Exercise for Neck Pain: Can We Do Better?

The Annals of Internal Medicine published an article in January, 2012 that tested three different treatments for neck pain:

  1. medication
  2. chiropractic manual therapy, and
  3. instruction in home exercise

The results?

  • patients receiving chiropractic care fared the best
  • those being instructed to perform exercises at home did the next best, and
  • those taking medication did the worst.

neck exercise

Statistically speaking, many of the differences between the groups were fairly minor. So, for instance, the research couldn’t determine if chiropractic care was truly better than home exercise or if the results were simply due to chance.

Still, from my own point of view, I was happy reading this article, since it seems to confirm that the approach to neck pain I take – which combines chiropractic hands-on treatment with instruction in proper exercise (plus I throw in targeted connective tissue treatment too) – combines the best of all worlds.

What’s Wrong With The Picture?

There was an aspect of the article which didn’t sit right with me, though.

I didn’t like the exercises that were tested.  The exercises that were prescribed focused on head retraction – tucking the chin in.

I would never suggest those particular exercises for my patients.

It’s true that many people – especially those with neck pain – carry their head in a forward position. In fact, it’s likely that every time you work on your computer or read something, and at many other times of the day too, you’re allowing your head to drift forward of its relaxed balance point at the top of your spine.

Because a forward-head postural distortion is so nearly universal, it would seem logical that retracting the head (using the neck muscles to pull the chin back) could have a beneficial effect.

But to my way of thinking, what’s missing from these retraction exercises is a vertical elongation component. If you simply pull back your head,

  • You haven’t engaged your core strength to integrate your posture from the low back through the rib cage to the neck.
  • You haven’t released unnecessary muscle tension.
  • And you haven’t developed your awareness of your posture.

These are concepts I teach my patients.

Surely those who prescribe neck exercise can do better than relentless chin-tucking.

But the burden of proof is on me (and on those whose exercise orientation is similar to mine.) After all, the exercises used in the study have now been proven to be more effective than medication in alleviating neck pain. I have to be well-armed if I want to propose alternatives.

So I sought out reinforcements. I created my own panel of experts in exercise and alignment and put these questions to them:

  • Do you like these exercises for people with neck pain?
  • What do you think is missing?
  • How would you approach this problem differently?
  • And, most importantly, in addition to your professional experience, are you aware of any research that supports your point of view?

Of course, I stacked the deck quite a bit.

Three of the members of my hand-picked expert panel (Clare Maxwell, James Crow, Jessica Wolf) were teachers of the Alexander Technique and a fourth (Deborah Novak) was a neuromuscular movement and education specialist. All four were likely to be supportive of my point of view. And, fortunately, they were.

So I invited comments from a fifth panel member, Paul Ingraham, who I hoped would offer a contrasting perspective. Fortunately, he did.

Here are the comments I received:

James Crow
alexanderplus.com

As an Alexander Technique teacher, I’d be keen to avoid the head retraction exercises being suggested. The Alexander Technique relies on preventing bad habits and replacing them with good ones, and I see head retraction as a bad habit.

Lets take using a computer as an example. Head retraction over the spine happens often enough as it is, like when we’re sit badly at computers. Rather than using exercises which include tightening the neck and pulling the head back, AT teachers would much rather see an expansive release of the musculature of the neck – to actively prevent any neck tightening or shortening that might be causing compression or pain. The aim? To encourage a lengthening in the vertical axis by reducing habitual tendencies of shortening or tightening the neck.

At the same time as encouraging a release through the vertical axis (allowing the neck and spine to lengthen and the head to balance well-poised on top), we’re aiming to increase the self-awareness needed to maintain this. From there, it’s a game of cat and mouse to learn how to avoid forgetting and being pulled down and into the screen!

So we’re aiming to empower people by helping them find more self-awareness in activity. Many cases of neck pain come down to the functioning of the specific individual – a result of how they sit at their computer all day or on the sofa at night, and how they react to life’s stimuli.

Learning to be embodied, conscious and aware of how we’re using our necks and spine brings a tendency to reduce any mis-use in the first place. It’s a long-term fix. So I’d be wary of head retraction exercises as a fix, if it’s head retraction that might be a part of the problem in the first place!

Clare Maxwell
www.claremaxwell.com

My observations of my students with neck pain (and I include myself in that category) are that most of these people are using their neck as if it was a lever – and that lever causes a damaging break in the neck at some point along it’s forward curve that is a misuse of the structure and causes various kinds of damage. Sometimes I get someone with a trauma – an accident of some kind – that happened long ago and has had lasting effects.

