertigo and/or nausea)
• Difficulty swallowing
• Problems thinking or remembering
• Numbness and tingling in arms, face and/or shoulders and other motor impairment
• Loss or impairment of tendon reflex
• Hypersensitivity and other sensory impairment
• Ringing in ears
• Impaired (blurry) vision

A radiology report and physician diagnosis is highly desirable before receiving myoskeletal work at Manchester-Bedford Myoskeletal LLC for whiplash and associated disorders. Massage for several whiplash conditions is contraindicated without physician clearance. A radiology report provides important specific information about a patient’s condition and injury that may not be evident to the patient, but will be extremely helpful to the therapist in developing an individualized treatment program for the patient. Radiologic films may be visually helpful in cueing specificity and relation to physical symptoms and muscular patterns as well as providing information for further query of patient’s physician or for referral to another type of practitioner.

Myoskeletal treatment work will depend each individual’s case, specifics of the accident, occurrence, or injury, and of course the individual’s perception of their condition. Manchester-Bedford Myoskeletal LLC believes highly in educating patients so that they will understand the treatment and to help the patient thwart psychological aspects of chronic whiplash and concentrate on improving in the shortest time possible.

In general, myoskeletal treatment at Manchester-Bedford Myoskeletal will seek to:

• tone down neural facilitation of head and neck extensors and re-establish the neural link between the motor control center and neurally inhibited head and neck flexors
• break up adhesive scar tissue along the posterior longitudinal and supraspinus ligaments, and ligamentum nuchae
• restore cervical joint movement, particularly at the occipital-atlanto (occiput-C1) and atlanto-axial (C1-C2) joints
• encourage proper vertebral facet joint movement in all planes
• discourage development of forward head-on-neck and neck-on-thorax biomechanical degradation
• reduce stress and muscle guarding in upper and lower back
• discourage or correct T-spine rib dysfunction
• discourage and correct muscular dysfunction at the lumbosacral junction and pelvis

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Torticollis

Torticollis is a neurological condition where the static head or neck is turned abnormally and held by asymetrical muscle length (sustained contraction) in any plane of normal movement. The condition may also be referred to as “wry neck”, and may present in a fixed or dynamic form. Other associated terms include descriptive indicators of direction of the condition: Laterocollis (flexed to one side), Anterocollis (tilted chin-downward), Retrocollis (tilted head-back), and Rotational Torticollis (rotated on the vertical or longitudinal axis). In some patients, any of these may be combined to describe complexity of additional planes affected.

Additionally, other descriptive names are used to further define symptoms: Acute, Chronic, Spasmodic, Idiopathic, or Secondary. All forms and descriptions generally lie in the realm of cervical dystonia, a neurological movement disorder.

Torticollis is classified as congenital or acquired according to diagnosed origin. Acquired torticollis may also present as persistent or spasmodic. The acquired class also includes a commonly found sudden-onset type of neck stiffness.

Depending on the type and class of torticollis, myoskeletal and remedial massage is generally indicated, along with other types of therapy, such as rehabilitative exercise for upper body, stretching, and heat. Particularly for the sudden onset condition type, as this type is most often seen in the general population.

Causes of torticollis number in the multitudes and can be easily found in Internet searches. Comprehensively listing them is beyond the scope of this page. However, a few noteworthy causes are presented here for discussion.

In infantile torticollis, as with the adult acquired version, posture is very often causal. New parents should remain aware of an infant’s position while the bones and tissues of the body are in early developmental stages. Change the baby’s position from time to time, particularly the head and neck, so as reduce the risk of developing chronic muscle stiffness or tenderness.

Of course, a baby can be born with congenital torticollis or delivery induced torticollis. It can be difficult to tell for certain because the bones are still soft and muscles undeveloped. Most cases of infantile torticollis resolve by six months of age, but can take longer than a year.

While several muscles can be involved in both congenital and acquired types, the sternocleidomastoid (aka SCM) and upper trapezius (the two main neck and head movers) are most often the guilty parties.

