Neck and Upper Back Pain
Computer screen time and the use of handheld phones has made upper back and neck pain a common finding. Acute pain can be related to a new activity (such as a new computer work station) or from a trauma such as a motor vehicle induced whiplash. Chronic neck strain can lead to secondary problems including headaches and decreased chest expansion which may influence asthma or mimic angina. Treating these regions is easy and effective.
History
Work
Activity
Recent trauma (such as motor vehicle accident)
Differential Diagnosis
Osteoarthritis of the cervical spine
Locked facet joint
Whiplash
Shoulder/rotator cuff: subscapularis or supraspinatus dysfunction (impingement syndrome) can cause referred pain to the neck region
Muscle spasm/torticollis
Overuse
Alert: Left-sided symptoms need to be carefully evaluated for cardiac risk factors (including hypertension, hyperlipidemia, age older than 55 years, tobacco abuse, family history of early heart disease) and to rule out angina.Physical Examination
Postural Assessment
Assessment can be done in sitting or standing position.
Determine the position of the head: neutral/forward/retracted and what position lessens symptoms.
Try to get the patient back to neutral or normal posture.
Neck and Shoulder Range of Motion
Have the patient move the neck to full flexion, extension, and side bending. Look for decreased range of motion (ROM).
Have the patient move the both into forward flexion, extension, abduction. Look for muscle asymmetry and substitution to determine if the shoulder is the source of neck symptoms.
If shoulder ROM is asymmetrical, perform more extensive shoulder assessment.
Empty Can, Neer, Hawkins tests for impingement
Apprehension testing for joint laxity
Special Tests
Cervical CompressionPain with compression may imply conditions such as herniated nucleus pulposus, facet arthropathy, and degenerative joint disease/osteoarthritis.
Have patient in neutral. Place your interlocked fingers over the head.
Use your body weight to gently push down, asking the patient if this action reproduces their symptoms, implying referred pain to the affected upper trapezius and arm.
Spurling Test
With the patient sitting, rotate the head toward the affected side and mildly side bend it toward the same side, then provide downward compression.
If this maneuver reproduces symptoms, nerve impingement is likely.
Cervical DistractionSitting
Place your hands on each side of the neck with your index fingers under the mandible and lift up.
A decrease in symptoms implies nerve impingement from HNP.
Supine
Place your hands under the occiput and on the forehead and pull caudally.
A decrease in symptoms implies nerve impingement from HNP.
Treatments
Remember the Rules
1. Move to a position of less pain
2. Stretch the SHORTENED muscle
3. Treat the region (above and below pain)
4. Tape to support neutral position
5. Support definitive treatment (physical therapy, orthopedics, neurosurgery)
Postural Correction
Gently move the patient to neutral and relax.
Then have the patient attempt to correct posture on his or her own.
Mobilization
Stretching Strap or Towel
The goal is to find the level that enables more motion with less pain.
Place a towel or strap over the point of maximal tenderness and move through ROM, then above and below that point.
Apply anterior pressure with the strap or towel.
Moving your hands in coordination with the head, move the head through ROM: flexion (forward) and extension (backward) and side bending for 10 repetitions.
Chin Tuck
Place a rolled towel under the chin and gently press the jaw down into the towel. Relax and repeat.
Reposition head and towel slightly to find best pain-relieving position.
Manual Therapy
Anterior Neck and Upper Back
With the patient supine, have the patient put the uninvolved hand on their sternum and place your hand on top of the patient’s hand.
Place your other hand on the side of the patient’s head.
Rotate the head away from affected side to end point (furthest motion before causing pain, muscle guarding, or spasm).
Hold the head and sternum while the patient attempts to turn their head back to the midline with 10% effort for three belly breaths.
As the patient relaxes, turn the head further away from the side of discomfort by taking up the slack; then repeat for a total of three cycles.
Lateral Neck and Trapezius
Have the patient side bend the neck away from the involved side and move the involved shoulder inferiorly.
With one hand, hold the head in place. Cross your arms and with your other hand, hold the shoulder down.
Ask the patient to move the ear toward the shoulder with 10% effort against resistance while taking three belly breaths, then relax.
Move the head and shoulder further apart. Repeat for total of three cycles.
Levator Scapulae
With the patient standing, move the involved arm posteriorly and medially.
Ask the patient to side flex the neck away from the involved side, rotate away from the affected side, and forward flex the neck to the end point (like trying to “look at your hip”).
Ask the patient to hold their head in place with the uninvolved hand.
Place your hand on the involved shoulder to stabilize.
Have the patient try to bring the ear toward the involved shoulder with 10% effort while taking three belly breaths. Then relax.
Take up the slack in the neck and repeat these steps for a total of three cycles.
Medial Upper Back: Rhomboids
Have the patient lie on the unaffected side with the hips and knees bent 90 degrees.
Place your arm under the axilla.
Reach across and grasp the medial border of the scapula with both hands.
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