Understanding Chronic Neck and Shoulder Pain
Pain in the neck and shoulder areas can be caused by many different things, with some being more serious than others. It is important to make note of the symptoms and consult a physician if the pain is severe or persistent, to rule out any serious injury or disease. Causes of neck and shoulder pain can be the result of muscular pain, nerve pain, referred pain from your upper back, damage to the bones, joints, or connective tissues. Symptoms can be the result of a recent or past injury, or it may occur from the way you are sleeping or sitting. It is also common to feel referred pain in your shoulder from a neck injury or pain in the upper back from a shoulder injury. The pain may also be the result of a developing chronic condition. Any of these symptoms occurring for more than a few days should be looked at by a health professional with a view to preventing long-term damage. High pain levels can sometimes result in pain in the form of a headache. This occurs because the nerves in the neck become pinched and this pain is felt in the base of the skull and can travel over to the head.
Causes of Chronic Neck and Shoulder Pain
The most common culprit is the trapezius muscle whose job is to stabilize the shoulder blade, help move the shoulder blade, and support the arm. The trapezius attaches the neck and the shoulder, so when it is tight, it will refer pain into the neck and the shoulder. The Levator Scapulae muscle also refers pain into the neck and the base of the skull when it is tight. This muscle elevates the shoulder blade, and when the shoulder is chronically elevated, the muscle will be overworked and become tight. A common problem in computer workers and students. The scalenes will usually refer pain into the side of the neck and the rear of the neck and shoulder. When the scalenes are tight, the pain will often be felt somewhere else other than where the muscle is. An anterior head posture will cause these muscles to remain tight. The sternocleidomastoid muscles are responsible for rotating and tilting the head. When these movements are done with only a little resistance, the sternocleidomastoid will become short and tight, and it will refer pain at the base of the skull and into the rear neck. The pain is always felt in a general area where the muscle is located, and people often mix up SCM pain with TMJ dysfunction pain as it refers into the jaw joint.
Common Symptoms of Chronic Neck and Shoulder Pain
Symptoms of chronic neck and shoulder pain can vary and may include any combination of the following. In general, the painful, stiff neck primarily affects movement of the head and neck. Stiffness often has a gradual onset and resolves over time with the correct management. In some cases, the pain may be quite severe which can lead to secondary muscle spasm, usually in the surrounding shoulder muscle. Headache may occur from the neck pain. Usually, the pain is on one side more than the other, and the neck pain is usually contained to the one area and not spread down to the upper back or shoulder. Pain from the neck is usually a local pain, although in some cases the pain can radiate to the upper back or shoulder blade. A common symptom of chronic neck and shoulder pain is the presence of pain and restriction when using the arm, especially above shoulder height. This can affect simple activities such as changing light bulbs, washing hair and reaching into the back seat of the car. The pain referral pattern into the shoulder and sometimes the upper arm can be quite severe, which in turn can affect strength in the arm and hand. Pain and restriction in neck movement often leads to further irritation of the shoulder and upper arm. This is because the normal coordination between arm and scapula (shoulder blade) movement during arm activity becomes disrupted. This leads to abnormal shoulder blade movement and possible impingement of the tendons of the rotator cuff muscles, further perpetuating shoulder problems and arm pain. Global Ratings of Change. A patient may have problems with specific arm activities from the neck, but other arm problems such as tennis elbow or simply a painful wrist may not appear related to the neck condition. This is why it is important to take note if there is a decline in general upper limb function and not just assume that pain and limitation at the site of the problem is the only problem!
The Impact of Chronic Neck and Shoulder Pain on Daily Life
The physical impact of chronic neck and shoulder pain can be quite obvious and show itself in all aspects of life. The pain is an extremely discomforting phenomenon which can be an unpleasant reminder every time one tries to move. Some people may end up trying to move less in an attempt to not aggravate the all too familiar sharp sensations. The lesser that the area is moved, the stiffer it can become, and this leads to even more discomfort. Posture changes can be a common side effect, which in turn can create other problems in the back area. The body is very adaptable and over time it will find new ways to perform tasks to achieve them with least discomfort. Unfortunately, this may involve muscle overuse in other areas, which can lead to different types of referred pain. Over an extended period, chronic neck and shoulder pain can be responsible for chronic headaches. This occurs as the area at the base of the head and upper neck spreads tension up to the bottom of the skull. This type of headache, known as tension headaches, can often be attributed to the least obvious and forgotten kind of pain, and many will be able to relieve these headaches by curing the chronic neck and shoulder problem.