SCMs occur on both sides of the sides and front of the neck. They are the ropy-looking muscles attaching to the skull behind each ear and run down to the sternum (breastbone) and clavicle (collarbone) on their respective sides. SCMs are the powerful head flexors when contracted at the same time, and they rotate the head to the opposite side when contracted only on one side. They also assist the scalenes in lateral flexion (bending head ear-to-shoulder) to the same side. They also engage in an eccentric contraction to control backward head movement, which is why they are also implicated in whiplash injuries.

The trapezius muscle is a flat sheet, diamond-shaped muscle located superficially on the upper back. Its fibers generally form to perform certain functions, so the “trap” is commonly referred to by its various sections, upper trapezius, middle trapezius, and lower trapezius. The upper trapezius is the section most affecting torticollis. The upper trapezius basically forms a sheet across from shoulder blade to shoulder blade as a flat sheet, draping over the top of each slope of shoulder to attach to the collarbone. Near the neck, the sheet differentiates into two thicker bands, one on each side of the back of the neck. These bands have attachments to the ligamentum nuchae (a band of ligament spanning the spinous processes of the cervical spine) and the spinous processes of C1-C7 before terminating at the occiput. When the shoulder blades are stabilized, contraction of both sides of upper trapezius causes the head and neck to extend, among other movements at the shoulders. Contraction of only one side causes weak head rotation and lateral flexion (side-bending the head and neck).

Anterior, middle, and posterior scalenes are small but important neck muscles that attach from the transverse processes of neck vertebrae C2 to C7 superiorly and the first and second ribs inferiorly. As a group, they bend the neck to the same side and lift the first and second ribs as secondary muscles of inspiration. The scalenes are implicated in several medical conditions, including torticollis.

Chronic muscular hypercontraction results in inflamed muscle tissue, accumulation of metabolic wastes within the tissue, and may cause impingement of cervical nerve roots, peripheral nerves, and blood vessels, as well as asymmetric head and neck alignment.

Manchester-Bedford Myoskeletal treatment of torticollis, of course, depends on diagnosed cause of the condition. Generally, we work to relieve the muscles of the contraction using various massage, stretching, and strengthening techniques, as well as myoskeletal techniques for ancillary problems, such as freeing jammed facet joints and restoring joint lubrication and release fascial restrictions, promote free joint and soft tissue movement, and orthopedic massage techniques for breaking up scar tissue.

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Cervical Neuralgia

The term cervical neuralgia describes in blanket terms pain and other symptoms resulting from or associated with cervical nerve dysfunction in the cervical spine. Associated disorders occipital neuralgia and Arnold’s neuralgia may be included with cervical neuralgia with the inclusion of cranial nerve dysfunction. Note also that cervical and occiptal neuralgia extend symptoms elsewhere in the body, since it is the nerves which are affected. It is our intent to focus on neck problems on this page. Other areas may be discussed on other pages in our website.

Cervical neuralgia (CN) is used to describe non-specific pain in the neck and elsewhere due to nerve dysfunction, not necessarily a specific cause of pain in and of itself. Conditions that can present in are commonly found in people as they age; in other words, normal wear and tear and degeneration of soft tissue as well as arthritic and metabolic buildup.

Types of pain and discomfort felt by patients with CN range from dull ache and headache to sharp, traveling pain or burning sensation, stiffness or creakiness with neck movement, head and/or neck range of motion limitations, point tenderness, inflammation, and heat difference.

When CN is due to restrictions or compressive forces by hypertonic musculature or compression between muscle and bone, myoskeletal and remedial massage can provide relief of pain symptoms and stiffness.

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Cervical Hyperlordosis/Hyperkyphosis

Lordosis and kyphosis are conditions describing curvature of all spinal sections, i.e. cervical, thoracic and lumbar sections of the spine. The natural curve of the cervical (neck) spine is lordotic; that is, a backwards “C” curve. However, the neck can both lose or increase its lordotic curve, resulting in a straight or even backwards curve in the former case, or an exaggerated curve in the latter.

