Neck pain is so common it is not so much a disease as a condition of life. The evidence is that virtually all of us will suffer from it at some point. The causes of chronic back and neck pain are many though by far the commonest is ‘degenerative disease’. This degeneration is the normal process of wear and tear that occurs with life. It affects the discs, bones, joints and ligaments of the spine. If it arose anywhere else in the body it would be called arthritis, though medics tend to call it spondylosis.
For more information regarding wear and tear of the spine, please press here.
There is more to it than just wear and tear for whilst it is more common amongst those who do heavy manual work or play heavy spinal sports such as rugby, there are many sedentary sufferers. Thus, there are familial patterns of inheritance, the random genetic lottery of our make-up and specific injuries adding to the mix as well as yet unidentified biological processes.
This degenerative process arises earlier in the spine than in any other joint of the body, frequently being seen on MRI scans in the late teens. This is not surprising when one considers the complexity of the spine, its mobility and the amount of movement the neck does and the weight it carries.
Each bone in your neck is only about the size of the end of your thumb and there are seven of them stacked one on top of the other. Your head is heavier than a big melon. Imagine running down the road with a big melon stuck on the end of an upright seven jointed thumb - it would thrash about and the thumb would break. The discs in your neck hold these seven bones together. They may hurt and have gotten worn out but remember the job they did for all those years. They have been valiant and brave little soldiers who deserve a bit of attention.
For more information regarding intervertebral discs or the anatomy of the spine, please press here.
For detailed information regarding the cervical spine/neck, please press here.
The main strength of the spine in fact comes from its muscles and this is very important in the neck. Rugby players have bones, discs and joints no stronger than your mother it is just that they have a good deal more muscle.
The degeneration of the spine, seen on MRI scans, principally affects the discs and joints and nearly always predates the onset of symptoms. Neck pain arises when inflammation occurs in these worn joints and discs. You cannot see the inflammation on the scan though you can see it when you sprain your ankle. The initial injury hurts but the real pain and swelling develops over the following hours and days. The ankle becomes red, hot and angry.
Similarly, in the spine an injury to any of the joints or discs may be minor but then slowly produces inflammation which results in pain.
Thus, neck pain may be thought of as inflammation arising on a long-term background of wear and tear in the joints and discs of the spine (arthritis or ageing).
Two common patterns arise:
In the first, the process is chronic and ongoing and symptoms are relatively constant and persistent – “continuous neck pain/ache”. The pain is generally provoked after exercise, made worse by prolonged reading or driving and is often worse in the morning especially after a heavy day. It gets worse as the working week goes on.
In the second, the episodes of inflammation wax and wane, often with dramatic onset in pattern sometimes called “acute relapsing”. A trivial normal action, often as benign as reversing the car, triggers a tweak which develops over the following hours into incapacitating pain. Some may experience locking where the head gets stuck turned to one side. The attacks may last a few days or a few weeks and will often begin with episodes occurring once every few years. Patients describe an absolutely normal pain free life being intermittently placed on hold. As time passes, the episodes may fail to fully resolve so there is an element of continuous low neck ache or pain and the frequency escalates into episodes every few months. Some get into to a severe episode which will not settle.
Brachalgia, or arm pain, (sciatica of the arm) emerges when the nerves servicing the arms, which pass through the spine, are compressed by the swollen joints or bulging (slipped/herniated/prolapsed) discs or irritated by inflammation in theses joints and discs. Brachalgia is therefore called a referred pain and arises because the pressure excites the nerve and the brain thinks anything that comes from that nerve comes from the leg.
To read more about brachalgia, please press here.
There is another type of referred pain that comes from our internal organs not being localised well. Hence, we feel heart pain in our left arm. This is not because the heart presses on a nerve going to the arm but as a result of the brain incorrectly localising the heart in the arm.
