"Pain in the Neck" --need help with client

[uk_staffie]

Hi folks, I want to pick all the brilliant brains out there and see if there is something I am missing with my treatment of this client.

Her complaint: "burning and aching" posterior neck and top of shoulders. A little stiffness in right arm. Worst at the end of the work day, she constantly wants to rub base of occiput/upper neck area. She has had tension problems like this the past 2 years, with ache and burning no longer between scapulas and now having migrated to neck as described.
She is an RN, but a resident care manager and about 2/3 or her day is spent at the computer. Her desk setup is "pretty good" and has been set up by a professional, including training.
She is in late 20's, normal weight, slight build, only exercises half-heartedly about 2x a week.

Things that help: Stretching, massage, chiropractic adjustments, movement in general.
Things that worsen syptoms: Lack of movement, stress, working.

Chiropractor reviews that she adjusts very easily, doesn't seem to have any problems. However, client reviews that she gets the most relief from chiro. adjustments, and feels better for about a week after. Currently she is able to get Chiro adjustments 1x a month.

Last year she got 12 acupuncture treatments over 4-5 months and reviewed no improvement.

I massage her for 30 minutes, focusing on musculature in the ant./post. shoulder girdle, neck and head appx. 1x every 2-3 weeks. I use heat therapy, do swedish/deep tissue techniques, check for trigger points, last session I did some myofascial release, which wasn't all that restricted. I always check neck ROM in all directions, and stretch if necessary, but she is rarely restricted. Also do occipital release.
She always wants her massage at the end of the week, so she will "feel good/normal" for the weekend. She reviews feeling a little sore for about 24 hours after a massage, and then, relief from burning/aching for about 3 days.

My observations: client carries shoulders higher when sitting and laying on massage table. Client has normal, and what I would consider quite good range of motion in all directions of neck and shoulders. Last session I noticed that the middle aspect of the R Scalenes, was the only hypertonicity that I noted. And occipitals. She has moderate adhesions at the insertion of the lev. scapulae, but nothing to right home about.

Client also reviews that when she "consciously" tries to relax her shoulders, it "feels weird/unnatural". It feels good for a few seconds, and then weird........

So...........I have been massaging her for about 2-3 years, and have always encouraged after/home care of stretching pecs, and ant neck, to keep shoulders back and down, and to be more conscious of where her shoulders are during the day. More recently I have encouraged her to focus some energy on building muscle tone in post. shoulder girdle.

Don't know if I can do much more for her if she doesn't want to pursue these issues at home or can afford to come more often.
Or maybe I'm missing something.

I appreciate your input,
Noel

 

[Garrett R]

Try stretching her pec minors. When we sit at the computer, we tend to be head forward, shoulders rounded. When prone, I would wrap my hand underneath the shoulder and then pull into a good stretch and hold. Repeat 2-3 more times, then do the same with the next shoulder. For the head-forward position, she needs to work on it herself. The chin is supposed to be directly above the sternum, not a couple inches in front of it like so many hold their heads. Sometimes people can't understand how I am telling them to hold their heads, so I say, "back your head up" and the lightbulb comes on.

Try sitting at her head while she is prone AND while supine, push both shoulders away from you. That stretches the lev. scap, upper traps...and you know - all those muscles. (I can be lazy, right?)

She can do pec stretches herself in any doorway. Have her "hook" her elbows in the door way at various hights.

She needs to intentionally practice good posture. Head straight on top of the body, not ahead of it, shoulders dropped down and back, and no arching the back - "drop your butt" helps to fix that. It will take practice to retrain herself to have good posture all day long, but it's worth it. When my posture improved, all my back/neck/shoulder pain went away.

 

[Incense & Peppermints68]

You mentioned that she has good results from the Chiro for a few days, I am wondering if the upper thoracic and lower cervicals are pushing forward or backward due to her holding pattern. I would try some traction at the occiput/head after working on the neck and shoulders. A lot of the clients I have worked on have had a lot of good results when I have done this to them. Keep us informed how it goes.

 

[Slappy LaRue]

She says it feels good for a few seconds then "weird" to relax her shoulders? "weird" how? Does it make her fidgety? vulnerable? angry? Seems to me there might be an emotional component.

