Cervical spine pain is pretty common. Most of the time, it seems like we only see these patients when their symptoms progress to the point where they are having radiculopathy and loss of strength or sensation down their arm.
But what do you do with the younger person who seems to have the beginning of cervical issues? Here are our thoughts.
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#AskMikeReinold Episode 338: Strategies for Cervical Spine Pain
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Show Notes
• Integrating Upper Cervical Flexion with Postural Exercises
• Epicondylitis and Cervical Radiculopathy
Transcript
Sean Riley:
All right, so Kate from Mississippi asks, “As I get started in my career, I’ve seen many people in their thirties and forties with mild sub-cervical pain, not the advanced patient that I learned about in school with radicular symptoms down the arm, weakness, and numbness or tingling, but more just neck pain, sometimes with occasional pain moving down to the back of the shoulder. Is this the beginning of it getting worse? How do you help these types of patients?”
Mike Reinold:
Awesome. Great job, Sean. I love it. Kate, good question. I actually love this question. You know why I love this question? PT is changing, right? Call me crazy, but I feel like, if we look back 10, 20, 30 years ago with cervical pain, we saw people that were messed up. People would wait forever to come, until they’re like, “Yeah, I don’t know why I just can’t hold a can in my hand anymore.” And then, you have to take a huge step back and say like, “Well, all right, it’s kind of too late, buddy, but we’ll go from there.” But we’re actually starting to see humans, our society is trying to take care of themselves a little bit more. And I think they notice things better, like subtle changes things or subtle discomfort. They notice them better and they want to address them right away. So it’s actually awesome that we’re seeing that.
So it’s funny, I like the way Kate said this, because when you learn about cervical issues in school, it’s usually the ones like, all right, they have pain, they have numbness, tingling, they have weakness somewhere, that type of thing. But how many times do you see somebody with neck pain and you wonder to yourself, “Gosh, is this the beginning? In five years, if this person doesn’t do anything, will this now be a loss of grip strength and that sort of thing? And do we have an opportunity to jump in and actually make a difference in this person?”
So for me, I think that’s pretty interesting. Dan, I know you do a lot of neck training yourself, heavy isometrics with BFR on your neck. Sorry, that wasn’t good. What is your summary of thoughts here? Because I feel like, of all the PTs probably in our clinic, you’re seeing the most of these people that are having these subtle cervical issues early on. And I know, in your head, you’re thinking like, “All right, this is the beginning.” What do you do? What are your strategies with these people?
Dan Pope:
Yeah, I think these are pretty tough for a variety of reasons. I’ll get into that in a minute. But I would treat it like any other area of the body. I think, first and foremost, you just need to do a good job diagnostically because there are a few things within the neck that are probably treated a bit differently. So you could be dealing with your garden variety neck pain, but if you have pain that’s radiating into the shoulder blade region, that could be radicular pain and it might not be a radiculopathy. So radicular pain is basically pain coming from the nerve root. Radiculopathy would be associated weakness or sensory changes. So you might not actually have that going on, but that pain certainly could be coming from that nerve root. You also could be dealing with some sort of brachial plexopathy. Thoracic outlet is another big one right in that region.
And a lot of those are treated differently. And the other thing I will say is that, if they fail conservative treatment, oftentimes, the next step’s a little different. So we have local docs that do BOTOX injections in the scalenes for thoracic outlet, which is really nice. Epidural is sometimes nice for someone who has a disc herniation within the cervical spine. So I think a lot of it is getting a really good diagnosis first. With any injury, you’re probably trying to offload the things early on that give folks a lot of issues. So if certain postures feel god awful, we’re probably avoiding them temporarily. From an exercise standpoint, we want to push a lot of good exercise. It feels great. A lot of patient education, just to keep them moving as much as possible. So largely, I think, that the neck, and I say this a lot on social media, is something that we tend to treat differently than other joints.
A good example is like, let’s say that you have some sort of pain at your knee joint. We’re oftentimes strengthening on the musculature around there. With a neck, we’re often very cautious. We’re afraid to move it. We don’t want to load it very much. This is my own personal opinion, but I think a lot of folks probably need to load the neck a little bit more. I do some jiu jitsu. We work with contact athletes. These guys need to use their neck, so we probably can be a little bit more intense with those folks. For the average librarian, maybe you don’t need that so much, but what I will say, with the neck and the low back, and particularly compared to a lot of other areas, it’s more so an issue here, I think, is probably some of the psychosocial elements. Things like anxiety and depression, stress.