Both types of referred pain occur in the spine as disc, facet joint or bone pain and may be poorly localised to the scapula, shoulder blade, or to the shoulder tip. Likewise, if you press on a nerve in the spine it does not always go all the way down the arm to the forearm or hand. Any pain felt centrally in the back of the neck is due to the discs, bones or joints of the spine themselves.
Any pain felt below the elbow comes from the nerves being pressed on. A common pattern is to have pain in the back from a prolapsed disc and pain in the forearm from the pressure the prolapse places on the nerve root. Pain felt to one side of the spine, in the shoulder or upper arm is in “everyman’s land” and may reflect poor localisation or limited referral.
To read more about referred pain, please press here.
In broad terms, nerve root pressure is best treated with rest and passive gentle treatments whereas neck pain and stiffness is best treated with active exercise bases treatments. If you have lots of arm pain most of the exercise-based elements of what follows will not be for you.
With this understanding of the mechanisms of neck and arm pain the programme of conservative therapy outlined below can be addressed.
The four part plan
The measures below are generally found helpful, though they need to be tailored for the individual – we help you do this at The Spine Surgery London.
You will see that, in principle, you need to do exercises and stretches whilst modifying some aspects of your life-style. These measures will not have an immediate effect, though in the long-term may bring benefit and are essential if the process of progressive pain is to be halted. Even for those of you who ultimately require injection therapy or surgery, it is very important that the underlying programme of neck care is optimised if the long-term results are to be good.
None of the suggestions outlined below are effective in their own right. However, when effectively combined they are often a sufficient gust to knock over much spinal pain. Aspects from each of the areas need to be combined into an effective Four Part Plan, as described below.
The strategy is to allow you to become more active without increased levels of pain and then to help the pain ease.
1) Physiotherapy stretches - you do not need to go for regular hands-on physiotherapy but to develop a programme of stretches which you perform two to three times a day on your own. It should be developed with the guidance of a physiotherapist. The idea is that it will loosen the spine so that your movements are freer. In that way, you will avoid spraining the spine when you wish to bend or stoop. You should loosen up with these stretches on first emerging from bed, halfway through the day, in the evenings and when you have finished exercise or prolonged periods of sitting, such as after a car journey or study.
A simple series of stretches might be as follows:-
Stand up. Relax the shoulders – let them drop- take a few deep breaths. Place your head upright. Gently try to reach up with the top of your head to touch an imaginary finger held just above. Relax again. Now try to hold the head upright and looking straight ahead while touching an imaginary finger held just in front of your nose. Return to neutral and relax. Now move the finger round to the back of your head and try to touch it there. Return to neutral and relax. Repeat and hold this one several times – there is a tendency with neck troubles for the chin to come forwards and this exercise trains us to have a better posture which opens up the spinal canal and relieves arm pain and strain.
Now, bend the neck forwards and look straight down at the floor. Gently come back up to neutral upright. Bend the head back, looking up at the ceiling behind you. Return the head gently to neutral. Look slowly round over your left shoulder. Back to neutral. Relax – take a few deep breaths. Do the same to the right. Come back to neutral and relax. Tilt your head over to the left as if to touch your ear on your shoulder tip – do not bring the shoulder up – you will not be able to reach your shoulder but go as far as you comfortably can. Come back to neutral and relax. Repeat to the right. Relax. Finally, rotate the head and neck around as if to draw an upturned cone in the air. Relax and repeat the whole regime up to five times, depending on the time available.
2) Regular exercise - you should develop a therapeutic exercise regime with the aim of strengthening the muscle support to the neck and shoulder girdle. The latter is made up of the scapular, or shoulder blades and clavicles, or collar bones on each side joined into a ring at the front by the sternum. To this ring are attached the arms. The ring hangs from the neck, thoracic spine, chest and head to which it is attached by numerous muscles such as the trapezius, latissimus dorsi, rhomboids, pectorals and sternocleidomastoid – test out your physiotherapist by asking where these are and what exercises you are doing to help them.
