COVID-19: A Pain in the Neck (Tips for how to manage your headaches, neck, and shoulder pain.)

Days spent inside, away from the sunshine. Longingly wanting to return to some semblance of normalcy. Romanticizing evenings spent with loved ones in social spaces. Remembering the salty buttery goodness of overpriced popcorn at the movie theatre. Not wanting to throttle whoever it is that you are shut into your home with. Welcome to the Spring of 2020 – a true “pain in the neck!” 

These are trying times for all of us, let’s face it. Even more challenging is the total lack of physical exercise that we are ALL suffering from. Personally, I went from exercising over an hour every day to being proud of myself for getting up and going to the fridge. What a change. Unfortunately, with increased sedentary lifestyle changes comes increased levels of headaches, neck pain, and shoulder pain. Of these increased pains, neck pain can be one of the most common and severe issues that we can face. 

Regardless of whether or not someone is working from home, there is a high chance that the time they spend sitting is in less than ideal positions. That comfy couch? The one that sort of makes you all cozied up in the fetal position to watch TV or read a book while you’re sitting in it? Well, that puts a lot of pressure on your spine in areas that are already susceptible to injury and subsequent pain. 

What if that isn’t you spending more time on your couch or bed? Maybe you still have a full work-day to suffer through at your kitchen table with your hard, lumpy dining room chair that only Emily Post would approve of since it puts you in a maximally uncomfortable position to enhance your presentation of manners. In a sense, this is just as bad. 

Whatever your situation is, I would bet 10 packs of toilet paper that we are all spending more amounts of our time stationary. This is tragic! Our bodies are designed with amazing amounts of detail to MOVE. Blood courses through our veins and arteries, it doesn’t just pool (unless there is a problem that is). 

Joints contain synovial fluid that carries nutrients to the tissues; the only way to get it in and out of the joints is to move. Our stomachs churn and burble to push the things that we eat through our bodies and are made more effective when we are active. Even the hair on our bodies moves using tiny muscles called piloerectors to regulate body temperature when we get the cold shoulder or fiery wrath from our aforementioned loved ones.
Forgive the terrible cliche, but if you have ever been in a physical therapy clinic, you have probably heard one of us drone on about how motion is lotion. That rings true! Essentially, I am being obnoxiously verbose to tell you; our dear reader, that I want to go through some basic motions that could reduce your neck pain during these troubling times. Let’s start at the top!

Summary: For Those of You Who Don’t Want Long-Winded Explanations

Here is how you can manage and alleviate your pain. If you want more, go read what I wrote below or come in to see us if you were already studious in your curiosity. 

  • Headache = Repeated or sustained upper cervical flexion
  • Neck Pain and Shoulder Pain = Cervical retraction with a thoracic block
  • Shoulder and Mid Back pain = Thoracic Extension

Now, let’s dive in!

Headaches and the Cervical Spine

Tension Headaches, commonly referred to as cervicogenic headaches as this is the source of the pain; affect up to 78% of the population and can be utterly debilitating. Despite being the most impacting headache factor, it is also the type of headache that is least researched. 

However, using repeated motions and screenings to decide what needs to be done, almost all of these cases can have positive benefits from simple motion in one direction. Below is a picture of someone with terrible seated posture. Even if your posture isn’t this bad, prolonged time with even slight irregularities can cause these issues

To understand these tension headaches we need to know the following: Cervicogenic headaches originate from C1-2 in the spine, which in the above picture is about where the bottom of the man’s hairline is. As you can see, he is poking his head out which places increased stress on that area of the spine. C1-2 refer pain around the head in a pattern like the picture below:

In order to remedy this, we need to get that area of the spine moving. For headaches, we want what is known as upper cervical flexion to occur. For headaches, upper cervical flexion is effective approximately 66% of the time. Should it prove to be ineffective, other things can be done but for the sake of simplicity, we are only going to cover that motion at this time. Here is what upper cervical flexion looks like:

To effectively complete this motion, it is necessary to pull your head straight back as seen in the picture above. From there AND ONLY FROM THAT POSITION, pull your head downward with a grip on the crown of your head. Your head will not move more than a few centimeters at most if performed correctly. This should produce a stretching (possibly painful) sensation at the back base of your skull. 

