Chronic neck pain (CNP) is a highly prevalent global issue associated with considerable disability and economic cost. CNP is found in all socioeconomic classes, with the leading causes being altered neuromuscular control (abnormal movement patterns and postural imbalances) and previous neck trauma.
CNP has been associated with forward head posture (FHP), loss of cervical ROM and scapular dyskinesis. (The presenting neuromuscular imbalance in FHP was discussed previously [May 2021 issue].) Imbalances in length-tension relationships of these muscles cause increased shear forces on the cervical spine, contributing to an increase in pain. The good news is these imbalances can be treated with CMT, exercise and lifestyle modification.
Don't Ignore the Thoracic Spine
Chiropractic adjustments for CNP are obviously patient specific. CNP that presents with cervical spondylosis often prefers low-velocity techniques, traction and instrument adjusting. Contractures of the suboccipital muscles create atlanto-occipital joint dysfunction, requiring adjustments at C1-occiput and myofascial release.
However, there is growing evidence in the literature that CMT of the thoracic spine is a huge player. The thoracic spine needs to be able to achieve neutral, especially at T4 (there is often a loss of extension); and the costovertebral joints need to be freely movable as well.
Clinical Tip: Mobility of the upper thoracic spine is essential to maintain the sagittal plane line of the ear over the shoulder. More than simply a P-A or anteriority adjustment, long-axis extension, rotation and lateral flexion all need to be assessed and restored in the thoracic spine.
Stabilization Exercises
Neck stabilization exercises for the deep cervical flexors and extensors have been a mainstay for cervical spine rehabilitation, and current research emphasizes the incorporation of scapular stabilization exercises for a synergistic effect. Retraining scapular retraction and depression is an excellent starting place for CNP because it addresses FHP, corrects stability dysfunction of the cervical spine, and relaxes hypertonic upper trapezius and levator scapulae muscles.
In the stability-mobility continuum described by Boyle, the thoracic spine desires mobility and the cervical spine seeks stability. The assessment for whether the cervical spine needs local strengthening or scapular stability is to compare cervical ROM standing and supine. If pain and dysfunction are reduced when the patient performs ROM lying supine with the head supported as opposed to standing, then scapular exercises are indicated as a starting point of the CNP treatment. These patients also need thoracic spine CMT and minimal or no cervical spine CMT.
Clinical Tip: If the patient cannot relax the upper trapezius and levator scapulae with scapular retraction and depression while standing, have them perform their corrective exercises supine. An even better exercise to strengthen the mid- and lower trapezius with minimal upper trapezius activation is prone external rotation with the arm at 90 degrees abduction.
Assessing Scapular Motion
As doctors of chiropractic, we take a whole-body approach to assessment and treatment; in CNP that includes postural and dynamic assessment of the scapula as part of the kinetic chain. While static scapular position is an indicator of dysfunction, there is no agreed standard on ideal scapular position as it relates to ADLs.
The overhead athlete, for example, will have significantly different positioned scapulae without compromise of function. Conversely, tightness / shortening of the levator scapulae will create tension in the cervical spine and a downward rotation of the scapulae, due to its attachment to the superior angle of the scapulae.
Clinical Tip: The modified Kibler method is a technique to assess scapular position and compare sides. Measure the distance from the spinous process of T2 to the spine of the scapula; and from the SP of T7 to the inferior angle of the scapula. Comparing the measurement bilaterally, the difference should be within 2 cm, especially the inferior measurement. If the superior measurement is greater than the inferior measurement, downward scapular rotation deficit is present. Remember that this may not apply for overhead athletes.
Functional assessment of scapular motion is more applicable to the chiropractic model of rehabilitation. Assess the motion of the scapula as the patient elevates the arm in scaption. Assuming the patient is not involved in a unilateral overhead activity at work or sport, during movement the scapula should remain against the rib cage and rotate symmetrically in the frontal and sagittal planes, with the inferior angle reaching the midline.
Topical Analgesic Support
Chronic pain patients need to have a discussion concerning realistic expectations to manage their condition and function, as they will cycle in and out of pain at varying levels. Topical analgesics are excellent for symptomatic management of pain. Specifically, topical cannabinoids are demonstrating great promise in treating both the neuropathic and athrogenic pain that accompanies spondylosis, and can have significant impact in CNP management.
Topical CBD stimulates the endocannabinoid receptors in the skin, reducing joint hyperalgesia, which assists in the prevention of progressive joint damage, chronic pain development and disease progression.
Clinical Tip: Keratinocytes contain CB2 analgesic receptors. However, the outer layers of the skin provide a significant barrier. Therefore, to be effective, CBD from hemp oil needs a transfer agent to penetrate the skin to reach the keratinocytes; otherwise, the oil sits on the skin. Maximum effectiveness of CBD topicals occurs with transdermal serums that are not oil based.
Practical Takeaway
The chiropractic approach to CNP management is effective and applicable. Be sure to adjust the thoracic spine, occiput and rib cage; add scapular stabilization exercises into the traditional cervical stabilization exercises; correct postural imbalances such as forward head posture, downward-rotated scapulae and rounded shoulders; counsel your patients on ergonomics at work and in recreation; and dispense effective topicals for pain control at home between visits.
Also be sure to explain to the patient that CNP needs to be managed to achieve reduced exacerbations and maximal function. Finally, CHP patients may also require counseling in pain neuroscience, so be prepared to refer these patients for counseling in addition to chiropractic care.
Resources
- Javdaneh N, et al, Focus on the scapular region in the rehabilitation of chronic neck pain is effective in improving the symptoms: a randomized controlled trial. J Clin Med, 2021 Aug 8;10(16):3495.
- Javdaneh N, et al, Pain neuroscience education combined with therapeutic exercises provides added benefit in the treatment of chronic neck pain. Int J Environ Res Public Health, 2021 Aug 22;18(16):8848.
- Safiri S, et al, Global, regional, and national burden of neck pain in the general population, 1990-2017: systematic analysis of the Global Burden of Disease Study 2017. BMJ, 2020;368.
- Bryk M, Starowicz K Cannabinoid-based therapy as a future for joint degeneration. Focus on the role of CB(2) receptor in the arthritis progression and pain: an updated review. Pharmacol Rep, 2021 Jun;73(3):681-699.
- Xu DH. The effectiveness of topical cannabidiol oil in symptomatic relief of peripheral neuropathy of the lower extremities: randomized controlled trial. Curr Pharm Biotechnol, 2020;21(5):390-402.
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