Non-Medical Approaches for Neck and Shoulder Pain Relief
Posture is the position in which you hold your body upright against gravity while standing, sitting or lying down. Good posture involves training your body to stand, walk, sit and lie in positions where the least strain is placed on supporting muscles and ligaments during movement or weight-bearing activities. Correct posture in both standing and sitting can be a preventative measure in avoiding neck and shoulder pain. Positions and supporting furniture are what you should focus on. When sitting, there should be a small arch in your lower back, this can be facilitated by using a small pillow or lumbar roll in the curve of your back. Your knees should be level with your hips, with your feet slightly elevated. When standing, aim for a similar position and use straps or a backpack when carrying heavy objects. The idea is to avoid positions where your body is not being supported by its frame (e.g. slumping or slouching). A conscious effort is required to break poor habits and to remember to maintain good posture. Over time, it will become habitual and will not cause discomfort during maintenance.
Stretching and strengthening exercises are the most widespread non-medical approach for relief of neck and shoulder pain. Neck muscles can develop trigger points (commonly known as muscle knots) that lead to referred pain around the shoulder and shoulder blade. There are specific exercises to ease the pain and prevent the pain from returning. Stretching the neck muscles is typically part of a treatment program. The best way to do this is by tucking your chin the whole way in and looking down. You can then apply pressure by placing your hand on your head to increase the stretch. Studies have shown that simply stretching the muscles of the neck can be a successful way to lessen certain types of neck pain. Stretching and strengthening programs are best done with the recommendations of a health professional to ensure they are specific to your neck problem and that you do not cause any further damage.
Stretching and Strengthening Exercises
The first step is to stretch the tight muscles around your neck and shoulders. This can often be quite uncomfortable as when muscles are in spasm they do not ‘like’ being lengthened. However, stretching should be done slowly and pain should settle after the stretch is held for a few seconds. Always make sure you adopt a good posture when stretching, as slouching can cause muscle imbalances and make the pain worse. The best way to stretch the neck is to bend your head forward, sideways and backwards when sitting or standing in an upright position. These stretches can be done 10-15 times in each position as long as the pain does not increase. It is important to be careful when stretching the neck backwards as it can sometimes exacerbate pain if there are significant degenerative changes in the neck.
These exercises aim to stretch and strengthen the muscles around the neck and shoulder area, eventually reducing the amount of work these muscles need to do during activity. This should in turn reduce fatigue in the muscles and may reduce the frequency or severity of bouts of pain. It should be noted that it is recommended to commence these exercises gently and gradually build up over a period of weeks to a point where they are of some therapeutic benefit. This will protect against exacerbating symptoms in the short-term and making pain worse. It is also recommended to apply heat to the neck before exercising as this will loosen the muscles and make the exercises more effective.
Posture Correction Techniques
Sit in a chair at your school with your back resting against the back support. Are your feet flat on the floor? Aha! You probably didn’t realize that your posture is affecting the level of pain or dysfunction in your neck and shoulders every day. Poor postural habits change the anatomical stresses on your neck and shoulders and can lead to muscle imbalances, trigger points, and increased load on spinal discs and joints. Regression of posture is slow and occurs over the span of many years; yet how often do you catch yourself with your head poked forward and shoulders rounded? These upper crossed syndrome-like postures are a forward head with rounded shoulder posture and are becoming a common sight, giving people that aged look long before their time. By consistently practicing ideal postural control, you can prevent further aggravation to structures in your neck and shoulders and reduce the probability of developing osteoporosis or a kyphotic spinal posture in older age. But how can one recognize ideal posture and what type of exercises are best for postural control? Well, if a picture is worth a thousand words, then a Posture Picture is the place to start. This is where you have a visual of your static posture. Stand with your back against a wall with your feet 3 inches away from the wall. Your glutes, upper back, and head should all be in contact with the wall but try not to force it. There should be a small curve in your lumbar spine and a very slight forward curve of your neck. Now you know what you should be aiming for.
Heat and Cold Therapy for Pain Relief
Injuries usually heal within a six-week period, and heat is best used for chronic pain or injury. Heat may be used prior to exercise to improve the elastic properties of joint ligaments and to reduce the potential for re-injury. Heat pack, warm shower, or hydrocollator treatments are the most beneficial. Heat should not be used after activity, and should not be used where swelling is involved. Cold pack applications are best used for acute injuries, which occur when swelling is present. The cold pack will reduce blood flow to the area, which will reduce the amount of inflammation and swelling. It will also reduce pain by acting as a local anesthetic and by slowing down the velocity of nerve impulses. Cold packs are usually baggies filled with ice, or commercial cold packs that can be stored in a freezer. A towel should be wrapped around the ice pack and should never be applied to the area for more than 15-20 minutes, to avoid frostbite to the skin and underlying tissues. Icing should be used 3-5 times a day during the first 72 hours after the injury occurs, or until the swelling has subsided. A note of caution when using heat and cold therapeutics-be sure to read all directions and be aware of preexisting contraindications before use. High blood pressure, diabetes, vascular diseases, deep vein thrombosis, open wounds, or dermatological infections are just a few examples of conditions that may conflict with heat or cold therapy treatments. In these cases, it is best to consult a physician or physical therapist before using these treatments on your own.
