Stiff Neck – Un-puzzing the Problem by Nancy Dail

Stiff Neck – Un-puzzling the Problem
By Nancy Dail

Clients regularly complain of having a “stiff neck”. It may hurt to rotate, flex, extend or laterally flex the head or just feel like the head does not respond to movement well. Complaints may also include pain or discomfort on top of the head, general headache, or specific headache pain patterns. Discomfort may run from the back of the head through to the front, and include the entire superior area of the scapula to between the scapulae medially. Multiple complaints may also include upper extremity pain in the shoulder or elbow joints and/or hand and wrist.
The medical history form and interview will help to answer many questions – occupation, repetitive actions, injuries and accidents, sleep patterns, pain patterns, activity and response to other types of care both medical and holistic. What aggravates the condition? What relieves it? Observation will answer postural questions. Is there a head forward posture, protracted shoulders, short upper arms, and a marked handedness? How much pressure is on the posterior cervical muscles based on the head forward posture?
Posture is a repetitive action, and can over time, cause as much discomfort as a sudden injury. The constant head forward posture and position of the shoulders, causes isometric holding patterns for the head extensors, and puts additional stress on the deeper suboccipitals. What other repetitive actions (shoulder girdle and shoulder joint) the individual has, determines what other muscles will play a part in the dysfunction. Muscles work in groups and in paired opposition. This is the aggregate muscle theory – a kinesiology theory that pairs agonist and antagonist action. So, when analyzing and unraveling the stiff neck, the massage therapist must determine active and passive range of motion for the head, neck, shoulder girdle, and shoulder joint. What contributes to the discomfort? Does the individual elevate the shoulder with actions? For example, have you ever tried to shovel snow without lifting the shoulder?
Armed with action information, determining which muscles are culpable is next. Muscles work as agonists, antagonists, synergists, stabilizers, and neutralizers. Some muscles may be primary, but others assisting in the action may also have to be treated in order for the issue to be resolved. There is also order involved. What muscles do you work on first and in what position? In the case of the stiff neck, the sternocleidomastoid, is a primary muscle. It is often shortened because of posture or my personal favorite when I travel, “hotel pillow syndrome”. Passively shortening this muscle is key to unwinding it quickly. Flex the head and lateral flex the head. Short strip the muscle off the mastoid process while rotating the head toward your thumb. Grasp the length of the SCM with a pincer palpation and work towards the sternum and clavicle. Deep transverse friction the sternum and clavicular attachments.

Working on the SCM before you begin releasing the longissimus dorsi and splenius capitis will allow a more efficient treatment plan. These muscles assist in lateral flexion with SCM being a prime agonist. With SCM’s release, the lateral flexors palpate easier than before SCM’s treatment.



Releasing the SCM may also assist the relaxation of the trapezius. The two muscles share the same nerve – the accessory nerve. Bilaterally, the trapezius is the antagonist for flexion of the head – the prime action of the SCM.
Of course this is only the beginning of unraveling the stiff neck and solving the puzzle of the involved muscles and actions. There are many more muscles to visit in a specific order to release the stiffness, increase range of motion, and relieve pain from lack of movement, headache, or posture issues. Levator Scapula, splenius cervicis, specific suboccipitals, and even the scalenes play important roles in contributing to the common “stiff neck”.

Sorry I could not get the pictures to copy here!!! ND

Sternocleidomastoid diagram by Barbara Cummings illustrator; Myofascial Pain and Dsyfunction, Trigger Point Manual, Travell and Simmons
Technique picture from Kinesiology for Manual Therapies, McGraw-Hill, Dail, Agnew, and Floyd.