I read a study back in JOSP years ago where they gave patients intense cognitive tasks and the EMG of the neck musculature goes up. So folks are really stressed out, they have anxiety, they have depression, it’s probably going to play a role with their pain. And if you look at some of these studies, they’re really interesting. On the neck, what correlates with the onset of neck pain? It’s things like anxiety, depression, commute time, how much autonomy you feel like you have at work. So it’s very much something that’s related to some of these psychosocial issues.
So if you’re not screening out for some of these yellow flag things, you probably should. And I think the other element that’s really hard is that, even if you screen them out and even if these folks do go on to get some help, I think, oftentimes, our interventions aren’t great and their pain just lingers. And that’s just an issue that we deal with as physical therapists. So unlike, let’s say, a tendinopathy or strain issue, where I think we have a straightforward plan, for these folks, it’s not as straightforward and it’s going to be a little more complex, depending on the person.
Mike Reinold:
I really like that answer, Dan. And it’s funny, you have somebody with cervical pain, we tend to do the opposite of a lot of joints. We tend to guard, we tend to immobilize, we tend to say, “Oh, I want to move my neck less,” which almost always seems to backfire in this population with me. It’s you stop moving, then you get this weird spasticity, almost like this tension, this muscle tone, that you get, this guarding with that, which then makes you feel worse, which then gives you more anxiety about the whole situation, which makes you move less, blah, blah, blah, right? It’s an amazing approach. So Dan, how do you differentiate with somebody though that’s like, is it just muscular versus something more cervical? So maybe stenosis, like you said, a nerve root or a disc issue type thing. Is there anything you differentiate? Or does it even matter? Do you just treat them kind of all in the same bucket with the same treatment style?
Dan Pope:
It is just kind of interesting, because if you look at something like cervical radiculopathy and you look at the treatments for cervical radiculopathy and you look at the treatments for, let’s say, standard neck pain, it’s actually pretty similar. So to answer that question, it probably doesn’t matter too much. But like I said, if you have someone that has symptoms that aren’t getting better and they need next steps… If someone has, let’s say, a plexopathy or TOS, like the treatment’s going to be a little bit different. If they do have a true disc herniation causing their symptoms, then they probably will benefit from something like an epidural. So I think that’s probably going to be important. The other kind of giveaway for folks that are having neurological issues is usually numbness and tingling, although that’s not always present. And then, I just did a lot of research on good special tests for radicular issues.
So an upper limb neural tension test is going to be one of the most sensitive and specific. Checking dermatomes and myotomes is going to be another one, right? Certainly do that. You have the Wainner Cluster, where they’re looking at like a Spurling’s test, but I think the big thing is that you’re trying to rule in more of these neurological issues. Basically, your symptoms are going to be a little bit different. So you have a little tightness within the neck, that’s different than having weakness down the arm or having some sort of numbness, tingling, abnormal sensation that’s worsened with certain positions in the neck too. So I think that’s how you differentiate between those two. But at the end of the day, the treatment might be very similar, but eventually, it might be a bit different if they fail conservative treatment.
Mike Reinold:
That makes sense. I like that. Good explanation of that. So it sounds like, from Dan’s perspective, and I agree here, a lot of these people need to move and they need to load more. And that’s just something that we’re probably not doing with a lot of these people. So I want to throw this to our strength coaches then a little bit for their thoughts here. Because you guys work with a lot of clients, both athletes as well as our adult fitness clients, that probably have some neck discomfort, some pain here and there, that you guys have to program around, that you have to do some things. What are some strategies that you do in your programming with somebody with some neck restrictions and mobility or pain or discomfort? Because a lot of times, I think you’re probably the front line for these people that see it and then, you’re the one referring them to PT, sometimes, because they don’t even think it’s a big issue at first. But what are some thoughts? Diwesh, you want to start?
Diwesh Poudyal:
Yeah, so I like how Dan said that it’s garden variety neck pain. That’s probably the type of person that we tend to see, where they’re like, “Oh, I woke up. I slept wrong and my neck hurts.” Something like that. Our first thing that we tend to do is get them to feel still pretty confident that nothing catastrophic is happening, especially if they are telling you, “Hey, I think I slept funny and I woke up with a little bit of neck pain.” So we want to get them to feel like they can still accomplish a lot in the gym and try to go through a pretty close to a full workout, as long as it’s not irritating the neck any further, and really prioritize a lot of general blood flow, a lot of good general movement and joints around the neck. We’re talking, “let’s get the T-spine moving a little bit more.”