As in most other conditions involving the cervical spine, there are many reasons why it may become hyperlordotic, straightened, or hyperkyphotic. Some reasons may result in the patient experiencing no pain whatsoever for many years. Indeed, many people are born with a straight neck (see also Military Neck) and may be in their thirties or forties before even realizing they have one. In fact, chances are good that they don’t have pain or discomfort with straight neck. However, people with straight neck tend to have a higher likelihood of early degenerated disc disease.

Exaggerated curves are far more problematic, both in terms of medical conditions of the neck resulting in pain and stiffness and in symptoms referring to other parts of the body. Additionally, muscular imbalances and posture may be severely affected and contribute to forward head posture (forward head-on-neck and forward neck-on-thorax).

There are two special postural conditions under the lordotic/kyphotic curve umbrella, and those are Forward Head Posture (FHP) or Upper Crossed Syndrome (see also Muscle Facilitation & Inhibition and what has become known as Text Neck, which conditions are described elsewhere.

Functional loss or exaggeration of neck curve sits prominently in the realm of myoskeletal treatment. These are most often either a developed compensation patterns, neural disconnects, or both. However, traumatic events, such as falls, whiplash, contact sports, and even high inertia amusement rides can result in changes to the cervical spine.

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Thoracic Outlet Syndrome (TOS)

NOTE: Some doctors may consider TOS symptoms stemming from structural problems within the cervical spine, such as compression from spinal stenosis or narrowing of the nerve canal within cervical vertebrae, bone spurring, spondylitis, or spondylolysthesis. TOS serves as an “umbrella term” for several other syndromes, many of which appear to be highly debatable among physicians. Symptoms of TOS often mimic more specific conditions, such as certain neuropathies, radicular symptoms, and myelopathies.

A physician should be consulted when TOS symptoms are present following head or neck trauma such as an automobile accident (whiplash), a slip or fall, sport related or repetitive strain injury, a fractured clavicle, and in patients over 50 years of age, tumors or enlargement of the lymph nodes in the armpit or upper chest.

Other reasons TOS symptoms may also appear in postural dysfunction, depression, certain sleep disorders, and weightlifting.

Description

Thoracic Outlet Syndrome is generally a compression or tension syndrome whereby structures act upon the Brachial Plexus, resulting in varying degrees of neuralgia and/or reduction of blood supply to one or both upper extremities. Symptoms of TOS are parasthesia (sensation of pins and needles), pain, numbness, shooting pain, or muscular weakness in the neck, armpit, shoulder, arm, hand, or fingers, or less often, restriction in blood circulation resulting in discoloration and/or temperature difference in the hands or some or all fingers. In extreme cases, there may be a significant reduction in or even loss of muscular control and strength, and/or wasting of muscle tissue.

The thoracic outlet is the area where the neurovascular bundle known as the Brachial Plexus exits the deep cervical column through the superficial soft tissues at the side levels of the base of the neck. The brachial plexus innervates and supplies blood to the upper extremities. Nerves include the lower three or four cervical nerve roots (C5, 6, 7, and 8) along with the first thoracic nerve (T1). The right and left subclavian arteries (and their laterally named continuations, the axillary and brachial arteries) and subclavian veins are included in the Plexus.

Within the conventional medical community, true Thoracic Outlet Syndrome results most often from a compression of the C7 nerve root specifically by a band of tissue attaching between the transverse processes of C7 and the first rib. However, further complicating matters, TOS may be divided into vascular TOS, which is itself divided into arterial and venous TOS, and neurogenic, which is divided into what is termed “true” and “disputed” TOS.

Common Compression Points

Scalenes: As a bundle, the brachial plexus first encounters the lateral neck flexors. The anterior and middle scalenes originate at the transverse processes of cervical vertebral C2-4 or 5 and insert at the first rib. In most people, the bundle passes between the anterior and middle scalenes, while in some people (approximately 1% of the population), it actually pierces the anterior scalenes. In both cases, this is the first place where TOS is likely to become symptomatic, and symptoms in either case are normally considered compressive in nature.

