Neck Pain - Chronic & Recurrent (Part 1)
The neural and kinematic processes of chronic non-traumatic neck pain or on-going post traumatic neck pain are interesting to me as a day to day practitioner. When I see patients that have on-going pain, the big question I think of is ‘What’s the biological or psychological factors to this pain, what have other practitioners missed, or just not measuring yet?’ Does neck pain and other pain contribute to psychological stress or does stress lead to pain? In my experience in dealing with patients that have had motor vehicle accidents (whiplash) with on-going pain, this is what contributes to psychological distress, rather than stress leading to pain.
There has always been a lot of talk about cervical soft tissue healing based on the natural soft tissue healing cycle or repair, but sometimes, somehow, the tissues did not heal properly and the patient stayed in pain or even became ‘super-sensitive’. That was the language I learned in Dr. Dan Murphy’s excellent course called Certification in Chiropractic Soft Tissue (CCST) approximately 20 plus years ago. We imagined that the tissue or fibrosis of repair (scar tissue) at the site of trauma was sending signals back into the cord and up to the brain. Then the conversation started changing – I started hearing ‘maybe the brain got re-wired’. I hear concepts like ‘The brain memorizes pain’, or ‘chronic pain is the pain your brain won’t forget’ or ‘the brain changed how it controls movement’. We have come to ask ourselves (biological factors) and somehow ask the patient (measuring) whether there ‘could be an issue with the link between the brain and the muscles’. Like a chess player that has the ability to see several moves ahead, we as chiropractors need that skill, plus the skill to reverse engineer the cause of the patient’s issues. Whatever the cause, my starting place is to examine the muscles and joints for stiffness, hypomobility, or a feeling of being ‘stuck’, and/or hypermobility, and whether it's related to the way a person moves during daily tasks. My therapy begins with bringing awareness of static posture and movement to the patient.
I get that the biopsychosocial techniques has helped so many people with on-going pain, and I’m happy to sit and talk with patients using my listening skills, experience, education, and offer advice on self-management, reassurance and guidance in this regard. I will try just about anything to help chronic pain patients. I am the first chiropractor in the country that I know of to use virtual reality in my practice to help patients practice breathing techniques and relaxation strategies. You should see the look on patients faces after sitting in a quiet room with goggles on and they just ‘virtually’ swam with dolphins or helped a garden grow more flowers by better breathing. We ‘hi-jacked’ there brain and they relaxed and the parasympathetic system reveals it’s magic. Together my patients and I are looking at all the alternatives to psychosocial determinants causing pain. But I’m sure that if we can identify a biological cause of the pain, then we could design better treatments.
I am like you, a skilled chiropractor in observing posture, and measuring range of motion, and the way people complete functional movements, and then helping them correct abnormal movement patterns. Exercise therapy and creating better natural movement has been a ‘core’ function of my practice. I look at movement within multiple planes not just single planes, and my practice of introducing corrective exercise movement based on posture and its relationship between pain, movement, and the deviation of neutral has served my patients well...but not everyone!
My patients are those who suffer with back pain, neck pain, shoulder pain, knee pain, or other pain and many are healthy athletes from all ages looking to stay resilient and increase their performance. My primary workspace is a combined consultation room, examination room, a movement evaluation lab, and a treatment room all in one. I use standard range of motion with and without instruments and functional movement analysis to observe what is natural for the person in front of me, hoping to see what’s causing pain, or what aberrant movements they are doing that may be contributing to their pain. I watch them move, and I palpate them and I record what I see and feel. Most importantly I help them feel and become aware of there movement. They learn to self-measure and monitor their own movements. One of the things I may find in investigating neck pain or back pain, is that it's not a particular movement pattern causing problems, it may be that it's a lack of movement.
See Part 2:
Jeffrey Tucker DC DACRB
Dr. Tucker has been evolving and integrating contemporary concepts of chiropractic rehabilitation for more than three decades. He has lectured extensively and authored countless publications on these concepts.
References:
Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani, Muscles: Testing and Function with Posture and Pain: Fifth Edition © 2005 Lippincott Williams & Wilkins
Phillip Page et al, Assessment and Treatment of Muscle Imbalance: The Janda Approach © 2010 Benchmark Physical Therapy, Inc., Clare C. Frank, and Robert Lardner
Shirley Sahrmann and Associates, Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spine © 2011 Mosby, Inc, an affiliate of Elsevier Inc.
Peolsson, A. L., Peolsson, M. N., & Jull, G. A. (2013). Cervical muscle activity during loaded arm lifts in patients 10 years postsurgery for cervical disc disease. Journal of manipulative and physiological therapeutics, 36(5), 292-299
Falla, D., Jull, G., & Hodges, P. W. (2004). Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain. Experimental brain research, 157(1), 43-48. (Delayed onset of DCF with arm movement)
Jull, G. A. (2000). Deep cervical flexor muscle dysfunction in whiplash. Journal of musculoskeletal pain, 8(1-2), 143-154.
Jull, G., Barrett, C., Magee, R., & Hodges, P. (1999). Further clinical clarification of the muscle dysfunction in cervical headache. Cephalalgia, 19(3), 179-185. (Decreased activity of deep cervical flexors)
Jull, G., Kristjansson, E., & Dall’Alba, P. (2004). Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Manual therapy, 9(2), 89-94
Falla, D., O'Leary, S., Farina, D., & Jull, G. (2011). Association between intensity of pain and impairment in onset and activation of the deep cervical flexors in patients with persistent neck pain. The Clinical journal of pain, 27(4), 309-314.
Falla, D., O’Leary, S., Fagan, A., & Jull, G. (2007). Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting. Manual therapy, 12(2), 139-143