How is her home life? How much responsibility does she have at work or at home? Does she get much support? (Resident care managers and employees are often under tremendous stress and pressure.) Is she holding her shoulders up because her muscles are tight or because she's "watching her back?" If she doesn't have a massage before the weekend, does she feel better on Sunday night than she did on Friday night anyways (even if she would feel even better with massage?)

On the physical side, it sounds like things don't stay in place, not because they are too tight but because they lack tone. She may need to add some real weight training if she is going to get relief from symptoms. If she is easy to adjust, and you are not finding any exceptionally tight areas, the burning might be because she isn't efficiently firing what muscle she has to maintain a relaxed posture.

I see a couple of chronic pain clients like that, and though I am happy to have the regular client giving me money, I have an instinct that they would get better if they did some strength training, and I have told them that. Both young women are dancers (or were dancers,) ballet the whole time growing up, and have lost tone after they quit dancing, both very thin. They have hyper-mobile joints and ligaments, do NOT need to be stretched. They are like rubberbands that have lost all their "snap." They NEED to tone up.

Obviously without seeing your client, I couldn't say if that's the issue, but it's worth checking out.

 

[Gab :)]

I would tend to agree with stretching the pecs, also if possible evaluate her sitting posture to see what else is shortening.

Tim

 

[squishy]

I would think that in 30 mins. it would be difficult to get longer lasting results with all the work that you have to be doing in that short amount of time. Would she be willing to try a few hour sessons to see if that gets longer results?

I have lax-ligaments. My neck is a tight mess, but my range of motion is fine because my ligaments are so lax. My adjustments last me about a week, I can quickly come out of alignment. I also get my massage right before my adjustment to help with the spasms I get after the adjustment. It helps a lot.

I do a strengthening exercise where I lay with my head supported at the occiput by a bed (just barely hanging off). I will then lift my neck up towards my chest and hold for a second (or more) and then release. I rotate my neck to the side and do the same in the same direction, toward the ceiling not the shoulder. It is an easy exercise and it helps with the burning and tension feeling I get both in the front and back of the neck.
(Thanks Intuitouch!)

 

[shorty150217]

I would like to add a few suggestions. 1 hour per week, mainly upper body for a minimum of 8 weeks. Try to get her out of the "habit" of raising those shoulders. Add in anterior cervical work, possibly deep ant. cerv. work.

She can also get on a wall doing some wall exercises. I had written this previously somewhere on the forums, but can't seem to find it. It may have gotten lost in the move last year. Exercises: Stand back against the wall, pull shoulder blades together and raise the arms to the side with elbows bent (so that you have somewhat of an 90 degree or a little more angle in the arm) - with arms flat on the wall. Raise the hands above the head. The look a lot like snow angels and are called "Wall Angels". In most instances, these help tremendously with neck issues. The chiropractor should know what these are.

Also, you may want to address the psoas and the leg adductors. According to my rolfer, the adductors have a reciprocity with the cervicals.
She does pretty deep work (it is uncomfortable) on my adductors and it does seem to give some relief. I have some pretty serious neck issues from some major MVA's over the past years since a child, which is part of the reason I perform a lot of neck work as a specilaty in my practice.

Here's another thread I replied to that may give you some more insight as to how I work some clients. C5 - C6 disc compression with radiculopathy

You probably already know about this thread: Cervical techniques, which has more info on Masthera's occipital technique (she mentioned above) in it.

Hope it helps.

 

[R4u]

I would think that in 30 mins. it would be difficult to get longer lasting results with all the work that you have to be doing in that short amount of time. Would she be willing to try a few hour sessons to see if that gets longer results?

I agree, a longer session may very well be necessary.

I have lax-ligaments. My neck is a tight mess, but my range of motion is fine because my ligaments are so lax. My adjustments last me about a week, I can quickly come out of alignment. I also get my massage right before my adjustment to help with the spasms I get after the adjustment. It helps a lot.

Like my Cyber-twin, Masthera, I also have lax ligaments. (Yet another of the million little things we have in common!) Unfortunately my adjustments don't always make it a week... as I can have mine "re-adjust" itself in front of the chiropractor as I put my coat on to leave. I have found that I Have to Have a massage scheduled right before my chiropractor adjustment or it just won't even pretend to hold at all. I usually request a 1.5 - 2 hr massage appointment though, because an hour isn't really long enough anymore.