In this case, symptoms appear if the scalenes become hypertonic for whatever reason. Symptoms may also be transient in nature with positional movement of neck structures (e.g. turning the head and neck as if looking over one’s shoulder, or extending the neck as if looking up overhead, or while sleeping with the neck craned by pillows), or by other movements that compress the area, such as lifting arms overhead, opening arms wide and extending backward, or by sleeping with arms raised over head.

Costoclavicular Space: After the plexus passes through the scalenes, the next structures which may cause compression on the bundle is the costoclavicular space. This is the space between the first rib and collarbone. While this may occur anyone, is it markedly seen in that population which has an “extra rib” above the first rib.

For several reasons, the first rib (the one originating at vertebra C1) may rotate to narrow the space the plexus follows through this area. Anatomically, the rib and clavicle may simply be located close together. Several shoulder dysfunctions may also cause a narrowing of the bony passage, particularly those which displace the clavicle upward or rib downward.

Locally, the compression may be created or complicated by the proximity of the costoclavicular ligament or hypertonic subclavius muscle or tendon.

Also, the scalenes, mentioned above, are secondary muscles of inspiration, and functionally elevate the first rib during forced inspiration. If there is a neural facilitation or other dysfunction of the diaphragm muscle, secondary muscles of inspiration may overwork, causing a chronic contraction in those muscles. Since the scalenes attach to the first rib, strain is placed on that structure, pulling or rotating it to approximate the costoclavicular space.

Pectoralis Space: The third likely culprit for compressing the plexus is where the bundle passes beneath the pectoralis minor muscle. Again, a hypertonic or thick pec minor muscle may cause TOS symptoms. Like the scalenes, pec minor is a secondary muscle of inspration. Pec minor originates on the coracoid process of the acromion and inserts at the third, fourth, and fifth ribs. During forced inspiration, pec minor lifts the upper ribs. In the case where pec minor is neurally hyperactive, it may become facilitated and habitually contract, shortened, and compress the brachial plexus against the costal (rib) cage.

Myoskeletal for TOS

When indicated, myoskeletal massage works to restore length to affected musculature and fascia, and affect positioning of bony framework to remove compensation patterns causing compressive and tensional TOS symptoms.

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Muscle Stiffness

In this general category, all the muscles of the neck are apt to become involved in some way or another. The neck is extremely complex in terms of musculature and other fascial structures and soreness and stiffness may be tied to surrounding structures through lack of lubrication, adhesion, scar tissue, overwork, neural compensation, positional forces, gravity, stress, emotional aspects, structural dysfunction, trauma, or other disruptions.

Within the neck, muscles are divided amongst the extrinsic and intrinsic categories. Most muscle neck pain is related to extrinsic musculature; that is, functional muscles that control cranial and cervical movements, such as turning, flexing, or extending the head and neck. However, if it was that easy, everybody would be able to enjoy quick relief by simply restoring normal muscle length by rubbing or stretching.

Some muscles, such those at the base of the back of the skull or temperomandibular junction, are neurologically connected to other organs, such as the eyes, tongue, and vocal cords. And positioning of the head and neck while tight muscles stress their bony attachments create problems within joint capsules and affect nerve pathways, constrict blood vessels, and cause a variety of neurological problems in the eyes, sinuses, ears, and so forth.

More than anything, muscles and joints live for motion. It’s what they do. When they don’t get it, all kinds of problems develop. Muscles may become short and tight, stretched and tight, neurally inhibited and facilitated, proprioception (sensors that tell you where you are in space) can be affected, golgi tendon organs (GTOs) change what they perceive to be a “normal” muscle length, fascia surrounding muscles become sticky and adhere to structures laying side-by-side, and so on.

Moral of the story is: MOVE IT! Do not stagnate in a chair at work or a sofa at home or even in your seat in the car. Take breaks, move around, stretch before, during, and after long drives or stressful days. There are 80-something year old women out there doing gymnastic moves on parallel bars! There’s no reason anyone else can’t move.