The first idea I am going to have to get across to them is that how they use themselves affects how they function. Use affects functioning for good or bad. The second idea is that since they can become aware of how they use themselves, they can change it. This second idea is a big stumbling block and it’s not for everyone! Some people really don’t want the responsibility because it seems like too much.

I don’t know if either of those ideas is really accepted in the scientific world at this point. You probably have a better idea!

As far as I can tell, there is ALWAYS an issue of twist involved, since almost everyone has some degree of postural twist. So if I can help the person unwind, which implies a conscious relationship between the head, neck and whole spine – and even pelvis since that is at the other end – I can help them reduce their (and my) neck pain.

I use my hands and the floor in order to this. In other words, I use their ability to sense changes in their contact with supporting surfaces (what we call “widening” in the Alexander Technique). If there is unwinding, there will be “widening” AND “lengthening.” They can feel this if you bring it about repeatedly and help them identify what is going on.

As an educator, of course it is my job to help the student be able to sense and feel accurately if they are becoming more or less rigid (the relationship of head to spine/torso/legs) and to be able to alter that pattern if they wish via their own thinking. THERE IS A SIGNIFICANT ABSENCE OF EDUCATION implied in this study you sent me. There is manipulation, drug intervention, and exercise, but no one is considering that the patients may have crappy ideas about how to move in the first place. So that as they continue on their own to do the exercises, after the initial contact with a living thinking human being who actually put hands on them, they probably will go back to their own more familiar patterns of movement, thus reducing the scientifically measurable impact of that touch.

It would probably be the same with an Alexander Teacher, because we all know that our students do return at some level to their habits, but at least we give them procedures (which I differentiate from exercise because I am adding the significant element of that persons AWARENESS of and ability to change their USE) to work on that help that return from becoming absolute. At least I do – I ask all my students to do “lie downs” and I show them developmental movements they can do on their own on the floor or in a chair that will counter the force of their own habits if done consciously – that is, with awareness of the tendency to “narrow” or “widen”, narrowing being defined as a withdrawal of the body from the support of the ground, which we need to lengthen and support our whole structure.

I think that just having another person touch you is in fact educational – if that’s the intention of the touch. So that would explain the observable improvement. That’s just my thought – I can’t prove it but I see it all the time in my group classes, where I ask students to touch each other mindfully.

I make it clear to all my students that if they do exercise unconsciously, they are at risk for re-injuring themselves (if that’s why they came to me in the first place.)

Since the focus of the Alexander Technique is that use affects functioning, HOW one does the exercise is more important than the exercise itself. And the role of the teacher is to give the student some conscious control – that that individual person can actually feel for themselves – over the incredible variety of ways that one can do ANY given exercise.

As far as published studies go, it is such a struggle for the Alexander Technique in general to get access to the resources with which to establish a good scientific study protocol – and then to get the study published (many have been done and rejected) – the primary focus of those who CAN get any study done has been back pain. To separate out “neck pain” and create a study of it has not yet been done.

There are two recent back pain – Alexander Technique studies

2011:
by Tim Cacciatore, which adds the element of postural twist. Tim is trying to actually measure what he calls “postural tone,” as opposed to “balance” or “strength.” Here’s a link to the most relevant study. He raises the issue of ADAPTABILITY of postural tone – that is “people who tend to be stiffer” and “people who tend to be less stiff.”

alexandertechnique.com/resources/statcacciatore.pdf

2008:

Study of Alexander Technique and the alleviation of low back pain
http://www.nhs.uk/news/2008/08August/Pages/BackpainandAlexandertechnique.aspx

Paul Ingraham
www.saveyourself.ca

I’m not sure I have enough of a view on that to comment substantively. I do not feel confident about the rationale for any specific exercise component, like vertical access lengthening or any other.

Deborah Vogel
www.thebodyseries.com

I’m not big on head retraction – it focuses too much on a posterior movement, when I think a vertical correction – which may include some shifting toward the back, but as a consequence of elongating the spine and getting the head, shoulders, hips, knees, and ankles in alignment.

As far as exercises that I would prescribe… there would probably be something that addresses the mid thoracic area as the forward head alignment gets set up there. I usually focus on improving rotation and then thoracic extension. There are a wide variety of ways to do so either simple rotation exercises in the chair (while envisioning the rotation to engage the nervous system, my fav) and doing some form of strengthening such as elbow planks with their arms on the arm of the sofa so they don’t have to get on the floor or doing simple cat curls if they are really stiff placing their hands on a chair or again the arm of the sofa. Once the thoracic spine gets mobilized better and in better alignment the neck will follow the new line and correct itself.

