Upper Back and Neck Pain

Upper back and neck pain

Firstly, I want to be clear as to the type of problem we are talking about. This is an aching pain and muscular tension in the upper back and neck which is not due to a specific injury. It is most common in office and desk based workers and sometimes drivers who are sat in one position for extended periods.
If your neck pain is more severe such as a sharp, stabbing pain on movement or causes neural symptoms like tingling or numbness into the arms or hands then we recommend you seek medical attention. Similarly, if your neck pain has occurred after an initial injury or event such as a car accident or fall, we recommend visiting your Family Doctor or Physical Therapist.
As a sports physio, upper back and neck pain forms a large part of my workload. In fact, I would say that it is the most common problem I see. It is certainly far more common in my clinic than lower back problems, which may come as a surprise to many.
The reason for the vast majority of these problems is poor posture. This is especially true for those who spend their days sat at a desk. To fully understand why poor posture causes upper back and neck pain and how it should be treated, we need to understand the anatomy of the region.

Neck anatomy
When we refer to the neck we are talking about the cervical spine. This is the uppermost section of the spine which consists of 7 vertebrae, starting with C1 at the base of the skull, down to C7 which can be felt as the bony prominence at the base of the neck.
The main functions of the neck are to support the head and allow us to rotate, tilt and nod the head. The head is surprisingly heavy, weighing in at around 4-5Kg. Just holding this large, heavy orb on top of a relatively thin structure (the neck) is quite a challenge and places a lot of demands on our neck muscles.
There are many small muscles in the neck, deep and close to the spine. These help with small movements and stability. The larger muscles which we can see and feel tend to be the ones which we associate with being ‘tight’ and achey. These muscles almost act as guy ropes on the neck to hold the head upright. They attach to the bony areas around the shoulders such as the scapula and collar bones and course upwards to attach either to the upper C spine or the skull. Examples of these muscles include upper trapezius, levator scapulae, and sternocleidomastoid.
The muscles at the back of the neck are responsible for extending the neck and head (moving it backwards) and many also help rotate and tilt the head. The muscles at the front of the neck perform neck and head flexion (bending the neck forwards) and allow us to nod our heads. Several also help with rotation and tilting.

Poor posture
Poor posture is frequently blamed for numerous injuries and pain problems. I honestly believe there is no injury where this is truer than in the case of upper back and neck pain. In other injuries, there are often other factors and posture is just part of the problem (for example lower back pain). But in this case, it is often the sole issue.
So, what do we mean by poor posture? This is basically anything which varies from the ideal, perfect position. The most common problems for those desk based workers with upper back and neck pain include:

• Retracted scapulae – the shoulder blades tilt and move forwards around the back (away from the spine).
• Excess neck flexion – the neck is bent forwards, often due to straining to see a computer screen.
• Chin poke – this refers to the chin jutting forwards rather than being tucked in.
• Scapula elevation – the shoulders are lifted up, either due to the desk being too high, chair being low or stress causing us to hunch the shoulders.

What happens when these postural positions are maintained for any length of time is that the muscles responsible adapt to make this normal and to reduce the stress placed on them. Muscles in a shortened position (such as the chest muscles and upper fibres of trapezius) become more permanently shortened and ‘tight’. Muscles in a lengthened position often become weak and allow other muscles to do their job. Examples include the deep neck flexors and scapula stabilisors such as lower trapezius and serratus anterior
Neck pain starts to develop in response to certain muscle groups becoming tight and overworked. The most common examples include the upper Trapz, Levator scapulae, Rhomboids, Sternocleidomastoid and Scalenes. The position of the neck may also place stress on additional structures such as the ligaments which support the C spine.

Treatment mistakes
Many people will allow neck pain like this to linger on for a long, long time before they do anything about it. It may only be when other symptoms such as aching or weakness spreading into the arms or tingling in the finger tips develops that they decide enough is enough.
What most people will do is head straight for a massage and blame ‘stress’ for their neck pain. Whilst stress can be a contributing factor, it is rarely the only factor. A relaxing massage might help temporarily; a deep tissue or sports massage may have slightly longer benefits, but in both cases it doesn’t address the cause of the pain and so it will only return.
What both patients and therapists need to address is the muscle imbalances and postural issues which caused the muscle tension in the first place. There are some very simple but effective exercises which can be performed to help correct these imbalances.
Treatment methods such as massage and acupuncture can help to ease muscular tension and stress and contribute to correcting muscle imbalances and treating active trigger points. But they should not be the only form of treatment.

Education
The most important step in treating upper back and neck pain is to understand why you have this pain and what you are doing in order to try and correct it. When you understand this, it makes performing your exercises correctly and remembering about your postural corrections and desk set-up easier.
As touched on in part one, most of these neck pain conditions are due to posture issues and muscle imbalances. The most common scenario is that the patient has rounded shoulders caused by tight chest muscles and weak scapula stabilisors, as well as a forward position of the head, caused by weak deep neck flexors and tight posterior neck muscles.
Postural re-education refers to learning about good posture and applying this to your working position. Whilst simply learning the best position for you, and trying to hold this position may help to ease pain temporarily, it is difficult to do and it may result in different muscular aches and pains due to not correcting the muscle weaknesses responsible for the problem. A rehabilitation programme is needed to correct these imbalances.

