Neck Treatment

Chapter II

Neck Treatment

Chapter 2 Neck Treatment

If you have been struggling to achieve the results you want when treating clients with neck problems, or if you simply want some additional treatment ideas, consider using some of the techniques described in this chapter, the theme of which is less is more. Many of the tips you will find here encourage you to relax, to be focused, and to explore the subtle changes that occur in the body as a result of very light touch. When you try a technique different from the one you have been using, you tend to work cautiously and are therefore likely to sense gentle, minor movements of the body and in the body tissues. Although subtle, these changes can be positive and are often profound. You may discover that by doing less, you facilitate an “allowing” of relaxation, and this helps stimulate the repair process. You might achieve greater success with a client by adopting a lighter touch than if you try to “worry” away tension, pain, stiffness, or discomfort with an overuse of manual techniques.

Other tips in this section encourage you to consider changing the position in which you treat a client, and some tips provide ideas for treating specific muscles such as suboccipitals, scalenes, and sternocleidomastoid.

If you are reading this as a massage therapist, you may be pleased to know that there is evidence to show that massage is effective for the treatment of neck pain. For examples of research papers examining the use of massage for neck pain, see Sherman et al (2009) and Ezzo et al (2007).

Tip 1: Less Is More

Have you ever treated a client with a neck problem that at first seemed to improve, but for whom, over time, your results began to plateau? Have you ever found yourself repeating the same kind of treatment with a client, hoping that things would improve while being secretly frustrated that you were not making better progress? Perhaps there have been times when you have utilized every technique you know, exhausting your entire armory of skills, yet the improvements you were hoping for were not forthcoming. It can be tricky to know quite what to do in such situations.

Usually there is some progress, and so it is tempting to keep going, to keep providing the same treatment or advice, hoping that there will be a breakthrough sometime soon and that your client will turn up for a session saying, “Hey! After that last treatment I wasn’t expecting anything different and yet when I woke up on Sunday I could look over my left shoulder again!” After all, we frequently tell our clients that it can take weeks or even months to resolve a problem, that a neck problem which has built up over many years is not likely to be resolved in a just a few treatment sessions. So with our client’s best interests at heart we begin with what we imagine will be a program of treatment, some point in which we will identify a time when the client will no longer need us, a time when they will be able to manage their condition themselves, or their symptoms will resolve entirely. Yet you may have experienced a situation where you at first seemed to make good progress, with the client reporting immediate relief from symptoms, but with successive treatment sessions there was less and less improvement. If this happens toward the end of a successful treatment program, that is good, and one might expect the degree of change to be less with time anyway. There is often a gradual tailing off of treatment as the client’s condition improves, and they are naturally weaned offus. But if this slowing down in improvement occurs before a reasonable relief from pain, stiffness, or other troubling symptoms, it can be frustrating for you as a therapist. There is always the feeling that we ought to do more, that we want to do more. The good news is that, if the treatment you currently provide for a client is proving ineffective, there are many things you could do instead of continuing with the same treatment.

1. Reassess your client: You could reassess your client, right from the beginning, reevaluating their range and quality of movement, and asking questions to determine whether anything has changed in their work, hobbies, or lifestyle that may be relevant to the symptoms they are currently experiencing. The client may be doing something that they do not consider affects their neck, and so has not thought of telling you about it. This could be something quite simple, like deciding to watch an entire series of their favorite TV drama or to read War and Peace cover to cover or to knit a king-size blanket. All of these examples require the maintenance of a static neck posture, which, for most of us, is not a good thing. Static postures are likely to aggravate some neck problems. Being able to identify an ongoing aggravating factor is very helpful, so reassessment is useful. The tips in Chapter 1 provide over 20 further ideas for how you might assess your client. Could any of these be useful to you?