These muscles are vital to the strength and protection of the neck, just as much as the ones directly attached to the spine, such as the erector spinea muscles which run up the back of the neck and the thin ribbon of muscle, called longus colli, which run up the front of the spine just to the side of the midline. The size and shape of longus colli gives us insight into the second job muscles do – they tell us what position we are in. Longus colli is too thin and too close in as to be unable to meaningfully move or support the neck. However, it is perfectly placed to tell us where our head is in space by informing the brain of how much stretch they are under – if they are under full stretch you are looking up and if they are short you are looking down. The joints and ligaments do a similar job – it is called proprioception.
You should develop a programme of exercise to strengthen the muscles associated with the neck, shoulder girdle and chest with your physiotherapist and then perform a small amount often- ten minutes, perhaps twice a day to start with. It should not involve long periods of time or heavy work but you need to do enough of it often enough to build and tone up muscle. You then need to maintain it long term. You may work with light weights and do back stroke swimming as part of this regime. When you have developed these "good exercises" you may then start to reintroduce the sports or hobbies you find more fun.
Some of you will also have a general fitness issue and will need to address this too. Certain forms of exercise are particularly severe on the neck and are best avoided i.e., breast stroke swimming, prolonged jogging and squash. Indeed, you may find that most forms of exercise exacerbate your troubles when they are acute and you might be wise to suspend sports until the four part plan is established.
Whilst you cannot afford to ignore the other three, of all the measures in the four part plan this is perhaps the most important. As mentioned, rugby players have bones and discs in their necks no stronger than the rest of us. However, they all develop huge neck muscles and by so doing are able to avoid serious injury. Rugby paralyses people each year by breaking necks. A common pattern is for younger players with normal necks to be playing out of their league. You are not aiming at rugby but the principle is the same. By building muscle you can protect the neck from the daily micro-injuries of life.
3) Medications – there is no solution to your trouble in a bottle - medicinal or otherwise. You cannot get lasting complete relief with tablets alone. You may get some assistance from them but only when integrated with the other measures. Regular medications cause side effects and stop working. The ideal medication is one taken intermittently and before the onset of pain.
By using this pattern you may not get all you want from the tablets but as much as is available long term. There is one exception which we deal with at the conclusion of this section.
In general, there are two families of drugs used in neck pain. The aspirin family of anti-inflammatory drugs is often effective though may upset your stomach. The other group all essentially derive from opium and is the paracetamol family. The aspirin family includes: ibuprofen (nurofen), indomethacin, mefanamic acid, brufen and diclofenac (Voltarol). The paracetamol family include: codeine, dihydrocodeine (DF 118), paramol, or codeine and paracetamol mixes such as co-codamol, solpadeine, tramadol, and drugs commonly used in cancer such as MST, oxycodone and oxycontin and morphine.
Rather than taking your medications regularly, there are a few patterns you should consider. You might take them half-an-hour before undertaking an exercise or activity which reliably provokes pain. If you are stiff afterwards, you should take a further tablet later. If you wake in pain in the morning or cannot sleep undisturbed by pain, you may consider taking them at night before bed. If you are troubled towards the end of the day, an afternoon dose may be appropriate. In this way and if you only use a dose two to three days per week and thereby have four or five days off medication, you will probably be getting as much from the tablets in a sustained way as is possible. If you take regular doses more often, their effectiveness will wear off and you end up taking stronger and stronger medication with all the problems that follow. People caught on the analgesic escalator are often getting no more relief from powerful drugs than they would from intermittent paracetamol though have a pile of side effects to cope with in addition to the persistent pain.
The one exception to this principle relates to those of you who have a pattern of acute relapsing neck pain – episodes of severe pain separated by substantial periods of freedom from pain. Here, it is best to use a big dose regularly for a few days to a week to knock the pain over briskly. You should start taking them early – as soon as you see an attack coming. We often suggest 400mg of ibuprofen (nurofen) with 1000mg of paracetamol four times a day - this usually equates to two paracetamol and two ibuprofen four times a day though check the mg in each tablet on the packet. However, this is intended to be a short burst and cannot reasonably be expected to work long term or then to be free from side effects.
