The Neck: How it Works and Why it Hurts

After several years of working on the human body, there is one observation that always seems to hold true: with the exception of people who have issues with being touched, everyone loves neck rubs.  Seriously, both people and animals will stop whatever they are doing when someone skilled with his or her hands starts to work on their necks.  Why is this? All the neck has to do is hold up the head and move it around, and yet even with this relatively simple responsibility, most people start to experience neck issues starting in their teenage years that continue to plague them throughout adulthood.  Over time, this stiffness can lead to headaches, increased stress, depression, and anxiety.  There is even evidence of a relationship between high blood pressure and neck tension.  The purpose of today’s entry on the Caveman Medicine blog is to explore the reasons for this tension, what it means for overall health, and what an individual can do about it.  (As with any of the musculo-skeletal disorders that have been covered here, acupuncture and massage can be very helpful in relieving chronic pain and reducing the underlying tension issues that plague people with these conditions.)

What causes neck pain?
The most common cause of neck pain is tense muscles.  The reason for this are varied – poor posture, motor vehicle accidents, work-related incidents, sports, weather, diet, and sleeping habits.  The key common element is that for some reason certain muscles that affect the neck are holding more tension than they should, and this creates a strain among the other muscles.  As the muscles continue to strain, they start affecting the bones that make up the neck and skull, pulling vertebrae out of alignment and creating conditions that can contribute to arthritis.  (Many people are unaware of this, but arthritis literally translates as “joint inflammation”.  One of the major contributors to this is chronic muscle tension pulling and reshaping the bone, disrupting how it normally articulates with the other bones in a related structure, and is much harder to treat than muscle tension and is also often more painful.)
Because the head contains not just the brain but also the orifices responsible for both respiration and consumption, there is a massive amount of solids, fluids, and gasses that passes between the neck and the head.  When tension in the neck is increased, the pathways these substances use become constricted, further increasing the strain placed on the neck itself as well as making them less efficient.  This can contribute to headaches, poor respiration, sinus congestion, difficulty swallowing, increased anxiety, fatigue, and chronic pain.  The increased stress from theses conditions often further increases tension throughout the whole body, including the neck, so the cycle that will often continue, and problems will only continue to worsen over time without intervention.

What are parts of the body are involved in neck pain?
Many people think of the neck of consisting solely of the cylinder that runs from the base of the skull to the tops of the shoulders.  From a more anatomical perspective, the neck is the part of the body that allows the head to move around independently of the rest of the body.  It’s important to conceptualize it this way for two major reasons.  One, many of the muscles that affect the neck, especially in stabilizing it, actually start in the midback and chest and cross the neck to connect to the skull.  Two, there are many, many people who due to either excessive muscle development, poor posture, or obesity do not appear to have a neck.  While there are some medical conditions where an individual does not develop the vertebrae that make up the neck, if a person is able to shake their head “no” without turning his or her waist, then the neck is present and as such, it is able to suffer from all of the aliments described above.  (Some patients may have also undergone surgical procedures where the bones of the neck are fused together, but even in those cases, some mobility is usually retained.)
So, as mentioned in the above paragraph, the neck is connected to the torso in a number of ways.  One of the longest muscles that affects the neck is referred to as the paraspinals.  These muscles run along both sides of the spine and go from the base of the skull to the top of the sacrum (the triangular bone at the bottom of the spine).  Also in the back, there is the trapezius muscle, which forms a diamond shape that connects the skull, the neck, the shoulders, the shoulder blades, and the fascia in the low back.  Finally, in the back, there is a small muscle called the levator scapulae.  It’s a relatively small muscle that starts in the upper neck and ties into the inner, upper corner of the shoulder blade and helps with lifting the shoulder (shrugging, for example).  It is not a major muscle, but it plays a large role in posture, and can have a significant impact of the neck especially when one side is holding itself more tightly than it’s partner on the opposite side.
In the front of the body, the muscles in the chest have a major impact on the neck.  If the chest is pulled forward, that means that the neck and head is being pulled forward as well.  As a result, the muscles in the back of the body have to increase the amount of work they are exerting to pull the head upright.  The primary muscles responsible for this are the pectoralis major and minor.  These muscles are often much stronger than their partners in the back of the body, and as such, when they are tight, they have a greater impact on the posture.  Because of the strength discrepancy, the muscles in the back will feel fatigued far faster than the pecs and as such, most people will mistake soreness in the back of the neck for a problem with the back, when what they really need is to relax the muscles in front of the body.
Another major front of the body muscle that affects the neck without attaching directly to it are the sternocleidomastoid muscles (or SCM’s).  When a person clenches his or her jaw, these are the large muscles that pop out on either side of the windpipe.  They run from the sternum and clavicle to just behind the ear on the skull and are mostly involved in rotating the head. (Picture a dog tilting it’s head quizzically, and then picture a person making the same movement. That kind of movement would be impossible without this muscle).  Tightness in this muscle is often a factor in chronic temporal mandibular joint disorder (TMJD) but they can also affect the placement of the skull and therefore have an impact on neck tension (as well as occluding the flow of blood and lymph as the SCM’s pass right over these vessels in the neck).
Finally, there is the neck itself.  The neck is made up of numerous tiny muscles which are essential to posture and fine movement.  Many of these are so small that they aren’t taught individually in anatomy classes, but due to their locations, they can often have massive impacts on comfort and function of the neck.  In most cases of chronic neck tension, one of the pair is tighter than the other, and over time will start making small but telling shifts in the position of the vertebrae.  This can be a major source of discomfort that is often related to repetitive stresses or postural issues and when treated appropriately, can also relieve much of the pain related to chronic neck issues.