2. Consult a colleague: With permission from your client, you could enlist a colleague to carry out the reassessment. Perhaps a colleague will identify something you have missed? They may use a different handhold or phrase a question in such a way as to elicit a different reply; they may perform a test with a subtle change or palpate more firmly (or less firmly). It is always worth asking for a “second opinion” because a colleague sometimes has a different “take” on things. Observing how another therapist performs a neck assessment can be a valuable learning experience in itself.

3. Brainstorm: Maintaining the confidentiality of your client, you could brainstorm the problem with other therapists, asking for their advice. Someone might suggest an assessment, treatment, or technique you had not considered and which could prove helpful. Perhaps a colleague has even treated a client with a similar condition? In what ways was it similar? In what ways did it differ? What did they do that was helpful?

4. Explore internet forums for information: The value of sharing information about treatments that have proved effective cannot be overestimated. Sometimes this information can be gleaned from colleagues or you may find it on an internet forum. While you do need to be discerning in which pieces of information to accept, forums are a useful way of sharing information and much can be learned from reading the comments posted by forum users.

5. Consider referral: You could refer your client to a more experienced practitioner or to a different health professional entirely. It may be that your client has a condition that is not treatable with your particular therapy, or a condition of which you are not aware. Having to refer a client shows you are putting their needs before your own and should be regarded as a strength rather than a weakness.

Question: How long should you wait before referring a client to another practitioner?

This is a difficult question to answer definitively as this depends on the nature and severity of the symptoms as well as on any protocols set out by your governing body or insurance provider. Your answer must depend on what you consider likely to give your client the best treatment outcome.

6. Avoid hands-on treatment entirely: If you feel that you have correctly assessed your client, there is no need for referral, and you do not wish to discuss treatment options with another therapist, another option is for you to do less with the neck, instead of more. At the extreme end of the scale, you could avoid any hands-on treatment entirely. Consider all of the aftercare tips provided in Chapter 3 and select those that you feel might be appropriate for your client. Use the information in these tips to provide your client with the means to self-manage their condition while you remain on hand to offer advice.

7. Reduce your pressure: Sometimes, we risk over-treating. That is, we try to do too much, too soon, perhaps because we are so eager to help. Or we use too much pressure during a particular treatment session. Sometimes the client enjoys the sensation of deep pressure; sometimes it provides the results we seek; sometimes we feel that by “working” an area it will improve, especially if at the assessment stage, we discover there to be a palpable increase in muscle tone. If you are providing massage, try lightening your touch by half, so that the pressure of your strokes is halved. Then lighten the depth of your touch by half again. If you are a therapist used to using a lot of pressure, it can be difficult to change your approach, especially if you have achieved good results in the past with deep tissue massage. Yet sometimes, if we step back, take a breather, and choose to work with less effort, our treatment outcomes improve. This may be because by working more slowly, more gently, with far more patience, we become attuned to the nature of the problem. By sitting very still, with a lightness of touch that is only just perceptible, the clients with whom we are working may begin to find the emotional space to help bring about the healing they need.

8. Change your focus: You could consider treating a different part of your client’s body altogether. Sometimes, working away from the problem area rather than directly over it brings about unexpected and positive results. An example of how this might work is provided in Tip 2, where you will learn how to facilitate an increase in neck range of movement by treating the shoulder and not the neck.

Tip 2: Gentle Shoulder Traction to Increase Neck Mobility

Let us put this “less-is-more” approach into practice immediately. A good example of how a less-is-more approach might work is to imagine you are going to treat a client with tension in muscles of their neck. You know that the neck and shoulder cannot really be isolated anatomically, owing to the large number of structures which connect these two parts of the body to each other and also connect them to the face, skull, upper limb, and thorax.

Question: What are some examples of structures which connect the neck and shoulder?

Omohyoid is a strap-like muscle connecting the scapulae to the hyoid bone at the front of the throat; the upper fibers of trapezius connect the scapulae, clavicle, cervical vertebrae, and occiput; the brachial plexus is a group of nerves in the armpit originating from the cervical region; the fascia of the deltoid links the fascia of the chest and neck and arm; skin of the shoulder is continuous with the skin of the neck, chest, and face.