Let’s got the shoulders moving a little bit more. Even the lower body, just getting general blood flowing. It’s probably going to make them, in general, feel good and feel like they’re not really incapacitated. So I would say that’s the first general mindset that I have. And then, as far as actual movements and how I might modify stuff or maybe give them a couple things to do is I want to try to limit any added stress to the neck. So it might be a little bit of positioning work. So basic stuff like, all right, if we’re doing exercise with our head way past our body like this, with chin forward and stuff, we know we’re going to add added stress to the neck, when they’re already feeling neck pain. So let’s get them out of those postures when they’re doing exercise, maybe even throw in some light chin tuck stuff to try to get some of the deep neck flexors working and see how that feels. If all of it checks out and it doesn’t really make their pain any worse, I would be confident in asking them to try that.
And then, just making sure that there’s an open line of communication to see if pain is increasing or if it’s staying the same or if it’s even sometimes getting a little bit better as they move a little bit more and get some general mobility in there. And then, the next stage is going to be opening up the line of communication to make sure that they know that PT is available. And I’ll just say like, “Hey, keep an eye on this. If you tend to feel better by the end of the day, it might just be one of those weird things that you can’t explain, where you slept funny and you woke up to neck pain. If, towards the end of the day, it’s starting to stiffen up again, it’s getting a little bit worse, why don’t we have you see one of our PTs? And we’ll try to take a little bit of a look at it,” to just open up that line of communication and let them know that we have in-depth services that can really help diagnose the situation and not just kind work around it.
Mike Reinold:
I love it. And same theme, it’s continue to move, not be fearful. And I think that’s a lot of what Dan was alluding to. Once it gets to Dan’s lap or table, hopefully they’re not in your lap, but they’re probably already at the point where they are a little fearful or they’re a little concerned to an extent. So it goes from Diwesh, probably hopefully trying to calm them down a little bit, to Dan, where now, they’re probably a little worked up, but I like that. But Jonah, anything you want to add to that?
Jonah Mondloch:
Yeah, I guess I would say the other type of neck pain type person that we’ll get in the gym is someone who has very low level but kind of chronic neck pain. Oftentimes, I find this is your client who maybe doesn’t have a ton of physical activity background or, if they do, it is one thing and one thing only. So it might be somebody who golfs a lot, but doesn’t do anything but golf. And I think a big thing that Dan talked about that I would kind of add on to is just the importance of working the areas around that. So for them, focusing on things like T-spine rotation, I think, is going to be really important for us. If you’re stiff through your whole upper back, I think that’s just going to increase the stress we have on the neck. So that would be one of the big ones.
And then, even just strengthening the shoulder area, upper traps, focusing on that area again, I think, will help support the neck a little bit for you. And then, the last piece would be, with their, say, core exercises, setting them up in positions where they are focused, at least to some extent, on their head and neck positioning. So Dewey briefly mentioned the chin tuck idea. So even if we just have them doing planks, thinking about doing a bit of a chin tuck while they’re doing that plank, or whatever other exercises they have, just making sure we’re focusing on neck position as they’re doing an RDL or a deadlift, like staying out of big time cervical extension as they’re doing that. I think, if it’s anything more serious than that, that’s when we are trying to push them to PT. But if they feel that PT is not necessary or it’s one of those things, they’ve dealt with it for years, so it’s almost not a big deal to them, it’s kind of free up all the other areas and see if, over time, that helps take stress off the neck.
Mike Reinold:
That’s great. And it’s education and awareness. That’s kind of what you’re promoting a little bit here too is some strategies maybe to put yourself in a better position to succeed. So that’s great. I love it. So hopefully that helps. This is a big topic, but I kind of like how we address the subclinical one almost here, the one that’s maybe not having grip strength loss, somebody that’s having those subtle symptoms. And I think our general thought process is keep them moving, right? And for your treatment techniques, if that means things to neural modulate tone and pain, that’s great.
So even moist heat, soft tissue work, like range of motion, those types of things, just to keep them moving, I think that’s fantastic. But then, layer on their active motion and some loading on top of that. So capture that motion back a little bit, but then, get them to use it, I think, is a great kind of strategy. So good stuff, Kate. Thanks for the question. If you have a question like that, please head to MikeReinold.com and ask away. In the meantime, please subscribe, review, rate us, Apple Podcasts, Spotify, and we’ll see you in the next episode. Thanks again.