If their alignment is pretty good with the exception of a forward head (not as common, but possible) I would probably activate the neck muscles by placing a hand on the top/back quadrant of the head and ask them to gently reach or press up into their hand to feel the elongation of the spine and begin to self correct. They can do that as often as they find themselves slumped over so they begin to create a new alignment pattern. I would also work with them to create a new image of their standing or sitting alignment to make sure they have a clear picture of what they want to emulate. It usually doesn’t take too long for them to feel that when their head is out of alignment there is some other part of the body that will also feel the stress and that body part then becomes their feedback area. For example, if they are sitting at the computer and have slumped into a forward head position typically they roll back on their pelvis and now the lower back is rounded.

They may be able to monitor the placement of their ischial tuberosities better than the placement of their head so that is where I would have them check. Once they correct their sitting position the head/neck alignment usually comes more upright. Of course many have to change and put their laptops up on a stand so they aren’t always looking down.

So many influences upon alignment! But then again, that is what makes it interesting. Trying to figure out a way in to begin creating change in a chronic postural habit!

Jessica Wolf
www.jessicawolf.net

When a person experiences neck pain, the first step is to learn what may causing it.  Pain often has it roots in unconscious physical habits that have developed over time.

Human movement is complex.  As a teacher of the Alexander Technique, I observe my clients as a whole people. The technique is an educational method that can be learned by anyone to help people recognize and understand poor movement habits that affect postural tone and muscular coordination.  It is a form of  ‘self care’ that focuses on the  way we carry out daily activities, such as walking sitting, bending and standing.  When I teach, I do not address just a neck, or a shoulder.  I attend to the whole person.   In order to address pain, you first must become aware of the habits that contribute to pain.  Often, it is HOW we do something that creates the problem, not the activity itself.   Nature does not see us in parts – we are psycho-physical beings.   We benefit from a balance of the physical, mental and emotional conditions; this moves us towards ease and coordination.

When a patient with neck pain receives a prescription for physical therapy, they are generally taken through a series of exercises focused around range of motion, extension and flexion of the cervical spine.  The individual will stand or sit to perform the exercises. Often confusion and discomfort are the outcome because the patient has limited awareness of how to find a position of mechanical balance before beginning the exercise.  For example, when people are told to ‘sit up straight’ they grip their muscles and put strain on the torso. Often when patients stand, they lock their knees, grip their back muscles and hold their breath.  The cumulative effect is one of compression.  By the time the patient is ready to begin the exercise, he or she has already created a mechanical disadvantage that will interfere with the effectiveness of the exercise.

The relationship between the head and the neck is the key to unlocking compression in the spine. When physical therapists identify a forward pushing or “goosing” in a patient’s neck, they will often instruct their patients to overcorrect by retracting the neck which over-straightens the cervical spine causing more pressure.  The neck has a gentle curve, meant to be lengthened with the head balanced on top of it.

Here is some helpful information:

Our heads weigh between 10 and 12 pounds. There is pivot point between our ears where the head moves on the spine creating less effort and force throughout the body.  The head balance determines whether the rest of the spine will lengthen to encourage free movement for the entire body. A light and free relationship between the head and the spine contributes to resiliency throughout the skeletal system.  Alexander teachers refer to this relationship as primary control.  It is an important tool in solving neck problems.

Often, people collapse their spine when they sit.  They rotate their pelvis back and sit on their tailbone and counter that to balance by pushing their head forward.  This puts a lot of pressure down on the spine.  The vertebral column becomes compressed.  The involuntary movement of the breath is interfered with and exhausting breathing habits are developed.

The chest and shoulders get involved to “muscle the breath” causing a gripping movement which interferes with the freedom of the neck.

In order to sit with ease, it’s necessary to find and use the hip joints freely.  To accomplish this, find your “sit bones” (the ischia tuberosity) by sitting on a hard chair. Rock back and forth until you feel a balanced torso from the sitting bones all the way up to your head.

When standing, balance requires subtle shifts of weight through the feet to maintain the upright body and to encourage mobility.  Far too often I watch my students’ vain attempts at corrective exercise, all the while locking the knees, stiffening the body and holding the breath.  Let the gentle assistance of gravity encourage a release of your weight towards the floor.  You don’t have to hold yourself up.  This manner of improved standing will decompress the spine and allow for the head to balance freely using less muscular tension.

These thoughts can be applied to the discipline of exercise by using gentle instructions. The nervous system will calm and overall muscular skeletal tension will be reduced.

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About Ronald Lavine, D.C.

Dr. Lavine has more than thirty years' experience helping patients alleviate pain and restore health using diverse, scientifically-based manual therapy and therapeutic exercise and alignment methods. His website, askdrlavine.com, provides more information about his approach. Please contact him at drlavine@yourbodyofknowledge.com or at 212-400-9663.
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