Hence by reducing tension in the shoulder you may help to reduce tension in the neck via these interconnected structures. Stretching often alleviates muscular tension but instead of stretching the neck, how about gently stretching some of the tissues connecting the shoulder and the neck, without touching the neck itself at all? This does not have to be the only treatment you provide—you could also stretch the neck, massage the neck, and use any of the other techniques familiar to you. It is good, however, sometimes to start with something very simple, and experience just how beneficial this can be before moving on to more direct techniques.

Question: If the results are positive after this simple stretch, is there a need to do further treatment to the neck?

You may decide that there is no need to do further work, to apply further techniques. Sometimes it is best to let the treatment take effect and to reassess a client the following day or in a few days’ time. It can be surprising how effective these nondirect techniques can be.

Question: Are there any clients for whom this is specifically contraindicated?

Yes, this would not be appropriate for clients with shoulder subluxation or dislocation, with known hypermobility syndromes, or recent trauma to the neck or shoulder.

To perform a simple shoulder–neck stretch, read the question concerning contraindications and if you feel that it is appropriate for your client, follow these steps.

STEP 1 Position your client comfortably in the supine position and stand to one side of the treatment couch. Avoid use of a pillow beneath the head if possible. Gently take hold of the client’s arm, keeping it close to their body. In a moment, you are going to apply gentle traction to the shoulder joint, avoiding traction to the elbow and forearm. It is for this reason that you need to find a way to clasp the arm above the elbow joint. You may find that it helps if your client positions their hand on the inside of your own arm, as if holding your tricep, or for you to hold the arm with the elbow flexed. Whichever handhold you settle on, it is important that you avoid tractioning the elbow: you want your “pull” to be focused more proximally at the shoulder joint. Practice with different handholds until both you and the client feel comfortable.


Question: Why should I avoid tractioning the elbow?

When you traction the upper limb, force is transmitted through the soft tissues (skin, fascia, muscle, tendons, ligaments, nerves, blood vessels, etc.). If you hold the upper limb at the arm (i.e., the bicep/tricep region) and apply gentle traction, the force of this gentle stretch is transmitted through the shoulder, and through the soft tissues connecting the shoulder to the neck. If you hold the limb below the elbow (at the forearm region), this force is transmitted through the soft tissues of the elbow, through the arm, and then through the shoulder and neck, with decreasing stretch being felt in the shoulder and neck. If you hold the upper limb by the hand, the force of the stretch is transmitted through the wrist, forearm, elbow, arm, shoulder, and finally some of the soft tissues of the neck. There are two reasons for placing your hands superior to the elbow. The first is that you want the focus of the stretch to be in the soft tissues of the shoulder and the neck. Holding the limb superior to the elbow achieves this. The second is to avoid tractioning the elbow joint itself, or indeed any of the tissues distal to this, because even though the force you apply is extremely gentle with this stretch, in many people it can feel uncomfortable, especially where there is tension in tissues of the upper limb. There are techniques which involve handholds distal to the elbow, but for the technique being described here, try your best to hold the limb so that your stretch is focused on the shoulder and neck regions only.

TIP: With a colleague, practice holding each other’s arm at the wrist, at the forearm, and then as shown below, and compare how it feels when you are the recipient of the stretch as it is performed with each of the different handholds.

STEP 2 Keeping the client’s arm close to their body, apply gentle traction and sustain this. Maintain your position. Tell yourself to relax. Discourage your client from talking but, of course, encourage them to let you know if they feel uncomfortable and stop the traction if they report discomfort. As you maintain the traction, see if you can get a sense of the client relaxing. Can you also get a sense of the tissues of the arm and shoulder “releasing”? Relaxation and release may take a little time as the client settles into the position, acclimatizes to the technique, and allows themselves to “let go.”