Medical Treatments for Chronic Neck and Shoulder Pain
As we discussed earlier, chronic pain is usually due to tissue damage and inflammation. Therefore, most types of chronic neck and shoulder pain relief require some form of medical treatment in order to get long-term relief. I highly encourage you to make an appointment with your doctor to discuss your symptoms. Be informed on how long the treatment course will be and what you can expect in terms of relief. Ensure that the doctor knows that you only want the minimal doses for sufficient relief. You can usually tell if the doctor is unsure of the diagnosis or what the best treatment is if he/she is quick to recommend surgery or a quick fix. In this situation, it would be wise to get a second opinion from a doctor of medicine or osteopathy. Now, here are some different types of treatment and a brief description of each.
Over-the-Counter Pain Medications
Over-the-counter (OTC) medications are commonly used for relieving the pain and enhancing function in individuals with neck and shoulder pain. The most commonly used analgesic medications are acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen. These medications have been shown to be effective both for relieving pain and improving function in patients with various kinds of musculoskeletal pain. Acetaminophen is generally considered to be the first-line analgesic and is effective in reducing pain and inflammation at a cost of less than ten cents per dose. Ibuprofen and other NSAIDs inhibit the body’s natural production of prostaglandins, which are chemicals that promote inflammation. By reducing the production of prostaglandins, patients may then experience reduced pain and inflammation. A prescription is not required to obtain these medications, and for those with chronic neck and shoulder pain, long-term use (i.e., several weeks to months) has proven to be safe and effective. Lengthy use of NSAIDs may cause gastric irritation or ulcer, and in such cases, discontinuation of the medication will result in resolution of the symptoms. This, however, is not a reason to avoid these medications for pain relief. In recent years, newer types of NSAIDs have been developed which are less likely to cause gastric irritation or ulcer. High selective COX-2 inhibitors inhibit a specific enzyme involved in the production of prostaglandins and therefore pose minimal risk to the gastrointestinal tract. Although they are more expensive, this may be an alternative for patients who have gastric side effects from traditional NSAIDs.
Prescription Medications for Pain Management
The tricyclic, or older style, antidepressants are often used for chronic pain. Amitriptyline is the most commonly prescribed tricyclic for neck and shoulder pain because it is effective and relatively sedating. These medications are taken at bedtime and can cause morning drowsiness. Like gabapentin and pregabalin, tricyclic medications can take a few weeks to have an effect on pain. Narcotic pain medications should be reserved for severe unrelenting pain because of the potential for addiction and abuse. These medications are best used for short time periods after specific painful episodes or surgeries. Chronic use of narcotics is generally not recommended for treatment of chronic neck and shoulder pain due to the potential for long-term side effects and addiction.
Muscle relaxant medications such as cyclobenzaprine (Flexeril) and tizanidine (Zanaflex) are used to alleviate the muscle spasms which are often the cause of neck and shoulder pain. Both medications can cause drowsiness and dizziness, and should not be taken with alcohol or by individuals with a history of liver disease. Anti-seizure medications such as gabapentin (Neurontin) and pregabalin (Lyrica) are used primarily to treat conditions that involve chronic pain. Although these medications are not effective for all individuals, they can be highly effective in some cases for pain and radiating symptoms into the arms. Side effects can include dizziness, sleepiness, and weight gain. This class of medications often has to be built up in the system over a few weeks before any effect is noticed.
Acetaminophen and non-steroidal anti-inflammatory agents are often not enough to control severe neck and shoulder pain. If you are suffering from persistent pain and inflammation despite taking over-the-counter medications, prescription drugs may be the next step in seeking relief. Several different classes of medications are used to relieve neck and shoulder pain by acting on the brain and spinal cord. They range from muscle relaxants and anti-seizure agents to tricyclic and narcotic pain killers.