What are the long-term complications from too much tension in the neck?
The bones that compose the neck are seven individual vertebrae that sit one on top of another and which are separated by small discs of connective tissue.  The first and second vertebrae are significantly structurally different from the other five and allow movements like shaking the head back and forth as well as nodding the head.  The latter five vertebrae allow the neck to flex, bend, and rotate.  If the muscles in the neck remain tight over an extended period of time, these bones can be pulled out of alignment and cause increasing pressure on the small discs in between them. These discs will then start to bulge (or herniate) as a result, and this pressure can be responsible for immense amounts of pain.  Over an even greater period of time, the bone will respond to the pressure by changing shape, making articulation even more difficult and uncomfortable.  This is a major factor in the development of arthritis in the neck.  The common treatment for arthritis is anti-inflammatories (usually either steroids or a NSAID like aspirin or ibuprofen) which decrease the discomfort by reducing swelling.  While this will make the neck more comfortable, it does not address the underlying problem, nor does it prevent the continued degradation of the neck.
Chronic neck tension will also affect the flow of blood and lymph between the skull and the torso.  The brain requires very specific levels of blood flow in order to regulate the oxygen and fuel it needs to function, and if this is lessened by pressure exerted by the muscles, then the heart will be forced to pump both harder and faster to maintain it.  This increase in blood pressure can increase the incidents of both headaches as well as broken capillaries, which can lead to bloodshot eyes, nose bleeds, and congestion.
The lymphatic system is similar to the cardiovascular system, but it’s primary responsibility is as part of the immune system.  The lymphatic vessels are the primary means the body has for removing unwanted bacteria, cells, waste products, and more from the tissues of the body while isolating them from the blood stream.  This is why, when people get sick, their lymph nodes swell.  All of the white blood cells and waste products related to the infection are removed from the area of infection via the lymphatics and if there is an infection, those nodes will become full of that material.  If the muscles around those ducts are tense, then the flow becomes more constricted.  It is not uncommon for someone who suffers from sinus congestion to find relief after a massage as the relaxation of the neck muscles allows for the backlogged lymph of the sinuses to drain, releasing pressure and easing discomfort.
Because many of the muscles that affect the neck also affect the jaw, chronic pain involving the jaw and the mouth can often be linked to neck issues.  Over time, this tension can result in trouble with chewing and swallowing as well as affecting the health of the teeth and gums.  One of the reasons people with jaw issues have a hard time getting those muscles to relax is because the partner muscles are also tight.  An example of this that also ties into headaches involves the muscles in the front of the neck and the temporalis muscle located near the temple.  As the front of the neck gets more tense, the muscles in the front pull the jaw down and forward.  In response, the temporalis muscle will tighten to pull the jaw up and back.  Due to it’s location, these increases the amount of tension placed on the temples, often creating a chronic dull pain which occasionally sharpens as that muscle goes into spasm.
Finally, chronic neck pain is often an immense source of stress.  Most parts of the body can be relaxed one way or another, but because the neck is balancing the skull at all times, even lying down won’t allow the neck to relax completely.  The inability to release this stress can force the body to endure pain over extended periods of time which has been shown to have cumulative negative effects on the body such as anxiety, depression, fatigue, weight gain, sleep disturbances (aside from the problems caused by the pain), and irritability and aggression which can worsen social interactions (which leads to more stress).  Most pharmaceutical solutions only offer short term relief for the pain, and because of the underlying tension remains untreated and thus allowed to worsen, many of the symptoms return even stronger when the medication is removed.