STEP 3 For some clients, this very simple shoulder stretch may be enough to provide some relief for a stiff neck, as the soft tissues joining both structures gradually release. However, some subjects may get more benefit if they slowly turn their head away from you—simply rolling it to the opposite direction only as far as they feel comfortable—once you are in position and have applied the stretch. It is important that you apply traction first, before the client turns their head away from you. In this way, it is the client who is in control of how far they rotate, and therefore in control of how much tension is placed on the soft tissues of their neck and shoulder. Can you see how, if the client were to rotate before you applied traction, it would be you, the therapist, who was in control of the stretch? If you were to perform the stretch that way, with the client turning their head first, before you applied traction, you could potentially stress the tissues too much.

STEP 4 After a couple of minutes, gently release both positions: encourage the client to return their head to neutral (if they had rotated it away from you), and relax the traction. Gently return the client’s arm to rest on the treatment couch and repeat the technique on the opposite arm.

Question: Is this technique the same as a myofascial release (MFR) arm pull?

No, when performing a MFR arm pull you hold the hand and wrist, with slight supination of the forearm. MFR arm pulls can be very beneficial and it is worth training in MFR if this is something that interests you.

Tip 3: Two Techniques Using a Towel to Increase Range of Movement

Here is the first of two very gentle techniques that employ the use of a towel to increase range of movement in the neck. For each technique, you will find it helpful to use a towel that is not too thick, about the size of a hand towel.

Technique 1

Position your client in the supine position with the towel beneath their head. When they are comfortable, grasp each end of the towel as shown and use it to gently move the client’s head from side to side, letting the head roll one way and then the other. Be sure to move the head slowly.


TIP: Avoid the temptation to lift the head from the couch because when the head is lifted, some clients have an instinctive tendency to tense their neck muscles. Many clients feel safer, and are therefore more able to relax, when they can feel their head supported by the couch.

The advantage of this technique is that it facilitates rotation without you having to touch the client’s head and face with your hands. Some clients enjoy receiving the sensation of passive neck rotation but dislike having oily hands on their face or hair. It is worth experiencing this technique for yourself to help determine what speed of motion left to right and right to left feels most appropriate.

Question: Are there any clients for whom this movement is contraindicated?

For most of the clients who could receive neck massage, this technique is safe. However, as it involves a rotatory movement, be cautious when using this technique with clients suffering from inner ear disorders such as Ménière’s disease.

Technique 2

You can modify the previous tip so that instead of facilitating rotation, you facilitate lateral flexion of the neck. To do this, simply alter the position into which you take the head, taking care to get feedback from the client because, as you lengthen and perhaps stretch one side of the neck, you passively compress the opposite side of the neck.

TIP: Keep only the neck in lateral flexion for a short time because muscles on the shortened side sometimes cramp.


Tip 4: Releasing the Posterior Neck Tissues with Gentle Passive Stretch

In their excellent book, The Myofascial Release Manual, Manheim and Lavette (1989) describe how to release tension in the soft tissues of the back of the neck in a manner with which you may not yet be familiar: MFR. If you are reading this as a massage therapist, it is important to realize that the technique described in this tip should be performed without the application of a massage medium. The technique is very gentle, yet even so, use of oil or wax would make it difficult for your fingertips to get enough purchase on the skin to facilitate the relaxation in tissues. Therefore, when practicing this technique, do so without any oil or wax, but on dry skin only.

STEP 1 With your client in the supine position, make sure you too are comfortable at the head of the couch. Once you have performed this technique once, you will have a better idea of whether or not you need to change your treatment position, from standing to sitting, for example. Manheim and Lavette (1989) suggest that you position your client in such a way that you have adequate support for your elbows on the treatment couch.

STEP 2 Begin by gently cradling the client’s head, gaining their confidence and encouraging them to relax. Start stroking the back of the neck slowly and when you are ready, choose one of the four handholds shown in the illustration on the following page.

