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20 Articles in Volume 20, Issue #2
20/20 with Peter Staats, MD: The Future of Pain Medicine
Ask the APP: How useful and practical are pain assessment tools?
Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?
Axial Spondyloarthritis: Updated Medication and Imaging Recommendations
CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using A Checklist
Chronic Low Back Pain: Can We Find a Treatment Consensus?
Chronic Pain and Coronavirus
Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.
Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?
Diagnosis Is Everything: Low Back Pain As a Symptom of an Underlying Condition or Conditions
Editorial: From Just Say No, to Say Now and Say Know
Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
Experts Roundtable: Finding a Bottom Line in Back Pain Care
Inside the Potential of RNAi to Target the Etiology of hATTR Neuropathy
Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options
New Migraine Medications: Oral Gepants, Ditan Tablet, and More
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
The Emotional Impact of Chronic Low Back Pain
The Rise in Tianeptine Abuse: Our Next Kratom Problem?
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options

OMT can play a pivotal role in mitigating degenerative changes in the posterior neck, treat acute and chronic head and neck pain, and combat modern ills, such as text-neck syndrome.
Pages 54-56

Neck pain is a common complaint that patients have when visiting a healthcare office. Its prevalence ranges from 15% to 50% and was the ninth leading cause of missed workdays according to the Global Burden of Disease (GBD) 2017. In addition, neck pain causes 20% of chronic headaches, and if these were included in the amount of missed work hours, neck pain would rank closer to second in the leading causes of missed workdays. It is essential for the healthcare community to address the issue of neck pain and headaches, especially for the working-age groups in which the burden of disease is heaviest.1-4

Further, while the burden of disease falls mainly on the working-age groups, GBD does not take into account the teenage and young adult population. The prevalence of neck pain in this group is likely to rise with the increase in cell phone and tablet use as duration of such use has been positively correlated with neck pain severity in college students.5 The flexed forward position strains the neck extensors and rhomboids, weakens the flexors, stiffens the chest muscles, and shifts the center of head gravity anteriorly.6 The compensatory positioning compromises the surrounding nerves and vasculature, which can cause headaches.

Due to the expected increase in neck pain and subsequent headaches in the younger population, this paper will focus on specifically the negative effects of prolonged cell phone and tablet use and how osteopathic manipulative treatment (OMT) can aid in the management of those effects.

Neck pain prevalence ranges from 15% to 50%. It can include headache and text-neck syndrome (Image: iStock)

 

Mechanism of Injury

Portable Device Use and Improper Ergonomics

The use of portable electronic devices, which include mobile phones, laptops, and tablets, has become practically ubiquitous as the accessibility and practicality of these devices have increased. In 2018 alone, 1.56 billion phones were sold worldwide.7 As a result of this technological deluge, people are spending more time using their phones. In 2016, Statista reported that people in the United States spent, on average, 2 hours and 37 minutes per day on smartphones, with 1 hour and 40 minutes being spent on social media,and in Brazil, average use increased to almost 5 hours a day in 2017.9 However, excess phone use comes at an injurious cost.

Increased screen time on portable electronic devices is not only correlated with depression, sleep interruption, and poor food choices, but also rising rates of neck pain, especially in adolescents and young adults.10,11 Neck pain, including dysfunction of C1 and altered mechanics of the cervical spine due to poor posture, can lead to headaches, which is one of the most common reasons for healthcare office visits as stated above.1

When studying 56 young adults’ texting techniques and posture while texting, Gustafsson et al, found differences in technique, posture, muscle activity, and kinematics between young adults with and without musculoskeletal symptoms.12 Young adults without musculoskeletal problems sat in positions with back and/or forearm support and held their head in a neutral position while texting. It was also determined that musculoskeletal symptoms did not cause the differences in technique and posture between the two groups, but rather the approach to texting may predispose an individual to having musculoskeletal symptoms. Although the connection between posture, neck pain, and phone use is well established as text-neck syndrome, only 21% of young adults are aware of measures to prevent it, and merely 8% know it exists.13

To combat neck pain, healthcare providers frequently recommend one or more of the following: muscle relaxants, non-steroidal anti-inflammatory medication, manual modes of therapy, physical therapy, transcutaneous electrical nerve stimulation (TENS), anesthetic blockades, botulinum toxin injections, radiofrequency thermoneurolysis, as well as more invasive surgical options such as joint fusion and nerve ablation.4 As reported in a previous PPM article, the PostureJac (SomatoCentric Systems, Inc.) may also be beneficial in improving dysfunction of the musculature that commonly causes neck pain.14,15 Another treatment modality shown to be effective in the management of neck pain is OMT.4

OMT for Neck Pain and Neck-Related Head Pain

Osteopathic manipulation treatment uses a detailed knowledge of anatomy and physiology to augment treatment of bones, muscles, nerves, visceral organs, and circulatory vessels including blood vessels and lymph vessels. In terms of neck pain, the nearby musculature, nervous, and/or vasculature systems are described below to demonstrate the key role they play in the development of pain in the head and neck.

