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

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

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

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.”



Study of Alexan­der Tech­nique and the alle­vi­a­tion of low back pain

Paul Ingraham

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

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

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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