If you are to think logically about how the body needs to heal itself (because to be sure we do not “heal”), then you should be looking at a treatment order. If you accurately assess what structures are dysfunctional or not doing what they are designed to do, then you can apply the relevant techniques to return the structures to better function. It is effective to look at the nervous system first and then treat to correct muscle imbalance which can lead to joint capsular changes. However, if you are in the belief that the issue is nerve then joint as the primary problem then your treatment order will be mobilization first and the soft tissue secondarily and this is the views of chiropractic. Various techniques including muscle energy and myofascial release are amazingly effective in returning normal resting tone to both the superior and deeper muscles and try to include both strategies to the region of the head, neck and upper shoulders. Lastly, do not forget the power of the stretch to lock the structural alignment at the completion of your session; effective and long lasting and a reminder for your clients' to apply active and passive self-stretching through the day.
The anatomy of the neck is comprised of 7 cervical bones, various soft tissues and many nerves. These include the spinal cord with its exiting nerve complexes, one of the most affected soft tissue dysfunctions, being the Brachial Plexus. The cervical spine is both sturdy and amazingly flexible with the greatest range of movement of the entire spine. This is due due to the type of vertebrae, but also to the many muscles (via the tendons) that attach to the head, neck and upper body. These muscles run both superbly and deeply, twisting and attaching, according to relevance to any number of vertebrae, and / or the skull and the tiny muscles of the sub-occipital group that produce all of our smallest of head movements.
The area of the head and neck have always been of importance to the practitioner due to the volume of clients that come in complaining of a range of issues including neck pain and stiffness, to headaches in various areas of the skull.
With the complex and intricate nature of the region, and the many stresses and forces that can be placed on it through a trauma, gravity or simply active daily living, the cervical spine is at risk of developing a number of painful conditions. You see these broken down into two groups:
Acute neck pain , caused by:
- sprains of the ligaments,
- strains of the muscles which can occur due to positional awkwardness,
- prolonged static posture,
- sudden trauma to the head and neck or
- simply carrying heavy unilateral weight on the shoulder.
Chronic Neck Pain
By definition greater than 3 months, most commonly emanating from:
- The facet joints which often present with the same types of positional symptoms as a knee or elbow, this is due to their synvial makeup.
- Tears of the annulus fibrosus and leakage of the Nucleus Pulposus into the outer 1/3 or 2/3 of the fibrous rim which houses nerves fibers. (The Nucleus Pulposus contains inflammatory proteins that irritate the nerve fibers).
Often these two bony / joint conditions will cause the muscles in that vertebral region to spasm and reduce their normal length and motility.
What you see in the clinic
So the presenting picture of neck dysfunction is typically local pain in the neck which is commonly related to range of movement.
- Look for a head tilted, rotated or generally misaligned both with the client standing and sitting; is it coming from muscle spasm or facet joint sprain?
- Shoulder may be elevated if Levator Scapular or Upper Trapezius is involved Shoulder may be depressed if either the Latissimus Dorsi or the Lumbo-Sacral fascia is tight and shortened.
- A keen eye will see bony and soft tissue contours, evidence of ischemia in the upper limbs, changes to normal skin integrity including shininess, pallor, dryness, redness or swelling and facial expressions with certain movements.
What you hear in the clinic
This is as important as what you see – the complaints that are voiced by your clients are the things that are HIGH on their agenda and should be seen as their “wish list” of positive outcomes following the treatment. So this means that you need to communicate very effectively as to whether you believe that the pain is originating from the area they feel or whether it is a secondary dysfunction referring from a primary area elsewhere in the body.
- Acute neck pain with history of insult or mechanical overload generally means you can look at treating within the region to provide relief.
- The client complaining of chronic neck pain has more than likely many more regions to be considered in your treatment guidelines. The body will set up groups of synergistic muscles to take on the primary muscles' actions; left long enough, tertiary muscles will also be registered to aid in “normal” movement patterns.
- Headaches in the occipital, sub-occipital, frontal temporal or parietal regions, depending on the location, will depend on where the primary dysfunction originates.
What you test for in the clinic
So the effective therapist will look at each person entering their practice in the same fashion. By keeping your evaluations uniform you “practice” your skills often and this makes you very good at what you are looking for: feeling, hearing and sensing. You get quicker and do not miss warning signs and potential dangers that may require referring to a more suitable practicer.
Flexion, extension, lateral flexion right and left, rotation right and left done by the client let us look for quality and quantity of movements and reproduction of the pain that they are experiencing.
a) Increased pain, rotating or laterally flexing on the same side, indicating jamming of that side, and look for relief by focusing on the joints primarily, and soft tissue secondarily.
b) Increased pain rotating or later flexing on the opposite side indicators muscles, tendons and ligaments being our ultimate line of attack.
c) Increased pain going into expansion speaks joint, bony jamming, with the possibility of compression of the deep stabilizing muscles ie rotatores, multifidii, intertransversii, or possibly the larger posterior longitudinal ligament. Do not forget to see if the soft tissue of the front of the neck is reducing the movement; the Platysma can get super tight in some situations and the throat muscles such as the Infrahyoid group release well with treatment.
d) Increased pain going into flexion can be from the superior and / or deep muscles of the back of the neck and attachments to the shoulders. A taut posterior longitudinal ligament and any stiff facet joints can also produce pain in this movement.
Repeating the same movements is easier in the supine position and you can check the end feel of the passive movements, is there a capsular pattern suggesting joint conditions such as arthritis, bursitis, disc herniation, nerve impingement and / or facet joint dysfunction either of which may be forced in open or closed positions. Part of the passive movements' assessment is to garner information regarding the strength and stability of the ligaments within the neck. Assessing passive range and quality of motion takes in the anterior and posterior long ligaments and then each individual ligament which role is to fixate one bone and joint to the next.
These are often excluded due to time constraints but suggestions to any therapist worth their weight that if you have lots of positive symptoms from the previous tests then you should test for the strength of the neck muscles and the nerves that supply them. Myotome testing is used to confirm or refute serious nerve root impingement / lesions. Loss of strength in neck flexion = C1 and C2, lateral neck flexion = C3, shoulder elevation = C4, shoulder abduction = C5, elbow flexion & wrist extension = C6, elbow extension & wrist flexion = C7, thumb extension & ulnar deviation = C8 and abduction / adduction of hand intrinsics T1. Positive tests mean off to further tests from their chosen physician.
Once you have gone through the basics above you should have an idea of what kind of structures are damaged or in need of balance or alignment. This then leads you to assess further to get more information as to exactly where your focus should be and the order of treatment.
a) Vertebral artery test – tests for vertebral blood flow to the brain and will indicate how to position the head during treatments and for further investigation.
b) Compression or Spurlings Test – tests nerve root symptoms, facet joint sprain, osteophytes, stenosis, and disc herniation, and is best done in the seated position.
c) Distraction test – tests for nerve root and / or disc bulge, where the test reduces or removes the symptoms. Be sure to do this test in supine as, if it proves positive, then you can brace the neck and refer.
d) Shoulder abduction test – this is another positive test when pain symptoms are reducing or removed and occurs when the shoulder elevates and takes the stretch off the nerve root. This test is best done in closed position.
WHERE TO GO NEXT
Once you have gathered the necessary information and then cross referenced that there is no reason why you should not consent treatment, it is time to configure exactly the 'how' of the session to get best outcomes. In the second part of this article will look specifically on some common complaints and what techniques' and treatment order for best outcomes.