STEP 3 Apply very gentle, sustained traction, just enough for you to feel some resistance in the tissues. Hold this position and wait. Wait until you sense the tissues release. Once you feel this release, either stop or apply gentle traction again.

TIP: Practice using each of the four handholds, perhaps on different subjects, and decide with which hand position you feel most comfortable. You could practice all four handholds on the same person, but remember, you do not want to fatigue your client by overtreating them. You are likely to discover that, as with other techniques, given the variety of human anatomy, different handholds suit different clients.

Alternative handholds

Cupping the head at the base of the skull with one hand and applying slight overpressure with the other.


Cupping the base of the skull with both hands.


Cupping the base of the skull with one hand and placing the other on the client’s shoulder.


One hand on the client’s sternum, against their skin, and the other hand cupping the base of the skull. (You may feel that this is inappropriate for some clients.)


Tip 5: Be Careful with Overpressure in Neck Flexion

A better understanding of anatomy can help you to become a better therapist. A good example of how knowing your anatomy can help inform your treatment is when you consider the form and function of the top two cervical vertebrae. C1 and C2—atlas and axis as they are called—have facet joints orientated at a different angle to the facet joints of other cervical vertebrae. In vertebrae C3–C7, the facet joints are slanted at an angle. The facet joints between atlas and axis are also slanted, but to a lesser degree.


Relatively speaking, the atlantoaxial facet joints are orientated more horizontally than the facet joints in the rest of the cervical spine. So how does that information help inform our practice?

Well, flexion of the head and neck with overpressure is often performed to stretch the soft tissues on the back of the neck. Yet in flexion, the facet joints of the atlas and axis bones are compressed. Flexion with overpressure, as is common in neck flexion stretches, may put excessive strain on the facet joints between these top two cervical vertebrae. This is not a problem in most healthy individuals, but may pose a risk when treating clients with osteoporosis or those who have a pathology affecting their facet joints. In such cases, there is a good argument for avoiding both active and passive stretches involving overpressure in flexion of the head and neck. Alternative stretches may be safer. The next tip describes a method for stretching the posterior neck tissues without flexion.

Tip 6: Using a Towel to Facilitate a Passive Neck Stretch

For those clients who enjoy the sensation of a slightly stronger stretch than those described in Tip 4 (pp. 6465), this next technique may prove useful. It is easy to perform but note that the strength of the stretch as perceived by the client is partially influenced by how you hold the towel and the height of your treatment couch.

STEP 1 Position your client in the supine position with a small hand towel beneath their head. Make sure they have removed any earrings. Check the position of the towel. It should be placed so that when you lift it, it hooks nicely into the occipital bone, the base of the skull. Grasp the towel as close to your client’s face as possible. This is important because if you grasp the towel too far away from the face, the stretch feels quite different to receive and instead of gentle traction you end up tilting the head back a little into extension.

STEP 2 Slowly and carefully start to bring your arms toward you, gently stretching the muscles of the posterior neck.


TIP: One trick is to use the very edge of the towel, rather than a towel edge that has been folded over, as this gives a better “hook” into the occiput.

TIP: Your clients cannot hear you when receiving this stretch as the towel covers their ears. It is therefore useful to agree beforehand on a simple signal to indicate if the stretch feels too strong and the client wishes you to stop. One such signal is simply for them to raise their hand.

Tip 7: Changing the Treatment Position

One of the things you might consider in order to provide variety for both yourself and your clients, and as an experiment when working with clients with whom you are not progressing as quickly as you would like, is to change the position in which the client has been receiving treatment. Consider changing from prone to supine, or from supine to seated, or from seated to side lying, for example. Tips 8, 9, 10, and 11 provide ideas on how you might utilize different treatment positions to your advantage. To begin with, here is a summary of the advantages and disadvantages of each position.




Allows easy access to the back of the neck.

Tissues of the back of the neck can be seen and assessed visually, facilitating treatment to muscles such as levator scapulae, trapezius, and paraspinals.