The Main Players

People generally find the head and neck extensors to be the most bothersome muscles in the neck because they become so tight. But are they really? That depends on many factors, of course. But are they bothersome because they are tight or are they bothersome because something else is wrong and extensor hypertonicity is the body’s way of letting you know something else is wrong?

The extensor muscles tilt the head and neck backwards, among other things, but they are also support structures for the 8-12 lb block of wood sitting on top of your neck. These muscles are:

• upper trapezius
• splenius capitus and cervicis
• suboccipital group
• longissimus capitus, cervicis, and thoracis
• iliocostalis cervicis and thoracis
• semispinalis cervicis
• spinalis capitus
• sternocleidomastoid, and
• levator scapulae

Of these, we find the suboccipitals tend to become tight most often. The suboccipitals also relate to eye problems, headaches, migraine, and movement disorders. The suboccipital group attach between the back of the skull and/or the first two cervical vertebrae. Since most head and neck movement comes from the first two vertebrae, it follows that the muscles controlling these bones would be the most problematic.

After the suboccipital group, we very often find upper trapezius and levator scapula hypertonic along the slope of the shoulder, the sides of the neck, and base of the skull.

The question is why.

Cause and Effect

As mentioned previously, there could be many causal factors. Humans have the tendency to carry stress in their necks, shoulders, and upper back. Effects of stress are potentially endless and can affect all up and down the body and into the organs. Research shows that more than 90% of Americans are excessively stressed daily. This kind of statistic doesn’t give us much of a fighting chance of avoiding stress. But stress isn’t the only cause.

Neural Dysfunction

One type of nerve dysfunction is muscle facilitation and inhibition which, in turn, is often contiguous with poor head and neck posture. Specifically, if the neck flexors underwork, neck extensors become neurally facilitated, eccentrically contracted and weak, and if neck extensors become neurally facilitated, neck flexors become neurally inhibited and may become shortened and weak. This creates and allows muscle imbalances and pain that are self-perpetuating in the pain-spasm-pain cycle. Balancing out the neck on the thorax, and head on the neck, plus balancing flexors and extensors will help relieve muscle tension for the longer term.

Muscle Guarding

Stiff neck muscles may also be attributed to structural problems in the spine. In general, muscle stiffness will occur when the brain wants to protect the spine and central nervous system. If the brain senses instability in the spine and intervertebral muscles or laxity in the many ligaments involved in the cervical spine, it will call on the muscles to protect, guard, or brace the spine in order to stabilize it, reduce the chance for damage (or further damage), or to stop you from doing something that it feels may compromise the spine or CNS.

When muscle guarding is taking place, one must understand that manually relaxing those muscles may likely be contraindicated. First, the brain will tell them to tighten up again right away, and; second, there may be real cause for the brain’s concern over protecting the cervical spine, and relaxing soft tissue stabilizers would weaken the structure. Naturally, with a loss of stability close to the spine and muscle guarding taking place, distal mobility becomes hampered. In other words, mobility of the head and neck is forfeited by the brain in preference to stability at the spine. So the head and neck become stiff and immobilized and sore, but the bones and CNS are safe. That’s the concept going on here with muscle guarding.

Plain Ol’ Neck Strain

From posture to rotation angle to lack of movement to emotional upheaval to daily activities, neck muscles can become tight and sore just because of what they do. Neck muscles support the head and neck. The adult human head weighs about 10-12 lbs and it balances atop a stack of relatively small diameter bones. The quintessential “orange on a toothpick”. The main job of the muscles of the cervical column are to balance the orange on the toothpick and to stop it from falling over, much like the stays and shrouds of a sailing ship or radio mast. Muscles are the guy wires. And they get tired holding your head up.

Myoskeletal Work for Muscle Stiffness

As one might imagine, myoskeletal massage work seeks to restore normalcy to the soft tissues of the neck and the normal alignment of the head, neck, and thorax as a whole. Relaxing muscles when bones are out of alignment only patches the problem. Likewise, getting the cervical spine in order without attending to the guy wires will simply result in taut muscles pulling the bones back out of alignment.

