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.

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.

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?

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?

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?

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

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.

Question: Why should I avoid tractioning the elbow?

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?

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.

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

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.

• 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.)

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.

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.