Center of gravity – what?
There is an unwritten rule in most contact sports and martial arts – where the head goes the body will follow.  This is because for many people, the head is their center of gravity.  In laymen’s terms, the center of gravity is the point which sets the posture for the whole body.  If the head is too far forward, then the rest of the body will lean forward as well, and vice versa if the head is too far back.  This can create posture issues for the rest of the body.  A common alignment issue is for the head to be projected forward more than it should and as a result, the person is constantly leaning forward.  This increases stress on the low back, hamstrings, and calves as the body then tries to keep from toppling forward.  More esoteric and full body workouts like yoga, Tai Qi, Qi Gong, dance, and Pilates can teach people how to shift their center of balance to a lower point in the body like the chest or near the navel, but these lessons are much harder for people to incorporate into their lives if their neck is still holding a lot of tension.

So what does healthy neck posture look like? 
Every individual is different due to genetics and life history.  As such, a visible inspection of the neck is not going to reveal as much as a functional one.  There are some basics things that can be checked.  The jaw shouldn’t be thrust forward or pointed downward. The ear should be relatively horizontally level to the shoulder.  Neither shoulder should be overly higher or lower than it’s opposite number.   However, in order to properly diagnose the neck, a combination of palpation and movement assessments is really the best way to get an adequate picture.
In a healthy neck, there shouldn’t be any excess tension in either the front or back of the neck, and the sides should have an equal amount of tension (this may vary depending on muscle development).  The jaw should be relaxed and able to move freely without clicking.  The person should be able to rotate their head 90 degrees to both the left and the right, and he or she should be able to tilt it to at least 45 degrees to each side.  Finally the individual should be able to roll their neck in a full circle either direction without it locking up or making excessive noise (known clinically as ‘crepitus’).

So what specifically causes muscle problems for the neck?
There are numerous factors that effect the neck, both postural and environmental.  The most common issue linked to chronic neck tension is muscle strain.  This usually occurs due to one of two factors (or both combined over time): trauma and posture.  The neck, as mentioned above, contains numerous small muscles used for small movements and posture.  A common cause of trauma to the neck is accidents where the head is suddenly moved in one direction than quickly forced into another direction.  This often happens in car accidents where it is commonly referred to as “whiplash” but it can often occur in sports, falls, or other types of impact.  Those small muscles referenced before are ill-suited to adjusting to the quick changes in forces and become strained as a result.  The damage is not immediately apparent, but over time as the muscles struggle to compensate for their weakened cohorts, the stress on the neck builds and discomfort follows.  This is also why people tend to have less problem in higher speed impacts than they do in ones they see coming – the neck has less time to react so the muscles aren’t able to tense and thus don’t become strained.
Postural problems affect the neck in the same way, but take a longer time to develop.  As a person spends more time in a position where their head is too far forward or back, muscles related to putting them in that position become stronger than the ones that move them back to a more a neutral posture.  This inequality will slowly force the bones the first group of muscles are connected to also move out of position, increasing the stress placed on the second, which will increase the pressure and strain on both muscle groups.  Over time, as more and more of the muscles become weaker due to the constant demands placed upon them, the connective tissue over the muscle will start to become thicker, gradually immobilizing the neck.  This inability to move can contribute to arthritis, disc herniation, and other conditions which may eventually require surgical intervention.
Another, less considered issue, that effects the neck is climate.  One of the ways the body regulates temperature is through muscles contractions, which is why people shiver when it’s cold. If wind is added to cold, that cold then becomes more persistent.  This is because the heat that body releases will create a small envelope of slightly warmer air around the body, but in the case of a windy day, that small amount of heat is constantly being torn away.  Similarly, when the skin is wet, the moisture will also transfer more of the cold into the environment directly onto the parts of the body that are wet.  Most people cover-up their torso, head, and their extremities when it is cold out, but they often forget to cover their neck.  As a result, on a cold and/or windy day, the neck is constantly being exposed to cold weather.  This means that the blood that flows through the neck is also being cooled.  The brain, however, is very picky about the temperature that the blood should be, so when it does detect a loss in heat in the blood passing through the neck, it will tell those muscles to tense up in order to minimize it.  Over the short term in a healthy neck, this won’t create any issues.  However, if the neck has been compromised due to injury or previous tension issues, or if the exposure occurs over a longer period of time, the neck will have a more difficult time relaxing after the environmental factors have been removed.