Myoskeletal work goes the whole way — bony alignment, muscular relaxation, down-regulating hypertonic, facilitated muscles and up-regulating inhibited ones, affecting and resetting golgi tendon organ muscle links, restoring vertebral joint mobility, restoring facet joint movement, breaking up fascial restrictions, and restoring range of motion.

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Muscle Facilitation & Inhibition

This section refers to muscle imbalance caused by miscommunication between the motor control center (MCC) of the brain and skeletal muscles. The MCC tells a muscle to contract in order to conduct a movement of one or more bones connected by joints. In fact, movement is made in muscle or kinetic patterns and vectors, not actually by individual muscle movement. But we’re keeping it simple here.

The MCC communicates with a muscle through the nervous system (central and peripheral nerves). Messages are sent in both directions; outward (efferent) from the MCC by the motor cortex, and back to the MCC via several types of sensory receptors (afferent). When there is a miscommunication between the MCC and sensory receptors, the MCC instantly looks for another muscle to do the work. Precisely how the process takes place is not well-understood in scientific circles at this time, so there is still much debate among researchers. Unlike computer programs, which only follow instructions written for it, the brain is totally unencumbered by any limited set of rules.

Certain muscles, of course, are used for certain movements, and this makes some sense. For instance, it makes perfect sense that a big, thick muscle would be the correct choice to lift a heavy object instead of using, say, muscles that open or close an eyelid. But if the big, thick, muscle doesn’t answer when the MCC calls it, the brain looks elsewhere to get the job done.

Miscommunication?

Miscommunication is probably a misnomer. I use it here as a general term inclusive of many possibilities. There could be nerve damage or impingement. There could be an injury to the muscle. There may be a chemical imbalance affecting sensory organs or ability to receive input. The muscle could be too weak or unresponsive. There could be an overactive, hyper, up-regulated muscle that interferes with the communication. The MCC’s parent system, the limbic system, which drives human emotion, may be overactive. Whatever the neural cause, we’re using miscommunication here to describe the neural disconnect or “electrical short”.

Definitions

In short, an inhibited muscle is one that is neurally weak, down-regulated, or under- or inactive for whatever reason. A facilitated muscle is one that is neurally overactive, up-regulated, or hyperactive for whatever reason.

Common Compensatory Patterns

Muscle facilitation creates and muscle inhibition allows compensatory patterns to set up and exist. We all compensate in one way or another. Anyone is at risk. In fact, there is no real way to avoid developing compensations and compensation patterns. What is hoped is that the patterns are discovered and corrected early on. The longer a compensation goes on, the easier it is for the body to accept it as normal. Breaking a pattern after following it for many years is much more difficult to do than one which is relatively new.

If the brain learns by failure, then undoing failure is easy when the brain doesn’t find the compensation easier to do than what it is supposed to do. For instance, when you stub your toe, you tend to limp or favor the stubbed side for a while. Usually, this goes back to normal in a few days, and the compensation (the limp or avoided use of the injured foot) doesn’t get the chance to really set up in the brain as “normal”. Soon, you’re walking normally again and you forget all about the stubbed toe.

But what if it’s a broken ankle? It might be weeks or even months before the break resets and, through physical therapy and exercise, you can walk on it again. That amount of time can easily set you up for a compensation pattern. Compensations vary with the individual, the injury, the seriousness of the injury, the emotion attached to the trauma, and many other variables. You may even become unaware that you’re compensating — and probably are, anyway. It may take someone else to notice that, for instance, you might turn your hip out to walk up steps instead of lifting your knee vertically. Or that you’re walking on the outside of your foot. Or that your toes barely touch the ground because you’re lifting them out of time instead of pushing off with them as you normally would.

Nothing Personal

It is completely natural to compensate. People do it all the time. Active and inactive people alike compensate, though they may compensate entirely differently from one another. How a person’s compensation patterns develop depends on the individual’s motor control center, not in your DNA.

