Chapter III Tip 2 Acute versus Chronic – Basic Advice Tip 5 Enhancing Neck Stretches Tip 6 Neck Alignment while Sleeping It can be a struggle sometimes to know what to say to a client who is in pain with a recent neck injury or who has been suffering with a neck problem for many months or years. Often clients want a “quick fix” or they are fearful of reinjury and scared to move their neck at all. Sometimes a person is simply worn down by the constant discomfort of a chronic neck condition or with having to cope with a neck condition that flares up unexpectedly. The 11 tips in this chapter are all about the kinds of information you can give to your clients to help them to manage their neck conditions. This includes information you can provide to help explain their condition and how best to recover from neck problems, advise on safe stretches, and simple exercises they can perform, as well as a few tricks you may not have come across. The chapter begins with tips about how we can help educate, advise, and reassure clients by throwing light on neck care facts which you, as a therapist, may take for granted, but which clients may not be aware of. As therapists, it is probable that we are more informed about the body than most of our clients, and an important part of our role is to help educate people as to how they can prevent, manage, and resolve their symptoms. Of course, there are many clients with a high level of understanding about anatomy and physiology, and about injury and rehabilitation, especially if they are keen on being able to take part in a regular physical activity and want to lessen their chances of injury. However, even when a client exercises regularly and is fairly well informed, this does not mean that they have the same knowledge and appreciation about their bodies as we therapists do. It is common for clients to use the internet to seek solutions to their neck problems. The internet is not only a fantastic source for sharing knowledge, but also contains much misinformation. We have an ideal opportunity to help clients care for their necks and manage their neck complaints in a safe and appropriate way. One of the reasons why neck problems persist can be because a client continues to do something that aggravates their symptoms. Aggravating and easing factors are usually identified during the initial assessment and the information is used to help identify the condition the client is suffering from. The identification of aggravating factors is included here, as part of aftercare, because it often requires the client to take concerted action, outside of the therapy clinic, in order to determine what these aggravating factors are. Often a client can tell you immediately which movements, activities, or conditions give rise to more discomfort, pain, or a “flare up” of their neck problem, but in some cases they cannot. Sometimes, an aggravating factor is an activity that is so commonplace that the client fails to recognize it as an aggravating factor at all. The longer a person has been doing an activity, and the more commonplace it is for them, the less likely they are to consider it an aggravating factor. This is where we, as therapists, can help by asking open-ended questions that may prompt awareness. Further, the aggravating factor does not necessarily need to involve movement. A task that involves a person to keep his/her neck in a static position for a long period of time can also be problematic. Examples of when the head and neck are held static or almost static are reading, using a microscope, bird-watching, concentrating on close-work hobbies such as needlecraft, sitting at a desk using a laptop or computer, and watching television. Question: What if my client cannot identify any aggravating factors? A useful tip here is to suggest that your client keep an activity diary for 7 days, for a period of time that represents their normal routine. When the client returns for another appointment with you, ask them what it was they were doing when their symptom came on, and try to get as specific as possible. Were they moving or staying still? If they were moving, what were they doing? Can they remember which movement they made? Did it involve their neck only or did it involve their arms or shoulders too? Were they lifting or carrying anything, for example? Was it a whole body activity? Were they engaged in sport or exercise? If they told you, for example, that it came on when they were swimming, what stroke were they doing? A common example of a stroke that aggravates neck pain in some people is when the client does breaststroke while keeping their head above the water, their neck in extension. If the activity involved moving only their head, what did they do? Ask them in layperson’s terms whether they looked down (flexion), up to the ceiling (extension), over one shoulder (rotation), etc. Was it a combination of movements? If the client was in a static position when the symptom came on, what were they doing? Where they standing, sitting, crouching, or lying? If they were lying, in which position? On their back, side, or stomach? If the symptom came on when they were lying on their stomach with their head turned to the right, for example, does the symptom also come on when they rest prone with their head to the left? If they were sitting, what were they doing? Were they reading? Watching television? Did they fall asleep? If they fell asleep and woke up with neck pain, where were their head and neck when they woke up? Had the head dropped forward or to one side? Where a symptom