Introduction
Most people have experienced a stiff neck in there life or have woken up with a crick in their neck. In chiropractic this is sometimes called a “subluxation”. They are defined as complex functional and structural problems that create neuro-musculoskeletal irritation capable of influencing general health (1). I will be using the word “spinal segmental joint dysfunction” instead of the work subluxation in this article. This is when there is altered joint alignment, motion, or physiologic function in a spinal motion segment.” (2) This mechanical segmental joint dysfunction most commonly results in local dull and diffuse pain or discomfort.
Anatomy of neck joint restriction
There are two causes of joint restriction in the neck. These are mechanical and reflexive. Mechanical dysfunction happens when there is a brief trauma or extend period of overuse. Periods of overuse cause joint restriction because of imbalances between the surrounding muscle groups. Tightness and irritation are common in the following muscles: levator scapula, upper trapezius, suboccipital, pectoral and rhomboid muscles. Weakness is common in the deep neck flexors, rhomboids, and scapular stabilizers (3). Psychological and emotional factors can cause reflexive joint restriction associated with irritation of the organs triggering muscular guarding, resulting in altered joint mechanics.
Both causes of joint restriction affect the synovial facet joints. Decreased movement of these joints is what causes pain and alters the information that is going to the brain this is called mechanoreceptive input (4,5,6,7). Once neck joint restriction begins it can become a self-perpetuating cycle of discomfort in which the negative effects of decreased motion of the joint are perpetuated by inflammation, tense muscles (via Hilton’s Law) and imbalance. Joint restriction rarely affects only one joint and can affects the spine as a whole (3). Over time this can lead to degenerative changes of the joint (30,65).
Causes of neck joint restriction
Neck joint restriction is a common cause of headaches, vertigo, and temporomandibular joint dysfunction. If accompanied by midline cervical spine tenderness may require imaging.
Common symptoms of neck joint restriction
Neck pain is common and most neck pain is the result of joint restriction. Medical providers see over 10 million neck pain visits per year (8). Many people will have neck pain in their lifetime (9,10). This pain will lead to lost workdays (11). Neck pain usually lasts longer than back pain and is more common in women. (12,13). It is rare that imaging will find a specific medical pathology in 50-80% of neck pain patients, supporting the idea that joint dysfunction and its associated muscle tightness is the most common cause of this problem (14). Even though the causes are not well understood in the mainstream medical community neck pain often comes out of nowhere without a good explanation (15). The most common presentation is tenderness when you press certain points on the neck and stiffness. This pain can increase with movement especially with looking up.
How to evaluate neck joint restriction
Neck joint restriction is first noticed with a loss of range of motion and it can be evaluated which specific segments of the neck are restricted. The most common tool used to analyze the neck is motion palpation. (36) Neck joint restriction is associated with postural imbalances. Tightness and irritation are common in the following muscles: levator scapula, upper trapezius, suboccipital, pectoral and rhomboid muscles. (56) Weakness is common in the deep neck flexors, rhomboids, and scapular stabilizers. Orthopedic tests such as foraminal compression will cause pain and traction of the neck will provide relief. Extreme dizziness, loss of feeling in the face, fainting, or difficulty speaking are all indications that you must go to the Emergency room.
Radiographs may be appropriate for patients with a history of cancer, bone disease, systemic disease, inflammatory arthropathy, steroid use, immunosuppression, prior cervical surgery, or a failed trial of care.
Upper cervical chiropractic for neck joint restriction
Manual therapy and upper cervical chiropractic has been shown to produce results in fewer visits than physical therapy. (63) These treatments provide both short and long-term benefit for acute and chronic neck pain and is superior to other treatments (19-21,31-35,44,47-50,58,60,61). In conjunction with improving thoracic restrictions for optimal outcomes. (42,43,66)
Upper cervical adjustments are gentle and so there are very little concerns about the safety of cervical spinal manipulation. Even though this type of chiropractic treatment is gentle it is important to understand vertebral artery compromise, which may lead to stroke. Cassidy reviewed 100 million patient-years of data and concluded that chiropractic produced no greater risk of major complication, including stroke, vs medical care (23). Another study found that the benefits of cervical manipulation outweigh the risks (24). Another study concluded that using NSAIDs for neck pain produced 400 times greater risk when compared to spinal manipulation (25). The most common complication is transient local soreness (26).
The best treatment is combining upper cervical adjustments with exercise (27-29). Stretching, massage and myofascial release of the levator, upper trapezius, pectoral and rhomboid muscles is helpful. (37-39) Chin retraction exercises may encourage better head posture. Strengthening exercises will help address postural concerns and should focus on the deep neck flexors, shoulder external rotators, rhomboids and other scapular stabilizers.
In addition to this it is important to discuss workstation ergonomics and to reduce exacerbating activities such as backpack/purse weight and carriage, childcare, and sedentary hobbies. Sleep postures should be discussed and consideration of a small, single cervical pillow for nocturnal use is appropriate.
Exercises to help heal neck joint restriction
To see more videos visit the Dr. Noah Volz YouTube channel.
Conclusion
Neck joint restriction can be healed and this article gives you some suggestions on what to look for to determine you have a joint restriction and what to do about it. I hope that this information helps you. If you have any additional questions please leave a comment. In addition to this article you can also read the Guide to Chronic Neck Pain eBook.