The Posterior Neck Anatomy

The posterior neck is comprised of a superficial and deep layer of musculature. The superficial cervical muscles include the trapezius, splenius capitis, semispinalis, and levator scapulae. However, it is in the deep layer of the neck where other structures, such as vasculature and nerves, play a less obvious, but large, role. The deep muscles in this region, which is commonly the cause of cervicogenic headaches, are those that make up the suboccipital group: rectus capitis posterior major and minor, and the obliquus capitis superior and inferior.4 Directly overlying these muscles are the greater occipital nerves on either side. Irritation of this nerve causes pain along the posterior scalp and vertex of the head. Directly deep to the suboccipital triangle runs the vertebral artery/vein, deep cervical vein, and the suboccipital nerve, which innervate the deep cervical muscles.

When the suboccipital muscles are hypertonic, these nerves are compressed, further activating the muscles and creating a loop that sensitizes the muscle to pain. Inferior to the triangle is the third occipital nerve. This nerve courses down to the upper trapezius where it innervates the skin, and agitation causes pain in the caudad portion of the back of the neck. Therefore, if any of these muscles are hypertonic or if the tissue is tight, it can constrict the blood flow and impinge the nerves, causing cervicogenic headaches and pain.

General Facilitation

Deep cervical muscles that are dysfunctional can also cause restricted and/or altered motion at the related vertebral segment.16 The deep cervical muscles (rotatores brevis, interspinales, intertransversarii, and rectus capitis posterior minor) are short restrictor muscles that span across one or two vertebral segments.16 Because of their orientation and proprioceptive feedback, these muscles allow for balance of the spinal column and rapid response to segmental spinal cord facilitation. Facilitation involves the perpetuation of neurons (premotor neurons, motor neurons, or preganglionic sympathetic neurons in one or more segments of the spinal cord) in a state of partial or subthreshold excitation in which less afferent stimulation is required to trigger impulse discharge.17 In those with dysfunctional deep cervical muscles, pain may be produced even with minor insult. This facilitation leads to feedback that causes changes in the tissue and deep cervical musculature near the dysfunctional segment(s), which can be attributed to a change in hysteresis, ultimately creating a continuous and chronic loop of altered spinal mechanics.18

Hysteresis Changes

Hysteresis is defined as a characteristic of tissue texture. It describes the amount of recoil/response a tissue has after deformation. When the tissue is edematous and boggy, the recoil time will lag compared to normal, and in an opposite manner, fibrotic tissue will recoil faster than normal. Barnes et al, used a durometer that measured motoricity, mobility, frequency, and fixation in 240 participants to analyze the effects of OMT.19 Motoricity was defined by the overall dysfunction of a cervical vertebra; mobility corresponded to range of motion; frequency indicated the time it took to meet the end of range of motion; fixation measured resistance within tissues. Participants were divided into six groups (five different OMT modalities and one sham OMT group). Results showed significant changes in motoricity, fixation, and frequency for all OMT treatments but no change in the sham group from baseline, thus showing OMT having an appreciable effect on cervical tissue, which can improve the hysteresis of patients with neck pain.

Chronic neck pain and facilitation of cervical vertebral segments not only cause hysteresis changes and decreased range of motion but also suboccipital muscle atrophy.20 In a study by Greenman, irreversible atrophic changes to the rectus capitis major and minor muscles were observed in participants with chronic head and neck pain as compared to controls.20 Magnetic resonance imaging demonstrated increased high signal intensity for suboccipital muscles in patients with chronic head and neck pain indicating increased fatty tissue in place of atrophied suboccipital skeletal muscle. The authors hypothesize that decreased proprioceptive afferent activity in the affected muscles may lead to increased facilitation, which is ultimately perceived as pain. OMT can play a pivotal role in mitigating these degenerative changes by preventing or treating long-term chronic head and neck pain.

In the Acute Setting

In addition to chronic pain, OMT effectively treats neck pain in the acute setting. McReynolds et al, studied the impact of OMT on patients with acute cervical pain of less than 3-week duration in an emergency room setting.21 Participants were enrolled in one of two treatment groups and were treated with either one 30-mg intramuscular ketorolac injection or OMT. To assess pain intensity, participants reported their level of pain before and after treatment using an 11-point scale. To assess perceived overall benefit of either treatment, they reported pain relief on a 5-point Likert scale. Within one hour of treatment, OMT provided perceived pain relief equal to that of a 30 mg intramuscular ketorolac injection.21 Additionally, those participants who were treated with OMT experienced a statistically significant reduction in pain intensity as compared to the ketorolac group.21 Therefore, OMT may be utilized to provide relief for neck pain, reduce facilitation of cervical vertebrae, and potentially prevent long-term chronic neck pain and suboccipital muscle atrophy.

Conclusion

Neck pain is prevalent in the working-age and young adult populations, which leads to missed workdays and decreased productivity.3 Additionally, this issue negatively impacts social interactions and relationships. People with neck discomfort feel more isolated due to perceived incomprehension of their pain from family and co-workers.21 Those with chronic pain report decreased participation both socially and at work due to fatigue, lower concentration, and psychological struggles due to pain.22

Therefore, the burden of neck pain extends beyond the cost of missed workdays. Healthcare providers seeing patients suffering from neck pain should support them with a proper work-up, that includes investigating and adjusting lifestyle habits, especially portable electronic device use. They should also recommend available resources, including osteopathic manipulative treatment as an option for musculoskeletal causes of neck pain.

Last updated on: April 2, 2020
Continue Reading:
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
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