develops from a static posture, you will need to help the client identify whether it is the posture itself that aggravates the symptom or whether the symptom is duration-dependent. For example, if a person’s pain comes on when they remain static in order to read, for how long can they read (remain in this posture) before the symptom develops? Once you have specific information concerning aggravating factors, you are a short step away from providing the client with preventative advice. Question: Do clients really need help identifying aggravating factors? It may seem obvious that if a symptom develops after retaining a static posture for 40 minutes, for example, the solution is simply to avoid this position for more than, say, 30 minutes. Yet we all fall victim to these kinds of habits and having someone point out that we are sitting too long, for example, is a good thing. You have probably come across plenty of clients who will tell you, “Yeah, I know, you’re right, it’s just that when I’m into it I can’t seem to stop,” or “I forgot the time.” Maybe a solution would be to print a line of copy in books which says, “Stop, you have read 100 pages; do you need to take a break?” (By the way, if you are reading this book cover to cover, stop; you have read 117 pages.) Use these questions to prompt your own thinking and to help you when questioning clients in order to try and identify aggravating factors which you can then eliminate or reduce. These are by no means exhaustive, and are in no particular order, but will hopefully provide a jumping-off point for further investigation. When you noticed your symptom: Were you moving or staying still? If you were moving, what were you doing? Can you remember which movement you made? Did it involve your neck only or did it involve you arms or shoulders too? Were you lifting or carrying anything? Were you shrugging your shoulders? Where were your arms? Were they hanging loose by your sides, supported on a chair, or in some other position? Did you notice your symptom following a whole body activity such as sport or exercise? If so, what were you doing and which part of the activity aggravated the symptom? For example, if you were swimming, what stroke were you doing? If you moved only your head before the symptom came on, what did you do? Did you look down (flexion), up to the ceiling (extension), over one shoulder (rotation), or was it some other movement? Can you show me what you did? If you were lying, in which position? On your back, side, or stomach? In which position were your head and neck? Can you show me? If you were sitting, what were you doing? How were you sitting? Upright, or slumped, on a chair or on a sofa, at work, the cinema, in a cafe, or at home? Can you show me how you were sitting? Were you reading, watching television, or doing a craft activity? Can you show me the position you were in while doing this activity? Did you fall asleep sitting? Where were your head and neck when you woke up? Had the head dropped forward or to one side? For how long can you remain in this static posture before the symptom develops? Question: Why do we need to bother being so “specific” in trying to identify aggravating factors? First, aggravating factors help us clinicians to determine the condition we are dealing with. Secondly, once we know what aggravates a person’s symptoms, we can help them to find ways to eliminate or avoid these things. A client comes to you with a recurring neck problem and tells you they cannot identify anything that makes it worse. As part of your home care advice, you suggest that they keep a 7-day diary and when they return a week later they tell you that they still cannot identify what is aggravating their pain, only that “It came on when I went to see my neighbor.” You ask what they were doing and they reply, “I wasn’t doing anything different. It was a normal day.” Your task is to be the Sherlock Holmes of therapists, to discover what was different that particular day, that particular occasion. Has visiting their neighbor ever triggered this symptom before? What were they doing during the visit? Does the trigger have to do with how they sit or stand at a neighbor’s house? You ask the client to tell you exactly what they did (“Just the usual. We had coffee.”). So you ask, “Was anything different that day at all?” What would you think if they then said, “Nothing. Only I didn’t have my scarf that day”? “Do you usually wear a scarf?” you ask. They tell you that they always wear a scarf and when you ask, “Why?” they say, “I don’t know. I just feel better with it on.” “So what happened when you visited your neighbor that day when you didn’t have a scarf on?” “Nothing, but my neck started hurting.” “What were you doing?” “Drinking coffee.” Then the client remembers, “It was cold.” So now you are faced with an opportunity: was the symptom brought on by holding a particular posture to drink coffee, retaining this posture for a long period of time, sitting to drink coffee in a cold environment, or was it something altogether different that also happened while at the neighbor’s house that triggered the neck pain? Later the client says, “Come to think of it, I think the cold does make it worse.” You ask them to explain. “When I go to the cinema I can’t sit in an aisle seat because if there’s a draft my neck hurts.” Then they remember that when they sat in a restaurant one time under some air conditioning vent, they had neck pain the following day. You can see that from the information generated in this particular example, you are starting to