Of real significance, a compensation pattern is no reflection on you. As therapists, we make every effort to remind patients that compensations are not a fault and they don’t diminish you in any way. They are not a reflection on your strength or individuality. They are not proof of your strength or weakness. In fact, they have nothing to do with strength. Only neural response. Athletes compensate. Mr. Universe competitors compensate. Mr. Couch Potato compensates. Ms. Jane Doe compensates. Mrs. Mary Q. Public, mother of little Billy, compensates. Your mail delivery person compensates. The King of Atlantis compensates.

Don’t take testing, evaluation, and correction of muscle inhibition and facilitation personally. Rather, look at it as a way to get you out of pain or a way to make sure you do not develop compensatory pain patterns!

Neck Muscle Inhibition & Facilitation

The two main neck problems developing from compensation patterns are forward head posture and strain patterns from inhibition elsewhere in the body. While these are not the only two patterns, they are the two big ones. Let’s take a quick look at each and how they relate to neck pain.

Forward Head Posture (FHP) and “text neck” are very common patterns that are easily distinguishable to observers, and each of these are described elsewhere on this page. In this pattern, the neck leans forward in relation to the ribcage and the head (in FHP) tilts back to keep the eyes level or (in text neck) tilts downward so we can read, look at our computer screens or phones.

The extensor muscles in the back of your head and neck hold your head from falling forward. They become eccentrically stretched and weak. In other words, they feel tight, but they’re tight because they’re trying to contract while they’re elongated, not because they’re contracted. These muscles do not need to be lengthened! This is how the FHP compensation is created and how it keeps the pattern going. They’re already too long. They need to be neurally down-regulated. But they can’t be down-regulated until their counterparts, the flexors, which are supposed to help hold the head up, are neurally up-regulated. You have to be able to hold an isometric tension all around in the neck or the other muscles will be strained.

The flexors, located in the front of the neck, are inhibited because they don’t have to work in people who have FHP or text neck. They get lazy. They become neurally disconnected. They’re along for the ride, but they’re not doing their part to stabilize and keep the neck and head erect. They may even become naturally shortened if sufficient time is allowed to pass before the compensation pattern is corrected. This is how inhibited muscles allow the compensation pattern to develop, continue, and even worsen.

More on common compensatory strain patterns here and here.

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Forward Head on Neck

FHP is a common compensatory strain pattern (discussed in detail here) where the spine of the neck leans forward and the head tilts back to level the eyes, producing a craned neck appearance and a Dowager’s hump at the base of the back of the neck. In the short term, the dysfunctional posture may or may not develop pain problems. However, over time, the nervous system becomes overloaded and the brain lets you know your neck hurts.

Several problems occur with FHP. The first is the overloading of the neck extensors. Typically, their job is to work in conjunction with the neck flexors to balance the head properly. The law of reciprocal inhibition, however, finds that when the extensors become hypertonic, the flexors shut down in the neural sense. They become inhibited. The cycle continues because there is no break from the pain-spasm-pain routine, and the head leans further forward and the extensors become even more eccentrically contracted and stretched and, eventually, also become neurally inhibited.

To make matters worse, the head is craned back using the subocciptal muscles at the base of the skull. Just beneath the subocciptal muscles is the very busy occipitalatlanto (OA) joint where a majority of head movement takes place. The membrane also houses cranial nerves and blood vessels passing between the torso and the head. Commonly, headaches begin here due to the restricted posture of the craned occiput in relation to the cervical spine.

As if that’s not enough, the vertebral bodies become jammed closed where their facet joints would normally articulate, and head and neck movement become stiff and painful. Matters become more complicated, too, but please refer to the link above for detailed discussion.