For more practice on the neck and for specfic conditions of the head, neck and upper extremities, consider:

Techniques for the Neck and Multiple Crush Syndromes
Dimensional Massage Therapy with Nancy Dail
At the Downeast School of Massage
February 28 and March 1, 2015
Saturday 9-4 and Sunday 9-4
As massage therapists we have a wide variety of clientele who grace our tables. Some come for relaxation but more and more clients seek massage for relief of discomfort. Pain is a great motivator to seek treatment and there is no shortage of poor posture and repetitive actions causing many nerve related conditions. Do you know the difference between nerve entrapment and nerve compression? Do you know when to refer for diagnosis and/or how to work with another health professional with specific conditions?
Join Nancy Dail as she defines, evaluates and treats many difficult syndromes and conditions including: anterior scalene syndrome, “stiff neck,” pectoralis minor syndrome, thoracic outlet, whiplash, pronator teres syndrome, median nerve syndromes and carpal tunnel syndrome, lateral and medial epicondylitis, tendonitis, tendonosis, tenosynovitis, cubital tunnel syndrome, double crush syndrome, bicipital tendonitis, bursitis, sprains and strains, Dupuytren’s contracture, De Quervain’s tenosynovitis, and more. Expand your treatment capabilities in your massage therapy practice!
Nancy will lecture on the skeletal and neurological anatomy of the neck and upper extremity, with particular emphasis on the brachial plexus and its distal destinations. She will also address the specific etiologies, signs, symptoms and massage treatments related to the pathologies of these areas. She will demonstrate hands-on evaluation techniques designed to assess the pathologies discussed. Special attention will be given to discuss the history and exam findings that would warrant health professional referral. Nancy will provide by lecture and power point review of the muscles and soft tissue structures. She will discuss trigger points, and referred pain patterns and repetitive actions of involved muscles. Nancy will demonstrate techniques used in Dimensional Massage Therapy and provide supervision for hands-on practice by participants. Dimensional Massage Therapy techniques are deep tissue strokes and methods that have been designed to balance joints by working on all the muscles that produce, assist in, or oppose the actions of, or stabilize the joints. They include a wide variety of dual-hand techniques, elliptical movement of soft tissues, active engagement techniques and determining the appropriate sequence for many conditions. Careful attention will be given to the execution of these techniques, specific muscles and their idiosyncrasies, and to the individual structure of the receiving person on the table. Good body mechanics and safe use of the hands and wrists will be emphasized. Tables and minimal lubrication are required for the hands-on exchange.
Nancy W. Dail, BA, LMT, NCTMB has been a professional massage therapist and member of the AMTA since 1974. She is the founder and director of the internationally known program at the Downeast School of Massage in Waldoboro, ME (1980). A leader in her field, she has served on the AMTA national board, numerous committees, and was the charter President of the Maine AMTA Chapter. Nancy has taught and presents workshops internationally, is certified in Orthopedic and Sports Massage, and has developed the working philosophy of Dimensional Massage Therapy as lead author in Kinesiology for Manual Therapies published by McGraw-Hill. Her BA in Health, Arts, and Science from Goddard College helps her balance her administrative duties as Director with teaching Dimensional Massage Therapy, Advanced Skills, Kinesiology, Ethics, and related subjects at DSM. Nancy enjoys her therapeutic practice for her clientele, traveling and teaching, and playing with her grandsons, Alexander and Kingston whenever possible at her home in Waldoboro.
To register or for more information, contact Downeast School of Massage, 207-832-5531.