build up a picture of causal factors and might surmise that the client has a neck condition aggravated by cold temperatures. This kind of questioning and the responses the client gives help your client realize just how important it is for them to keep their neck warm. Although identification of aggravating factors is part of your initial assessment, you can see now how encouraging a client to identify aggravating factors themselves is key to successful intervention. A client may be reluctant to consider that an exercise they have been doing regularly could be an aggravating factor, especially if it was an activity which they took up initially to help overcome a problem, and which seemed to help alleviate the problem at the time. Example 1: A client may have once been advised to do neck “rolls,” circumducting their head which at the time alleviated their symptoms. Perhaps they were retaining a static posture for long periods of time and neck rolls were a way of alleviating tension in the muscles of the neck and shoulders? Perhaps they had a stiff neck and a reduced range of movement (ROM) and so neck rolls were given as a means of encouraging the client to move through, and improve, all ranges. Three years later, performing end-of-range neck rolls every hour while sitting at their desk may not be appropriate. Example 2: A client may have been told as a child that doing headstands is good for core stability and would help keep their neck strong. Years later, trying to do headstands as part of a neck-strengthening regime following a whiplash accident is probably not advisable. Clients sometimes continue to perform exercises prophylactically, believing these to likely prevent their symptoms from returning. Whilst some neck exercises are useful to perform regularly, most are prescribed to help manage a specific condition, at a specific point in time in the course of a person’s recovery. Many clients stick to old regimes believing these to be helpful when these may at best be ineffective now, or at worst are aggravating a condition. One of your tasks is to help identify where a client is performing an exercise that has long since become obsolete for the client’s needs, and to help educate them in this. • Reassure your client that X-rays and MRI scans often reveal degenerative changes in the cervical vertebrae. It would be wrong to assume that a neck problem is due solely to these changes. Many people whose necks show signs of degeneration are problem free and experience no pain and no stiffness. Degenerative change is normal and happens to us all as we age. • Reassure your client by telling them that the neck often makes a creaking sound known as “crepitus.” This does not necessarily mean there is anything wrong. • Reassure your client that there is much that can be done to help them, and many different interventions they can try. As a therapist, consider the main problem—is it pain, stiffness, impairment of function, etc.—and brainstorm all of the things you know are useful in addressing each of these. • Ask your client to consider the general advice provided here as well as the advice on staying active. • Most acute neck pain resolves at best within a few days, at worst within a few weeks. • The sooner you return to normal daily activities, the sooner you are likely to get better. • The sooner you are able to move your neck, the sooner you are likely to get better. • People who avoid moving their neck and avoid returning to their daily activities are at greater risk of suffering chronic neck pain and report coping less well with their pain. • People who start moving and who try to return to normal are likely to recover quickly and to cope best with neck pain. • Modify your activities to start with. • When we damage the outside of our bodies, we see evidence of damage—a wound, bruise, scab, or scar. When we damage the insides of our body, we cannot see the damage. The body needs time to heal on the inside just as on the outside, with blood vessels, muscles, tendons and ligaments, and, in some cases, fractures repairing themselves, and nerve inflammations settling down. Pain often resolves before the healing process is complete, so most of the time we simply need to be patient. • Most causes of neck pain are not serious. • For clients who suffer isolated episodes of pain, try to discover if there is a trigger. Encourage your client to try and pinpoint what brought on their pain. If necessary, review Tip 1 in this chapter, to see if you can identify aggravating factors and remove or eliminate these. • If the pain is due to an underlying condition such as degenerative changes in cervical vertebrae, remind your client that between episodes they often experience weeks or even months when they are pain free or have much reduced levels of pain. • If you feel it is appropriate, ask your client to consider pain medication as one way of managing if their pain is constant. Medication may not need to be taken all of the time but can be a useful way of helping clients to cope. • For clients suffering chronic pain, suggest they consider trying to pace their activities, reducing the duration or intensity of what they do. For example, make several shopping trips, carrying lighter shopping each time. • Suggest a client to consider attending a pain management clinic. Techniques such as cognitive behavioral therapy are an established means of helping people to manage long-term pain. Unless a client has an acute and potentially dangerous neck condition, the general advice provided here is likely to be safe and helpful.