So what can be done do to prevent or reverse neck pain?
The most important factor in neck health lies in understanding how it works and what effects it.  Quick and sudden movements should be avoided as well as holding the head in place for too long.   Reading, working at a computer, driving, or any other activity where the head remains motionless over an extended period of time are all major contributors to chronic neck tension.  Taking a break for a minute every half hour or so to simply move the head and neck around can make a big difference in reducing chronic neck tension.  Also, if the ergonomics of the area where the work is being done force the shoulders to be elevated, then this should be adjusted as well.  When the shoulders are drawn up towards the ears, the ability of the neck to move is reduced (see the article on this page concerning the shoulder for more details).  If there is a lot of computer work being done, the monitor should be level with the eyes so that the head can be held in a neutral position.  In other words, the person should not have to constantly pull their chin down to look at the screen.
The traumatic causes of neck tension are much harder to avoid, but if a person is involved in a situation where the head is jerked quickly one way then another, the sooner treatment is applied, the faster the neck will recover.  Immobilizing the neck is appropriate if there is suspicion that the central nervous system is at risk, but for most injuries, putting the neck into a collar will offer only slight relief and the lack of movement will actually increase the chance of complications and muscle atrophy.  If treatment must be restricted to home care, then the key is apply cold as long as the area affected feels warm to the touch (this is due to swelling), and then switch to heat as soon the area returns to a normal temperature (the heat will relax and release the muscles).
Another home option for chronic neck tissues is to use a pressure wedge.  Most medical supplies stores will sell a foam rubber product that applies steady pressure to the neck when placed but a cheaper alternative to take two tennis balls and tape them together in a bow tie configuration (athletic tape works well for this).  After it has been complete, lie face up on the floor and place the wedge under the neck between the skull and the top of the shoulders.  This steady pressure will relax the muscles in the back of the neck and can be used for extended periods.  It can also be adjusted to target the most affected areas.
Finally, if the person lives in an area that is particularly cold, wet, or damp (or all three), then wear a scarf.  Even a thin layer of fabric can have a noticeable effect on the amount of exposure the neck will have to endure, and the warmer the neck is kept, the less the muscles will tense up to keep the cold out.

When doing exercises, remember that these are presented from a rehab perspective – that means, in this case, pain is not something to work through, but should be a sign to take a break.

For ALL exercises listed below, remember to breathe! If you can’t breathe, your muscles will tense up.

Neck Rolls
One of the simplest stretches, simply rotate the head in a full circle several times in each direction.  Go slowly and carefully and don’t push too hard.  The most important aspect of this stretch is to keep the shoulders from rising up as you perform it.  Do several circles in each direction and repeat throughout the day.

Behind the Back Stretch
Stand with your feet shoulder width apart and clasp your hands behind your back (the “at-ease” position).  Now grasp your right wrist with your left hand and pull your right arm further behind your back.  Next lean your head to the left side.  You should feel a stretch in the front of the neck and shoulder on the right side.  After 15-20 seconds, keep holding the stretch and rotate your head upwards.  You should feel the stretch in a slightly different location in the right side of the neck. Hold again for 15-20 seconds and then rotate the head downward.  Again the location where you feel the stretch should change.  Hold again for 15-20 seconds, then bring your head back to initial stretch position, and slowly come out of the stretch.  Switch sides and repeat.  You should perform this stretch a few times a day depending how much tension there is.