Physical Therapy and Massage Therapy
Mention physical therapy and most of us cringe. Bad experiences in high school gym classes or on the football field have led to the belief that physical therapy is usually painful, hard work, and not much fun. That is not the case with modern physical therapy. Physical therapy “is based in both art and science.” The art of physical therapy utilizes a variety of procedures such as manual therapy and massage to relieve pain, and the science uses researched techniques proven to be effective. The physical therapist will perform a thorough evaluation of your posture, mobility, strength, flexibility, and functional ability to determine the cause of your pain and the best approach to relieving it. Treatment techniques they use can include: manual therapy, massage, specific exercises, posture training, mobilization, and other modalities such as ultrasound and electrical stimulation. Physical therapy has been shown to be effective in the treatment of neck and shoulder pain. One recent study showed that patients with chronic neck pain who received physical therapy reported significant improvement in pain, as well as improvement in the ability to perform everyday activities and improved quality of life. The study concluded that physical therapy was cost effective and provided positive outcomes in managing chronic neck pain. Believe it or not, massage has been shown to be effective in the treatment of chronic neck and shoulder pain. Most of us desire a good massage; however, it is commonly thought of as a luxury, and not a viable treatment option. Massage therapy is a broad and varied field. It can range from a light relaxation massage, to a deep tissue massage, to a targeted clinical massage. Massage therapists are trained to become experts of the human body and its movement. They understand the physiology of muscle and the factors causing pain. During a massage you can expect the therapist to use various techniques to manipulate your soft tissue, which can increase blood flow, increase flexibility of tissue, break up scar tissue, and promote relaxation of the nervous system. This will lead to decreased pain and improved function. Deep tissue massage has been shown to be more effective in the treatment of chronic musculoskeletal pain than NSAIDs or other medications. A recent study showed that patients receiving a one-hour session of deep tissue massage reported a significant decrease in pain and improvement in function in comparison to patients receiving medication management. This is a sign that perhaps we rely too heavily on pills to solve our pain problems. Furthermore, massage is a safe treatment with very low risk, and has a good track record of providing positive outcomes for various conditions.
Injection Therapies for Targeted Pain Relief
Corticosteroid injections are used to reduce inflammation and offer pain relief. It is important to note that steroids are used to reduce inflammation, not pain. Steroids are generally advised in the epidural space, that is the space around the covering of the spinal cord and nerve roots. The injection has to be placed as close to the target pain generating structure. These are 2 important points to remember as disparity between technique or target area can result in increased pain and an unsuccessful injection. Corticosteroid injections are more successful for arm pain or neck and arm pain than for neck alone. This is also a useful test to see if the primary pain generator is coming from the neck or actually the upper limbs. Corticosteroid injections do have side effects and are not supported for long-term use. They may provide pain relief from 1 week to a year. It is important to weigh out the potential short term gains with the reality they may not be a long-term fix and consider the benefits of other therapies in particular; manual therapy and exercise. The long-term use of steroids has been shown to be detrimental to soft tissue in a laboratory setting. This doesn’t rule out a repeat injection in the future and should not discount an initially positive result. The benefits of injections in particularly local anaesthetic or blocks can be a useful tool in symptom management and classify the pain generating area. This too can be a useful test for a potential surgery. Though it is advised not to rush to a decision for surgery following a positive injection, take time to analyse the efficacy of therapy post injection and the prognosis of the condition. This will be discussed in a later article on surgery types, the prognosis of surgery for neck pain and potential analysis of clinical scenario.
Lifestyle Changes for Long-Term Neck and Shoulder Pain Relief
There are several relaxation techniques, including breathing exercises, progressive muscle relaxation, and visualization methods. These all require some practice and usually work best in a quiet environment. Try to get a massage when you are particularly tense. It can provide immediate stress relief and a lasting sense of well-being.
There are several methods to manage stress, but most require altering some aspect of one’s life. Identify the source of stress and try to avoid it. Learn to say no. Avoid people who stress you out.
Stress management techniques Stress is a reaction to a stimulus that disturbs our physical or mental equilibrium. A stressful event can cause the muscles to tense, and if they are not released, muscle tension can lead to pain and muscle spasm.
Ergonomic adjustment on work and home The goal of ergonomics is to lessen muscle fatigue, increase productivity, and reduce the number and severity of work-related MSDs. It is important to maintain the normal curve of the cervical spine to prevent increased loading and eventual early degeneration. Sit all the way back in your chair. Use a small pillow or towel roll to support the low back if needed. A footrest can help to reduce the load on the low back. Do not sit with your legs crossed. Keep your feet flat on the floor. There should be 2 inches between the front edge of the seat and the back of your knees. Shoulders should be relaxed and elbows should be supported and close to the body. Use an ergonomic chair and change the sitting angles occasionally. If you sit at a computer, try to keep the monitor at eye level. Use document holders when using paper. Avoid cradling the phone between the neck and shoulder.