Neck Aftercare
Chapter 3 Neck Aftercare
Tip 1: Playing Sherlock
Useful Exploratory Questions to Help Identify Aggravating Factors
Example of How Getting Specific Information Can Help Identify Aggravating Factors
Identifying Obsolete Exercises
Tip 2: Acute versus Chronic – Basic Advice
Advice for Clients with either Acute or Chronic Neck Pain
Advice for a Client with Acute Neck Pain
Advice for a Client with Chronic Neck Pain
Recommendation | Rationale |
Relative rest | Resting for more than 1 or 2 days is not usually helpful for people with neck pain. |
Stay physically active | There are tremendous benefits for people with neck pain in staying physically active. Consider all forms of exercise that are deemed safe for that particular person, such as walking, swimming, and stretching classes. Remaining physically active does not have to involve formal exercise classes or sport. Walking to and from work or to and from the cinema, or to the shops instead of taking a car or public transport constitutes physical activity. Could your client do a home DVD exercise program? Could they walk their own dog or a friend’s dog? Try to think “outside the box” and ask not what they cannot do, but what your client can do. How could you work with a fitness professional to help them increase their levels of physical activity? How could they increase this themselves on a daily basis? |
Maintain active range of movement | While some people feel safer if they minimize the extent to which they move their head, in the long term, avoidance of all neck movements is not usually advisable as muscles atrophy with disuse and are therefore less able to support the head. Collars that keep the neck immobile are therefore not helpful in the long term. Even small movements can help reduce discomfort and improve recovery times. |
Avoid aggravating factors | Help your client to identify which movements and activities most aggravate their neck. Consider ways to avoid or minimize these. For example, if they remain stationary for long periods of time, ask whether the task they are doing could be broken into smaller segments. Could they split up this activity throughout the day? Or, could they do some stretches or movements to overcome this static position. |
Use heat or cold for pain relief | The application of heat and cold can be used for pain relief and which of them is used depends largely on the client’s preferences. In acute situations, cold is usually applied, and it has a general numbing effect on the body and thus decreases pain. However, applying cold to the neck region is not always pleasant and could give some clients a headache. For this reason, it should be applied for a short duration only, for a few minutes if tolerable. Caution is needed to avoid using heat at too high a temperature or for too long a period. Heat is useful for decreasing muscle spasm, one of the contributing factors to pain. Performing neck ranges of movement or gentle neck stretches may be easier after the application of heat. |
When we are cold, we tend to shrug our shoulders and this increases the tone in neck muscles. It is therefore important to keep well wrapped up in cold weather and to identify risks such as when the client is in an air-conditioned environment. Some clients with neck pain are particularly susceptible to cold. What preventive measures do they take? Do they avoid certain environments? Carry a scarf? Carry a heat pack? | |
Encourage relaxation | Feeling stressed or angry increases muscle tone and is likely to aggravate some neck conditions. Finding ways to relax physically and emotionally is important in helping to manage neck conditions and helps aid recovery. Consider asking your client to think constructively about how they could build rest and relaxation into their rehabilitation program, just as they might plan neck exercises. |
Tip 3: Get Clients Moving
The message here is that unless a client has suffered an acute injury, or has neck pain resulting from a serious pathology such as a herniated cervical disk, cervical fracture, or tumor, for example, movement and exercise is better for them than immobility.
The Advantages of Activity and Disadvantages of Inactivity for People with Neck Pain | |
Advantages of activity | Disadvantages of inactivity |
Helps maintain and improve range of movement in the neck | Is likely to lead to a decreased range of movement in the neck |
May help reduce feelings of stiffness | Is likely to increase feelings of stiffness |
May help reduce pain | May increase pain |
Helps elevate a person’s mood | May contribute to feelings of depression |
Helps maintain and improve muscle strength | Results in muscles weakening |
Helps maintain and improve proprioception in the joints of cervical vertebrae and can help maintain and improve balance | Is likely to lead to a reduction in proprioception in joints of cervical vertebrae and a reduction in balance |
Movement promotes blood flow to muscles, tendons, and ligaments, aids lymph drainage and stimulates repair | Decreased blood flow to muscles, tendons, and ligaments combined with reduced lymph drainage is likely to increase scar tissue and hinder repair |
Can help a client feel that they are in control and making progress | Can lead to feelings of helplessness and lack of progress |
Advice for clients on how to incorporate neck movement into their daily activities without aggravating an existing neck condition | |
Sleeping | On waking, lie on your back and gently roll your head from one side to the other. Next, sit on the edge of the bed and take your neck through its range of movement—flexion, extension, rotation left and right, and lateral flexion left and right, performing each movement one or two times. Neck and shoulder muscles are connected, so perform one or two shoulder shrugs or shoulder rolls. Together these movements can help get the joints of your neck moving and help you feel a little looser before you start your day. |