References
1. Leach RA. The chiropractic Theories: A textbook of scientific research. Lippincott Williams, and Wilkins 2004:8
2. Peterson DH, Bergmann TF. Chiropractic technique: principles and practice. 2nd ed. St. Louis: Mosby; 2002
3. Lewit K. Manipulative Therapy: Musculoskeletal Medicine. Churchill Livingstone / Eselvier, 2010
4. Schaible H, Grubb B. Afferent and spinal mechanisms of joint pain. Pain 1993; 55:5-54.
5. Jozsa L, Balint J, Kannus P, Jarvinen M, Lehto M. Mechanoreceptors in human myotendinous junction. Muscle Nerve 1993; 16:453-7
6. Peterson D. Principles of adjustive technique. In: Bergmann T, Peterson D, Lawrence D, editors. Chiropractic technique. New York: Churchill-Livingstone; 1993. p. 123-95.
7. Peterson D, Bergmann T. Joint assessment principles and procedures. In: Bergmann T, Peterson D, Lawrence D, editors. Chiropractic technique. New York: Churchill Livingstone; 1993. p. 51-121.
8. DL Riddle, SM Schappert Volume and characteristics of inpatient and ambulatory medical care for neck pain in the United States: data from three national surveys Spine, 32 (2007), pp. 132–140
9. Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine 1994;19:1307–9.
10. Hult L. Cervical, dorsal and lumbar spinal syndromes. Acta Orthop Scand 1954;17(suppl):175–277.
11. Kvarnstrom S. Occurrence of musculoskeletal disorders in a manufacturing industry with special attention to occupational shoulder disorders. Scand J Rehabil Med 1983;8(suppl):1–114.
12. Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: A randomized clinical trial. Man Ther. 2005;10:127–135.
13. Grimby-Ekman A, University of Gothenburg, Stress and neck pain are more common in women than men. ScienceDaily 2010:December 6
14. Hush JM, Maher CG, Refshauge KM. Risk factors for neck pain in office workers: A prospective study. BMC Musculoskelet Disord. 2006;7:81.
15. .Clair DA, Edmondston SJ, Allison GT. Physical therapy treatment dose for nontraumatic neck pain: A comparison between 2 patient groups. J Orthop Sports Phys Ther. 2006;36:867–875
16. Bogduk, N.; Marsland, A. “The Cervical Zygapophysial Joints as a Source of Neck Pain,” Spine 13:610, 1988
17. Nordin M, Carragee EJ, Hogg-Johnson S, Weiner SS, Hurwitz EL, Peloso PM, et al. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33(4 Suppl):S101–22.
18. Stiell IG, Wells GA, The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients JAMA October 17, 2001, Vol 286, No. 15
19. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulative therapy for low back and neck pain: a systematic review and best evidence synthesis. Spine J 2004;4:335-56.
20. Vernon H, Humphreys K, Hagino C. Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials. J Manipulative Physiol Ther 2007;30:215-27.
21. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine. Spine 1996;21:1746-60.
22. Gross A., et al. , Manipulation or mobilisation for neck pain: a Cochrane Review. Man Ther, 2010. 15(4): p. 315–33.
23. Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case40
control and case-crossover study. Spine 2008;33:S176-S183.
24. Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, Van Tulder MW. The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study. J Manipulative Physiol Ther 2007;30:408-18.
25. Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs NSAIDS for the treatment of neck pain. J Manipulative Physiol Ther 1995;18:530-6
26. Hurwitz E, Morgenstern H, Vassilaki M, Chiang LM. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study. Spine 2005;30:1477-84.
27. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine 2004;29:1541-8.
28. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Cote P, Hogg-Johnson S, Cassidy JD, Haldeman S. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33:S123-S152.
29. Aker PD, Gross AR, Goldsmith CH, Peloso P. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ 1996;313:1291-6
30. Cramer GD, Fournier JT, Henderson CN, Wolcott CC. Degenerative changes following spinal fixation in a small animal model. J Manipulative Physiol Ther 2004;27:141-54.
31. Korthals-de Bos, Hoving, van Tulder, et al. Cost-effectiveness of Physiotherapy, Manual Therapy, and General Practitioner Care for Neck Pain: Economic evaluation alongside a randomized controlled trial. BMJ, Volume 326, April 26, 2003.
32. Hoving JL, Koes BW, de Vet HCW, et al. manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. Annals of Internal Medicine, Volume 136, 2002, pp. 713-722.
33. Koes, BW, Bouter LM, et al. “Randomised Clinical Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up.” British Medical Journal, Volume 304, Number 6827, March 7, 1992, Pages 601-605.
34. Shekelle PG, Coulter I. Cervical Spine Manipulation: Summary Report of a Systematic Review of the Literature and a Multidisciplinary Expert Panel. Journal of Spinal Disorders, Volume 10, Number 3, pp. 223-228
35. Swenson R. “Therapeutic Modalities in the Management of Nonspecific Neck Pain. Physical Medicine and Rehabilitation Clinics of North America, Volume 14, 2003, pp. 605-627.
36. Humphreys BK, Delahaye M, Peterson CK. An investigation into the validity of cervical spine motion palpation using subjects with congenital block vertebrae as a ‘gold standard’. BMC Musculoskelet Disord. 2004 Jun 15;5:19
37. Sherman KJ, Cherkin DC, Hawkes RJ, Miglioretti DL, Deyo RA. Randomized trial of therapeutic massage for chronic neck pain. Clin J Pain 2009;25:233-8.
38. Zaproudina N, Hanninen OO, Airaksinen O. Effectiveness of traditional bone setting in chronic neck pain: randomized clinical trial. J Manipulative Physiol Ther 2007;30:432-7.
39. Gemmell H, Miller P, Nordstrom H. Immediate effect of ischaemic compression and trigger point pressure release on neck pain and upper trapezius trigger points: a randomised controlled trial. Clin Chiropr 2008;11:30-6.
40. Dunning JR, Cleland JA, Waldrop MA, et al. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther 2012;42:5-18.