Strengthening Exercises
As already established the muscle groups which are frequently weak are the scapula stabilisors (Serratus Anterior, lower Trapzius) and the deep neck flexors.
To strengthen the scapular muscles and improve their ability to hold the correct postural position, scapula setting exercises can be used:

1. Lie on the front with the arms by the sides and rested on the couch / floor.
2. If a breathing hole is not available, a pillow or rolled up towel should be placed under the forehead so that the head is facing straight down and the neck muscles can relax.
3. Keeping the neck and arms relaxed, pull the shoulder blades back and together as far as possible. Imagine trying to hold a pencil between the shoulder blades.
4. Ease off 50%, relaxing the shoulders back towards the resting position. At the halfway point, hold this position for 10 seconds.
5. Ensure the neck muscles stay relaxed throughout.
6. Rest and repeat 10 times.

This exercise can be progressed once it is not challenging. The next step is to lift just the hands up off the couch. After this becomes easy, the next step is to lift the whole arms up so they are hovering just an inch from the couch. This adds the weight of the arms into the equation.
To strengthen the deep neck flexor muscles:

1. Lie on the back with the knees bent.
2. Imagine a rod is passing straight through your skull, out of each of your ears.
3. Rotate the head, as if rotating around this rod, tucking the chin into the neck.
4. Rotate the skull using your hands (by your ears) for a physical cue if necessary.
5. Hold this position for 5 seconds.
6. Rest and repeat 10 times.

An additional challenge involves raising the head an inch off the floor once the chin is tucked in. Again hold this for 5 seconds, rest and repeat. Once mastered, this exercise can be performed in an upright position.
Stretching
Where some muscle groups are weak, their opposite (antagonist) group are tight. In most cases, this is the chest muscles (especially Pectoralis Minor) and the posterior neck muscles such as Trapezius and Levator Scapulae.

 Stretching the chest muscles

Stretching the chest muscles can be performed as described here:

1. Stand in a doorway, with the upper arm horizontal to the floor and the elbow bent to a right angle (like a stop signal!).
2. Place the front of the forearm against the doorframe.
3. Lean the body forwards and rotate the body away from the stretching arm, until a stretch is felt in the chest and front of the shoulder.
4. Hold for 20-30 seconds, rest and repeat.

To stretch the pec minor more specifically:

• Lie lengthways on a foam roller so the roller goes along the spine.
• Take one arm out to the side and allow it to relax down to the floor.
• Hold this position, whilst allowing the shoulder joints to drop down and towards the floor.
• A small weight such as a wrist or ankle weight or beanbag can be placed on the front of the shoulder to increase the stretch.
• Hold for 60 seconds and repeat on each arm.

To stretch the posterior neck muscles:

• Hold underneath your chair to anchor the shoulder down.
• Bring your chin down to the chest and then take the head over to the side, away from the anchored arm.
• You should feel a stretch between the neck and the shoulder joint.
• Hold for 20-30 seconds, rest and repeat 2-3 times on each side.

Postural Taping
Postural Taping can be used in the early stages of treatment to provide proprioceptive feedback about the position of a patient’s shoulders and thoracic spine. Taping tends to be applied from the shoulder blades, over the top of the shoulder to the front. The tape is applied whilst the patient is in an ‘ideal’ postural position with the scapulae retracted and depressed. If the patient strays from this position, the tape pulls on the skin and acts as a reminder.
Soft Tissue Therapy
In part one of this article we commented that many people’s initial response to this form of neck pain is to go for a massage. This can be helpful on a temporary basis when used alone, but if not combined with postural re-education the benefits will be short-lived.
That’s not to say that massage and other forms of soft tissue treatment should not be used. Registered Massage Therapy, trigger point therapy and acupuncture can be very helpful in reducing muscle tension, improving flexibility and de-activating trigger points in the traps, levator scapulae and chest muscles in particular. However, they should form only a small part of the treatment regimen.
Workspace Ergonomics
This refers to the set-up and positioning of your work space In most cases, this means the chair, desk, screen, keyboard, mouse and telephone. A poor set-up can be a major contributor to upper back and neck pain and to developing and establishing poor postures.
Professional ergonomists are often employed by large companies to ensure their staff have a good office workspace. As well as changing the positions and heights etc of workspace components, they may introduce new items such as wrist supports and foot rests.
Even if this is not normal company practice, if you think your desk set-up may be less than ideal, speak to your boss to see if it is possible to get a professional in to have a look. It may even save them money on sick pay for back pain in the long run!
Here are some key points to look out for:

• Make sure the height of your chair allows you to rest your forearms on the desk when your fingers are on the middle row of the keyboard.
• Your elbows should be supported by the arm rests and the wrists are straight (not arched upwards).
• Your elbows should be directly under your shoulders.
• Keep the mouse as close to you as possible whilst the elbow is supported on the arm rest.
• Use the hand and fingers to move the mouse, not the wrist or arm!
• The top of your computer monitor should be at eye level and directly in front of you.
• Good posture in the upper back and neck starts in the lower back! Ensure you sit with both feet on the floor, with the backs of the thighs on the chair seat and a natural lordotic curve in the lower back (i.e. not slumped).

In conclusion, the treatment approach for posture related upper back and neck pain should be multi-faceted. The main focus should be on correcting muscle imbalances through exercise rehabilitation and looking at desk set-up to address additional aggravators. Massage can play a role in treatment, but should not be used as the one and only form of therapy.