Remember be careful of your stomach. If you have been prescribed your tablets differently you should take them as per the instructions, though you may wish to consult with your doctor or us in this regard.
Please also read our Medications section which you should follow before you take any medications.
4) Adjustment of life-style - you should think about your daily activities both at home and at work and include how you travel. It is likely that you will be doing a lot of driving, often in a poor posture, or that you may sit at a desk at work which may be too low or in a chair which is too high. You should avoid slouching or hunching the shoulders or sitting with the chin forwards. Rather like grandma told you. “Hold your head up and put your shoulders back dear”. When considering your posture remember the spine would like to be in the position it is when lying flat on your back, i.e., sit up in the position you would lie down. When looking at a chair or the seat in your car or when adjusting the one in an aeroplane, you should consider that point. Sit them bolt upright.
You should avoid bursts of activities such as going for the entire week's shopping or mowing the entire lawn in one go. Break up car journeys, take breaks from your computer and avoid golf on two successive days.
The set up of your work station is very important. Many of you will spend long hours at your desk and if you can reduce how much it irritates your neck by just a few percent this might bring it below a threshold where inflammation and pain flare up.
If you get your desk right you may find golf not so bad. Your head position is determined by the position of your PC screen. After a few minutes of use, you will move to the comfortable focal length of your eyes. So, to end up upright with a straight and retracted neck you need to have the screen high and near. Sit down in your chair, draw yourself up straight and then imagine just how high and forward your screen has to be in order for you to use it in that ideal neck position. Its height will come as a shock. You may need to compromise a little. You also need to get to the key board so the desk itself will usually need to be higher. Papers should be on a tilted plinth so you do not have to look directly down to read them. Desks which have adjustable legs and tops which tilt like architects drawing boards are readily available. The usual work station assessment ends up with buying you a new chair. This might make you feel loved but a simple four legged kitchen chair will do. It is the desk height, the height
of things on it and the relationship between the desk and chair which actually matter.
Laptops are hopeless for neck sufferers. You have to lean down to see the screen and have to hunch the shoulders to squeeze you hands together enough to use the keyboard. Get a separate key board if these are integral to your work.
Think “Active Office”. There is no such thing as the perfect setup, chair or desk. You were just not designed to sit down all day. You were designed to potter about picking berries and occasionally run away from lions.
There is no good way to use a standard telephone. A wire free headset is ideal. It allows you to have your hands free and to relax, sit up or better still stand during calls. They are cheaper than chairs. How about doing your stretches each time someone calls.
Two chairs are better than one, providing they are different. Have the “ideal chair” as described above. In addition you need one that mimics standing and encourages core muscle activation. Two types are useful; a Swiss ball and the kneeling stool. The idea is that you move from one to another throughout the day.
Design your tasks so you are obliged to get up a lot. Put the envelopes on the other side of the room. Having carefully considered every aspect of your life and made whatever alterations are practical, you will need to carefully re-train yourself so that you take care but are not cornered by your problem. Do not give up on things but instead modify them to be less irritating to the neck.
Should you wear a collar?
In general, you should avoid the prolonged use of collars. Obviously, if you have been prescribed one by a doctor following an injury or surgery it may be essential for you to wear one. Also, in acute attacks of arm pain from slipped discs, they may be useful for a few days.
Otherwise they are best restricted for particular times when the neck can be troubled-an hour or so a day at maximum. Often during long journeys, it is sensible to wear one to make other people be gentle with you if nothing else. Some people find relief by wearing them at night, in which case a soft collar is usually adequate. However, if you wear them for prolonged periods the muscles which support the neck, and are your best line of defence from pain and injury, will weaken.