Once this position is obtained, an individual should hold it for 2-3 minutes to reduce a headache. Most of the time, symptoms will temporarily increase during the positional hold and then decrease to less severe than they were before doing the motion. 

Another sign of progress is to note where the pain is. If symptoms move towards the back of your head from wherever they are (ex: pain behind the eyes moves to the top of the head) then that is considered progress. This is called centralization and can be easily imagined by rolling a ball of yarn (synonymous with pain, numbness/tingling, nasty things) up to its source (where the problem is; in this case C1-2). 

You cannot do this too much if you have a headache unless it causes lasting increases to the pain that you have for more than 5-10 minutes. Keep in mind that if you are sitting 8 hours a day, a 3 minutes stretch will not be enough to negate all of that time spent in that position. 

I used the term repeated motions earlier and I meant it! When I work with people often I will have them complete an initial repeated motion every hour or an hour and a half. You must be persistent! If the motion helps at all, keep at it until your headache starts to disappear. 

Frequently people will have more than just a headache; they will have neck pain accompany it. Oftentimes this motion can increase neck pain while decreasing headache; more is to come on that later but the short story is to pick one and address it until it gets better and then switch gears. Prioritize pain. This is one of the most difficult things to say as a physical therapist but due to the nature of the curvature of the spine, this particular method can have that effect on the neck. 

Neck Pain and Shoulder Pain

This section of the neck is separated from section one by a change in the curvature of the spine. Starting at C3, the cervical spine reverses its curvature entirely. This curve goes all the way down the spine until T12, which is in the lower part of your mid-back. A great deal of musculature controls this part of your spine. Remember that they are large and powerful, but joints are even stronger than these muscles. Instead of focusing overly on the musculature, most often individuals need to address joint stiffness of the spine through this entire region.

Pain that exists in between the shoulder blades often has an origin story in this part of the spine. Symptoms have a special way of referring itself to the mid-back. A great way to address this is through an exercise called cervical retraction; this has already been reviewed above but pays attention to the way the spine curves. The motion is backward from the upper cervical spine. Essentially, this gets all the joints of the spine moving together to allow the muscles to start working more efficiently. 

Here is the catch; to get the most bang for your buck out of this motion you need to have a block to your thoracic spine. Oftentimes I get people standing against a wall with a firm object, such as a foam roller, at their mid-back to allow for their head to move backward, towards the wall. This isolates movement in the cervical spine, making the exercise more effective. 

The problem with the opposite curves of the cervical spine is that sometimes people have multiple symptoms that respond in opposite ways. For example, if someone has headaches similar to what was discussed earlier and pain in the neck and shoulders, it is common for the remedy to one issue to exacerbate the other issue. 

Fortunately, with the cervical retraction exercise using a thoracic block, we tend to get alleviation of both issues. However, this often makes progress happen slower as we will not be able to be as forceful with issues. If this is your problem, I suggest you come in to see us even more strongly as guidance in the moment can be very powerful. 

I keep referencing this mythical retraction and thoracic block exercise and have described it, but have not given a picture yet. For the benefit of our lovely readers here is the exercise in question:

The only difference that I would have someone to do compared to this picture is to actively push their head back with their hand. Common hand rest places are on the jaw or, in the case of TMJ, on the hard part of your skull under your nose called the Maxilla. Ultimately, we are more effective than the internet. There, I said it. Not only that, but we are nicer too! 

Unlike WebMD, we aren’t going to tell you that you have cancer when you feel a slight sensation in the side of your neck. The little details are what can really make or break an exercise, so keep that in mind. 

There are exercises that we can use to address neck pain with more force, as this is not effective for some people. This is usually where we start as there is progression to exercises to ensure that we are providing the most effective and beneficial counters to pain. Doing an exercise and having pain while completing said exercise is generally considered to be accepted for these exercises under the condition that your symptoms return to baseline or better within 10 minutes.