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Forward Neck on Thorax

Now commonly referred to as Text Neck, Forward Neck on Thorax is described as a forward-leaning neck and forward-craned head. Problems that stem from habitual text neck surround reduction or loss of lordotic cervical curve. In advanced cases, there may be a straightening or, in extreme cases, a kyphotic curve may develop in the cervical spine. Moreover, a greater head weight-neck angle ratio cause eccentrically contracted and weakened neck extensors supporting the head and stress down into the thoracic erectors and fascia.

When the text neck is maintained habitually, vertebral joint capsules gunk up from loss of synovial fluid bathing and facet joints tend to stick open, particularly at the cervicothoracic junction at C7/T1. Additional strain is put on the occipitoatlantal membrane, and cranial nerves and transient venous structures may become compressed, resulting in headache and other symptoms of migraine.

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Dowager’s Hump

Upper thoracic kyphosis, commonly referred to as “Dowager’s Hump”, is generally a degenerative excessive rounded curvature of the upper T-spine. In the past, it has mostly been associated with elderly people, particularly women, and has origins in osteoporosis and degenerative disc disease. Even though the kyphosis is mainly a thoracic occurrence, the hump does extend into the lower end of the cervical spine as well, affecting the cervicothoracic junction at C7/T1, and the C5/6 and C6/7 intervertebral discs as well.

From a myoskeletal viewpoint, the thoracic and cervical extensors have eccentrically elongated and spread out from the centerline of the spine in much the same way as the abdominal muscles and linea alba spread out in the bellies of pregnant women. The erectors, by definition, are intended to maintain the body in an erect form. If they are unable to do so, the spine bends forward and the erectors spread out laterally.

Forward Head Posture (FHP) and Text Neck, discussed elsewhere on this page and other pages of this site, are presently the biggest concern of myoskeletal therapists and other bodyworkers. These postures are resulting in much earlier development of Dowager’s Hump by starting the compensation pattern further up the spine. Without correction early on, we can foresee a median age of thoracic kyphosis sliding down into the population in their 30’s, 40’s and 50’s. Degeneration of the vertebrae will naturally follow, and we will soon have far too many people with permanently bent posture and spinal problems along with all the extenuating conditions associated with habitually flexed torsos, such as digestive, heart, lung, and arterial problems.

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Stuck Facet Joints

Cervical facet joint pain is considered by some to be the next leading cause of neck pain after whiplash. Facet joints are gliding, diarthrodial joints on the posterior aspects of nearly all vertebrae, and are the location of acceptable and articulating contact between two neighboring vertebrae. The articulating faces of the joints themselves are coated with hyaline cartilage.

Anatomy of facet joints is extremely complex, varies between sections of segments within the cervical spine, and incorporates many more structures than the joint pedicles themselves. This section should not be used for medical reference or discussion as it is very specific in nature to myoskeletal massage only. Furthermore, complications and conditions occurring within facet joints easily go beyond the scope of myoskeletal work and are not covered here. For an excellent public reference on facet joints, please visit this website.

Facet joint pain may be and often is degenerative in nature. As the slick hyaline cartilage is removed by normal wear and tear, osteoarthritis may cause facet pain. All facet joint conditions must be differentiated by a physician.

Myoskeletal Facet Work

From a myoskeletal aspect, facet jamming occurs due to soft tissue and postural restrictions on the joints. These joints assist in the various movements cervical vertebrae go through, namely extension, flexion, lateral flexion, and rotation. When one or more facets in one or more vertebrae become jammed, movement becomes restricted in at least one direction and spinal alignment is affected.

Facets can conceivably become stuck open or closed on one side or the other, or on both sides. Control of this movement is considered to lay with the intrinsic, inter- and intraspinal muscles: rotatories, multifidus, and intertransversarii. When one or more of these become hypertonic, restriction is held at the facets, causing them to jam open or closed.

Since joints live for movement, it is imperative to restore movement and full range of motion to the cervical vertebrae. In so doing, neck pain associated with facet jamming can be eliminated or significantly reduced.

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Other Compensatory Strain Patterns

• Upper Crossed Syndrome
• Thoracic/Lumbar Scoliosis
• Pelvic Imbalance
• Leg Length Discrepancy