The Negative Language of Back Pain

“Patient complaints that originate in the musculoskeletal system usually have multiple causes responsible for the total picture.” -Drs. Travell and Simons
“The first treatment is to teach the patient to avoid what harms him.” -Karel Lewit, MD “He who treats the site of pain is lost.” -Karel Lewit, MD
After seventeen years of running a private rehabilitation clinic, I’ve seen my share of back pain in my patients. It is one of the most common ailments I see, but it is also one of the most misunderstood concepts for the patient, mainly because of the confusing, and often negative, language in the medical field. Patients with back pain – much like pain anywhere in the body- are confused about why it exists: “How did it happen?” “I woke up with this,” are common statements. When the healthcare provider informs them “your back is out,” or “you have stenosis,” and “you have degenerating disks,” the patient assumes the worst ( “I’m degenerating?”). While these physical items might very well exist, and yes, back pain can be related, chances are the patient’s pain has nothing (or very little) to do with them. Yet the patient is told an MRI is “bad” because a disk is herniated (recent studies show that patients with herniations have no pain related to them).1 The patient begins to believe he or she is doomed. After an MRI is ordered – and they are processed at an alarming and completely superfluous rate in the United States 2 – the patient is hit with an onslaught of impossible medical jargon. Does the patient need to spend time listening to the radiologist so she can have a better understanding of the issues? Yes, but the delivery of such information needs to be filtered and converted into a more positive and educational bits. Over the years, many MRI reports I’ve read showed a myriad of structural changes (spondylolysis, lumbar stenosis, protruding disks, et al), yet in my own clinical experience most of the patient’s pain was not a result of these physical findings. Yet the MRI places the patient into an anxious mindset for therapy because of these “physical” findings and their foreboding visuals of “it,” the one thing that is the cause of it all. I’ve seen it again and again, the patient in obvious jabbing pain, unable to sit comfortably, pushing the MRI report in front of me exclaiming, “It’s the stenosis.”
The first thing I try to do when a patient brings in an MRI report is help relieve some of the anxiety associated with a “bad” MRI. For any therapy to take place, the clinician must establish a positive mind-set for the patient from the initial evaluation. I do this in part by explaining, in layman’s terms, how soft tissue reacts to stresses of the skeletal system, and how structural changes to the spine often are not the issues causing the back pain. I try, ultimately, to get her mind off that one thing that she believes is the problem. For example, I’ve had many lumbar stenosis patients who do not have every symptom of pseudoclaudication, but have a thoracolumbar muscle region that is completely dysfunctional. Yet most physicians overlook this. (And others, too. At a recent physical therapy symposium I attended, I asked the physical therapist who taught a course on back pain if he ever considered the sacral ligaments and related soft tissue in his manipulations. “No,” he said, “They really are not important.” Huh?) I also explain to the patient that, while we cannot eliminate the stenosis or structural change, we can focus on releasing the thoracolumbar area to relieve the pain and postural dysfunction. (That’s why massage therapy is so effective for back pain. See the story on NPR.) I have improved pain and quality of movement in my patients on this very premise, and have reproduced this result over and over in patients who thought they were destined for surgery. So “bad” MRI’s are not necessarily a ticket to debilitation and poor quality of life, and the patient, once she understands this, is in a remarkable position to improve her dysfunction.
Some of the Poor Language of Back Pain
• Your back is not “out.” This is one of the most common phrases I hear both told to and from
patients, and it’s understandable why it is used by the patient. The patient may often feel something is “out” when the thorocolumer region is in spasm. If disks are misaligned, research shows they will resolve themselves over time, sometimes with a little self-help. 1
• You are not “degenerating.” Yes, our bones undergo arthritic changes as we age, which means we need more muscle stability to help protect them, but we are not literally disintegrating.
Patients are not damaged but have dysfunction!
• It did not happen over night. While it might seem as though the pain suddenly developed over night, usually this is not the case. Soft tissue dysfunction has a snowballing effect; it develops from a single event that gets worse over time. 3
• Does the patient really need an MRI? Getting a second opinion is always a good idea. I recently visited a podiatrist to get a mucoid cyst removed from my second toe. He insisted he must order an MRI, even though it is one of the most common cysts that occur on the hands and feet. (I refused and the cyst resolved itself.) Radiological films are always a good start, too.
Timothy Agnew
1. Cherkin D, Deyo R, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic
manipulation, and provision of an educational booklet for the treatment of patients with low back pain.
N Engl J Med 1998;339:1021-9.
2. Magnetic resonance imaging and low back paincare for medicare patients. Baras JD, Baker LC.
Health Aff (Millwood). 2009 Nov-Dec; 28 (6):w1133-40
3. Bogduk N, Twomney L. Clinical Anatomy of the Lumbar Spine. Churchill Livingstone