For the purposes of this article we are not going to delve into those exercises as this is the most commonly beneficial for people. Given that there is an art to this approach, it is easy to get lost in the sequencing of knowing what to do and when to do it. 

The Thoracic Spine

The Thoracic spine, or “Jurassic spine” as a once favorite patient of mine called it, is a pesky beast. In the human body, the thoracic spine is a stiff column of 12 vertebrae where our ribs attach that supports our thorax; where our vital organs mostly find their squishy homes. There has been a very high correlation between thoracic spine issues and neck pain; so much so that in a physical therapy evaluation we are almost always going to also examine your thoracic spine when addressing a neck issue. Here is what one of the most common thoracic spine issues (kyphosis) looks like:

Does this look familiar to you? Previously we discussed curvature of the neck and the role it can play in headaches and neck pain. When analyzing this picture, go back to the neck pictures and see the similarities. I’ll pause and wait here, so go do it. If this was an instructional video I’d tell you to pause and review. Start scrolling. 

Right, now that you have compared pictures, can you see that the thoracic kyphosis puts the cervical spine in the same forward position that we linked to headache and neck pain earlier? Yes! While specific percentages of people with neck pain and poor thoracic posture are controversial, it is widely accepted that they are correlating factors. 

Throughout my career, I cannot remember someone with neck pain that did not have a thoracic role. Somewhere in the distance upon realizing this, I’m sure you could hear a maniacal laugh materialize from nothing. Fear not! There are things that we can do to address this. 

When looking at the picture above, most of us will see that we need to correct posture to improve the deficit. In the thoracic spine, this is commonly done with an extension (bending backward). The trick here is that when you do this standing you are usually moving through your lumbar spine as it is designed to be more flexible than our thoracic spine. Just like the cervical retraction and thoracic block exercise earlier, we need to be more targeted in our approach. Here are 2 ways that we can do this:

The first picture is representative of an easier exercise that is less forceful. When people come in with severe pain in the neck or into the back between the shoulder blades and spine, that tends to be where we start. Sitting and bending backward like that bends the spine into ways that are directly opposite of the various pictures that we have reviewed. To be clear, a spinal extension is not bad for you

The second picture illustrates a more powerful version of thoracic spine extension. It is important to move both your shoulders and your head up to help isolate thoracic motion. Many people can also feel lower back pain/tightness when completing this exercise. That is normal, as some cases of low back pain are actually referrals from the thoracic spine. Generally speaking, people can tolerate this well even though it is more forceful as the thoracic spine is a tough nut to crack. 

Summary: For Those of You Who Don’t Want Long-Winded Explanations

Here it is. If you want more, go read what I wrote earlier or come in to see us if you were already studious in your curiosity. 

  • Headache = Repeated or sustained upper cervical flexion
  • Neck and Shoulder Pain = Cervical retraction with a thoracic block
  • Shoulder and Mid Back pain = Thoracic Extension

I hope that this guide proves beneficial to you in these difficult times! If not, I am here to guide you along the way. Give us a call! (828)348-1780

Emerson Talbott, DPT

Sources:

Takasaki H, May S, Mechanical Diagnosis and Therapy has similar effects on pain and disability as wait and see and other approaches in people with neck pain: a systematic review., J Physio, 60(2):78-84, 2014

Donelson R, Mechanical Diagnosis and Therapy for Radiculopathy., Phys Med Rehabil Clin Nth Am, 22.75-89, 2011

Coeytaux R, Lallinger K, McBroom Brooks A, Sanders Schmidler G, Future Research Identification: Comparative Effectiveness of Nonsurgical Treatment for Cervical Disc and Neck pain, Patient-centred Outcomes Research Institute, October, 2015

Kjellman G, Oberg B:, A randomized clinical trial comparing general exercise, McKenzie treatment and a control group in patients with neck pain., J Rehabil Med, 34:183-190, 2001

Guzy G, Franczuk B, Krkowski A., A clinical trial comparing the McKenzie method and a complex rehabilitation program in patients with cervical derangement syndrome., J Orth Trauma Surg Rel Res, 2:32-38, 2011

Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH., Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain., Ann Int Med, 156:1-10, 2012

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