Levator Scauplae Stretch
This one can be intense so be careful with it.  The first thing you will want to do is find something that weighs between five and ten pounds.  It can be a weight, a water jug, or even the edge of a counter.  The key is that whatever you choose, it’s heavy or immobile enough so that you can tell if your shoulder muscles engage.  So first, take your chosen object in your left hand.  The shoulder should be as low and relaxed as possible.  Next, tilt your head to the right.  This may be enough for you to feel a stretch.  If it isn’t, then take your right arm and extend it straight out to your side.  Bend the elbow and place your palm on your ear.  DO NOT PULL!   Instead, let gravity provide the force as the combined weight of your head and arm increase the stretch on the left side of your neck.  If you feel your left shoulder start to rise, take a breath and try to relax it back down. After ten seconds, gradually come out of the stretch.  Switch arms and repeat the stretch for the other side of the neck.
The first few times you do this stretch, you might feel some discomfort in your neck.  This is due to the connective tissue being stretched as well as the muscles.  The pain should fade relatively quickly.  Be aware there is a chance to overstretch with this movement so proceed very, very slowly.  If the pain on the stretched side feels especially hot, there might have been a tangle in the connective tissue that tore (this is not a bad thing, just uncomfortable).  If that is the case, running an ice cube over the area can help reduce discomfort.

The Doorway Pec Stretch
This is one of the easiest and most effective stretches for the chest.  Find a doorway and place your toes so that they are level with the door frame.  Now rest the forearms against the door frame.  Your elbows should be bent to about 90° and should be about level with your nipples (or 5th rib space).  Now let gravity do the work as you fall forward, being supported mostly by your arms. If done correctly, you should feel a gentle stretch across the chest and front of the shoulders and your shoulder blades should be drawn together in the back.  Do this stretch for about 30 seconds at a time and whenever you feel it is necessary.

Morning Stretch
Stand with your feet hips distance apart (this one can also be done in the seated position once you have it down).  Now raise your hands directly above your shoulders with the palms facing forward.  Once the arms are fully extended, pull the arms down so that your elbows are bent and are alongside the body.  You should feel the shoulder blades coming together as the arms come down.  As you bring the arms down, come down slowly like you are moving through molasses.  If you feel unsure about this stretch, perform it with your back against a wall so that your arms are in contact with the wall throughout the movement. Repeat as often as you feel you need to.

This is one of the best exercises for balancing out the strength differences between the front and back of the shoulders.  If you have access to a gym, you can use the standard upright row machine, with a few caveats.  First, make sure you are using a weight that you can move comfortably. If you are grunting and straining, it’s too much.  These muscles tend to be weak, so especially when starting out, too little weight is preferable to too much.  Second, don’t hyper extend the chest.  When lowering the weight, stop the movement when the arms are completely extended. If your chest moves forward, you’ve gone too far.

If you don’t have access to a gym, or if your gym doesn’t have the right equipment, there is still a variation you can do.  You can use free weights, resistance bands, or even jugs of water for this.  Start by standing with your feet shoulder distance apart with the weights about a foot in front of your feet.  Now bend through the hips (not the waist) until your upper body is perpendicular to the floor.  Reach down and take the weights.  Then, with your palms facing each other and your hands under your shoulders, bring your hands towards your shoulders.  Your arms and shoulder blades should be the only parts moving during this exercise.  Try to use a weight that allows for 15-20 repetitions and multiple sets.  Finally, when you are finished, but before you straighten up, release the weights to avoid straining the low back.

As always, this has been a comprehensive, but by no means complete, look at one of the more chronically troublesome parts of the human body.  The neck, while stronger than most realize, is still a very touchy part of the human body, but as long as preventative maintenance and the quick application of therapy are used as needed, major problems can be avoided.  Be safe, be healthy, and I’ll see you next time.