Makes linking the back of the neck to the shoulders and thorax easy using massage strokes.

The therapist can stand at the head or at the side of the treatment couch.

Can be a useful position when treating clients who are severely kyphotic.

Can be useful when needing to treat the base of the occiput, insertion of sternocleidomastoid or the back of the head.

Tissues of the anterior neck cannot safely be treated; tissues on the side of the neck may be more difficult to treat in this position.

Not always suitable for clients who feel claustrophobic.

Communication is more difficult: Clients cannot always hear the therapist in this position; therapists cannot always hear the client.

Can make treating clients with a very lordotic neck or kinked neck difficult, unless the client is able to chin tuck comfortably.

Can be uncomfortable for clients with low back problems unless a pillow is placed beneath the stomach.

Is not appropriate for clients in later stages of pregnancy, or clients whose anterior is affected by discomfort, recent injury, or surgery (e.g., abdominal bloating, anterior knee pain, mastectomy).

Some clients dislike the temporary mark left on the face or forehead from the face cradle.

Resting in the prone position too long, some clients discover their nose starts to run.




Tissues of the anterior and side of the neck are easy to access, facilitating treatment to scalenes and sternocleidomastoid.

Although the posterior neck tissues cannot be seen, they can be palpated in this position and are sometimes easier to palpate this way owing to the decrease in tone resulting from a relaxed head position.

Can be very useful when treating clients who cannot comfortably lie prone.

Makes linking the front and sides of the neck to the chest easy using massage strokes.

Can be a useful position when there needs to be an ongoing dialogue between the client and the therapist.

May be more difficult to access tissues of the posterior neck.

Posterior neck tissues cannot be seen.

May be uncomfortable for clients with an exaggerated kyphotic curve.

Can be uncomfortable for clients with lumber problems unless they rest with hips and knees flexed or a bolster beneath their knees.

Is contraindicated in later stages of pregnancy.

Side Lying



It makes the side of the neck that is uppermost easy to access.

Can be very useful when treating clients who cannot easily or safely lie prone or supine, such as in later stages of pregnancy.

Tissues can easily be passively shortened or passively lengthened in this position, facilitating access to deeper structures.

Makes linking the side of the neck to the shoulder easy using massage strokes.

The client has to swap sides during treatment and this can interrupt the flow of the session.

Can be difficult for the client to find a comfortable position for the arm on which they are resting.

May not be suitable for clients with shoulder problems who could find resting on their shoulder painful.




It is a very useful treatment position for when you want the client to be more engaged with the treatment they are receiving or when it is important for there to be an ongoing dialogue.

Can be very useful when treating clients who cannot easily or safely lie prone or supine, such as in later stages of pregnancy.

Facilitates access to the front, sides, and the back of the neck.

The client may be less relaxed than in a lying position.

Tissues of the neck are under more tension when the client is seated than in other treatment positions.

Unless a face cradle is available, there is an increase in tone in muscles of the neck in the seated position as these work to support the head, even when the client attempts to relax.

Tip 8: Five Ways to Access the Neck in the Prone Position

1. Chin tuck: One of the ways you can gain better access to the back of the neck is to ask your client to tuck in their chin when they are resting in the prone position. By doing this they actively reposition their head into a more flexed position, thus lengthening the tissues on the posterior of the neck and helping to slightly gap the vertebrae posteriorly. This is especially helpful when treating clients with an excessively lordotic neck, a kinked neck, or with a dowager’s hump—a fatty overgrowth of tissue that makes accessing the tissues of the posterior neck tricky at times. Clients may choose to do the chin tuck while resting with their face in a face hole or face cradle, or they may chose simply to rest their forehead on their hands. Whichever method they choose, this repositioning helps you gain access to the posterior neck, but remember that in this chin tuck position the posterior neck tissues are lengthened and under slightly more tension than when a client rests prone.

Aug 25, 2019 | Posted by in MANUAL THERAPIST | Comments Off on Neck Treatment

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