Ergonomic Adjustments at Work and Home
The optimal posture is a comfortable, relaxed position that puts the least amount of stress on the joints. This is the position where the joints are aligned. Balanced or neutral posture is the most comfortable and least stressful on the spinal column. All static postures become fatiguing and painful. Change posture and shift positions at least every 20 minutes. Time spent in any one posture or position should be minimized.
If you use a computer or desk frequently, specifically identify tasks that cause pain, where pain occurs, and what tools are currently used. This assessment will help you identify which ergonomic recommendations are right for you. After identifying the tasks to be modified, we need to modify the elements of the workstation to user height and reach distances, recommend more neutral postures, and reduce repetition. When choosing new products, make sure they match the specifics of the task they are used for. No one product is right for everyone. For each product, a guideline is listed, but it is best to choose the one that best fits and feels right for you.
The goal of ergonomic adjustment is to modify the environment of your work to suit your individual needs. Ergonomics seeks to reduce strain and minimize the occurrence of injuries. Directing your environment can mean adding equipment, revising the tool, or changing the way a tool is used. Ergonomic adjustment is expensive, time-consuming, and sometimes frustrating. However, the right ergonomic adjustment is an investment in your health that will reduce pain and prevent further injury. It is suggested that you start in the office environment with relatively detailed, low-cost equipment and make gradual changes to more expensive equipment.
Stress Management Techniques
When looking at the cycle of chronic neck and shoulder pain, stress can be a major factor. Considering that pain causes stress and stress can cause more muscle tension and pain, it is important to break this cycle. By developing stress management techniques, you can reduce your current levels of stress and manage stress as it comes in the future. This will be beneficial for your neck and shoulder pain as well as for your overall health and wellbeing. Some of the stress management techniques that may be helpful include meditation, deep breathing, and laughter. Meditation can serve as a way to consciously relax your mind and body. When practicing meditation, it’s good to set aside 15-20 minutes in a quiet space and try to let your mind go blank. Focusing on a single word and releasing all thought can help. If your mind does start to wander, just refocus on the word. Try to avoid problem solving or thinking about things that cause stress. This may be difficult at first, and take time to practice. But studies have shown the benefits of meditation for pain reduction. Deep breathing may be useful as a way to relax and also as a practice with meditation. Taking slow deep breaths can help to relax the body and mind, and by practicing deep breathing at multiple times during the day and when you’re under stress, you may develop a habit of breathing more from your diaphragm, which is optimal. Laughing is an excellent way to relieve stress and provides a number of physiological benefits such as relaxation and an increased pain threshold. So try to find a good comedy and laugh your pain away.
Sleep and Pillow Support for Neck Pain
Back sleeping is the best way to rest the neck, however only a small percentage of people sleep this way. Most of us choose to sleep on our sides or our stomachs. It is not realistic to think that we can change our habits, nor should we make an attempt to. However, it is possible to affect change as to the way that we position our necks during sleep which can be of great benefit. When sleeping on our sides, the goal is to keep the neck as straight as possible in line with the thoracic spine. In this position, a relatively thick pillow is needed to fill the gap between the head and mattress thus allowing the neck to remain in a neutral position. An additional thin pillow should be used, placed between the knees to reduce torque on the lower spine. As aforementioned, the goal of offloading the lower spine is to be able to allocate more of the sitting and standing time of the following day towards the active use of the spinal muscles. When sleeping on our stomachs, the best support for the neck is no support at all. This is because the head should be facing down in a sideways position and using a pillow will force the head upwards. If one is able to change their habit and prop on two elbows reading a book before falling asleep in this position, it is likely that the habit will be broken because this is an effortful way to rest and those who are persistent will likely fall asleep in their more traditional side or back lying positions!
When trying to alleviate neck pain, it is very important to pay attention to the way that we sleep as we spend a third of our lives in bed. Understanding that our necks need to be properly supported while we are asleep is an important step towards correcting the well-established biomechanical and postural imbalances that are primary contributors to chronic neck problems. In the cervical and upper thoracic areas, the spine curves slightly toward the front of the body. When we are standing up or sitting during the day, the normal inward curve of the neck is supported as well as balanced by the strength of the neck muscles and the support of the shoulder girdle. When we lie down to rest, the neck now requires a supportive surface that is both comfortable and consistent with that of good standing posture. Failure to provide such support will lead to morning stiffness and pain, and over a long enough period of time, it contributes to the acceleration of spine degeneration (occurrence of osteoarthritis, disc thinning, and possibility of disc herniation). Note that the effects of poor support are often delayed until mid-age or later, and by then it is difficult to re-establish a healthy neck.