Driving | Holding your head, neck, and shoulders stationary for long periods of time increases muscle tension and can aggravate certain neck conditions. Consider how to drive less—consider fewer journeys or journeys of shorter duration. Can you use other forms of transport or get a lift for all or some of your journey? If you have to drive, or have a particularly long journey planned, break up the journey as much as possible, stopping to rest. During these rests, perform simple range of movements such as neck movements, stretches, and shoulder shrugs or shoulder rolls. Adjust your seat so that you are as comfortable as possible before your journey. |
Commuting and traveling | It is important to keep your neck moving, avoiding a static posture for long periods of time. Range of movement exercises and shoulder shrugs can be performed surreptitiously if you are concerned about people watching you, on a station platform or while waiting at an airport. If you need to travel on a crowded bus, train, or tram, sit if a seat is available so that you can avoid holding a bar or strap for support as elevation of the shoulder requires some neck and shoulder muscles to contract and shorten, and in some cases, this can lead to spasming of the muscle. This may be more likely to happen if you are prone to neck spasms. If you have to hold onto something by raising your arm, avoid using the arm on the side of your neck that spasms, or change arms where possible; practice depressing your shoulder blades a couple of times while you are holding on, contracting muscles opposite to those that are prone to spasm. |
Avoid remaining stationary without moving your neck for periods of more than about 40 min. Use commercial breaks as a prompt to perform simple neck movements and shoulder shrugs. Avoid sitting for long periods with your head turned to one side, even slightly. Is your TV screen in front of you or do you need to turn to watch it? Having to look up, to a wallmounted screen, or down, to a screen close to the floor, for long periods of time increases muscle tension and is likely to aggravate certain neck conditions. Where possible, have your furniture rearranged so that your TV screen is in front of you and the top of the screen is level with your eyes. | |
Working at a desk | As with watching TV, avoid remaining stationary without moving your neck for periods of more than about 40 minutes. Do not wait to feel stiff and sore before moving. Move before that happens! Take regular micro breaks—30 seconds or so—and use these to perform simple neck movements and shoulder shrugs. Use a visual or auditory screen alert as a reminder for when it is time to take a break. Check that any screen you are using is in front of you and that the top of the screen is level with your eyes. Where possible, vary the type of work you are doing so that you change the position of your neck. For example, swap between typing and writing and speaking on the telephone. If you know that your neck starts to ache or spasm when in the draft from air conditioning or a window, get into the habit of always carrying a lightweight scarf with you that you can use as and when needed. Shoulder and neck muscles are connected, and overreaching for things on your desk could aggravate your neck condition. Move things closer to you where possible. |
Hobbies | If a hobby requires you to keep your neck stationary for long periods of time, such as reading, needlework, painting, or fine model making, stop and take breaks every 40 minutes or so. Set a watch or phone alert to remind you when it is time to take a break during which you can move your neck and shoulders. Dog walkers report that sometimes a sharp tug on the leash can trigger their neck pain. Solutions are to swap the hand in which you hold the leash or to use an extendable leash. |
Daily activities and chores | Lifting and carrying can aggravate some neck conditions as the load is transmitted through the arms and the shoulders to muscles spanning both the shoulder and the neck. Minimize what you need to lift and carry, carry items close to your body or not at all—use a wheelie case or buggy or backpack. When we carry a heavy bag on one shoulder, we tend to shrug that shoulder; this can aggravate some neck conditions and lead to spasming of the muscles on that side. If you have to carry a bag, try changing hands and swap the shoulder on which you carry it. Avoid holding a phone on one side of the head for long periods of time as such use tends to cause us to laterally flex to that side; this too can lead to spasming of muscles on that side. Where possible, minimize using the phone in this way or change the way you use it—convert to speakerphone, headset, or Skype, for example. Certain daily activities can trigger spasm in neck muscles where the activity involves lifting a weight on one side or raising one or both arms above the head, for example, holding a hair dryer to the head, reaching up to put crockery into a cupboard, reaching up to hang drapes, hanging washing on a line, reaching up to wash a window. In the acute stages, avoid these activities. Avoid or minimize time spent vacuuming or ironing, activities that involve repetitive movement of the arms combined with a fairly static neck posture. |
Exercise and sports | Exercise and sports help people cope with pain, and help in the rehabilitation process. Impact and contact activities are potentially aggravating for people with neck conditions, so nonimpact and noncontact activities are preferable. Sports and exercise do not have to be stopped; they simply have to be modified. Ways to modify these are to change the activity itself (e.g., from cycling to walking), the intensity of the activity (e.g., every other day rather than every day), or the duration of the activity (e.g., 20 minutes a day instead of 60 minutes a day). Some activities can be modified to reduce their impact; for example, instead of doing breastroke when swimming, change to backstroke. |
Tip 4: Simple Neck Stretches
The most simple stretches you can give a client are active ROM stretches. Whilst ROM tests are used as part of cervical assessment, actively moving the neck through its normal ranges will constitute a stretch for some clients and they should practice these before attempting other stretches.