If the client is suffering from "head forward posture" I think one of the best things to recommend for a stretch is "wall angels"... which were taught to me as a "stabilization technique" for the shoulder, by Bob King (founder of Chicago School of MT, now owned by Cortiva) in his seminar "unlocking the thoracic cage."

Wall Angels (Three way shoulder stabilization technique):

1. Stand with your back to the wall, about 6-8 inches out from wall, feet shoulder width apart. Extend your arms to shoulder level and bend the elbows as if to do a "jumping jack." Bend your knees and gently roll your pelvis back to touch the wall, bringing your entire back, head, arms and hands back to touch the wall as well. Tuck your chin in to lengthen posterior neck muscles.
2. Pause briefly. (This is a good point at which to "spot" the client, indicating to them areas which are not making contact with the wall.)Inhale.
3. Exhale as you lower your elbows to your waistline (keeping them flush against the wall) and repeat from 20-100 times per day.
Perform the actions slowly so you can be conscious of contracting the extemal rotators, retractors and depressors of the shoulder. Once the exercise becomes easy light weights (1-3 lb) could be added.

(It should look as if their upper body was doing a slow "snow angel" or "jumping jack" against the wall.)

I know most of my clients aren't going to be able to do 100. But I definitely request they shoot for the 20, and I tell them if they can only do 5 in the beginning ... then do 5 reps spaced 4 times throughout the day. I figure this may help them to be more aware of their posture during the day as well.

Like with massage, results are cummulative, but some results may be seen (and felt) in as little as 2 weeks!

edit:
LOL, looks like Great Minds Think Alike Texas-Gal! (Wall Angels) and we were posting at the exact same time!

 

[Dark Mistress]

You probably already know about this thread: Cervical techniques, which has more info on Masthera's occipital technique (she mentioned above) in it.

Just to clarify. The technique in this post is a strengthening exercise. The technique from the post that Texas-Gal linked to is a massage technique.

Cyber-twin - We do have so many things in common. I have had many adjustments go out as I drove out of the parking lot at the DC's office.
I always get 1.5 hour massage because an hour is just too short. 1.5 hours is too short at times too.

 

[bossglaus]

Just to clarify. The technique in this post is a strengthening exercise. The technique from the post that Texas-Gal linked to is a massage technique.

Whoops!

 

[vampyre4blood]

Thank you all kindly for your thoughtful responses.

I saw my client on Friday and we had a nice talk about them; I have done at one time or the other just about every massage technique that has been described above and referred to in links.
She has a great home life and a job that she has been professionally successful in; she has been doing if for a few years, and although it's busy/stressful, she is well qualified for it, and only works 9-5 and has weekends off, and takes her vacations. So, that is not a concern. She doesn't seem to think there is an emotional component to "feeling weird" about her shoulders being in a "normal" position. Just weird because it feels unnatural. Basically fighting against muscle memory.

We concluded that although the massage (and chiro) is helping with symptoms, the problem isn't going to go away, and she has a lot of work to do on her posture and some strength conditioning. She did admit to kind of looking for the magic pill, but realized that there is no such thing, and was a little chagrined that she had been looking for so long. So, she's planning on skipping the chiropractor and working with a personal trainer to help her with the correct exercises at her gym. I gave her some information about upper-cross syndrome and highlighted the list of muscles that are tight/short, and those that are long and weak that need the work, so she can find the right trainer.

At this time we are going to continue with the 30 minute massages 2x a month, and I don't think I will be changing my treatment other than to always stretch her pecs, which I didn't always do, and I will to some deep ant. neck work next time. (Something I'm trained in, but haven't done on her) I think it will be especially helpful once she starts her strength training. And I printed out instructions for the wall angels for her, and we talked about putting a post it note on her computer or something to remind her to "back her neck up". I'll be in her hospital working this week, and I'm going in early to see her desk set-up.

Thanks again,
Noel

 

[Christa D]

Sounds like she has a long haul if she can't dedicate more time to getting worked on - which you undoubtedly already know.

On a side note, you mentioned the posture. It is interesting to me she'll go see a personal trainer and not come see you more frequently. Also, she may need to consider getting rolfed. I can vouch for it having done wonders for me.

 

[freebienutter]

work her pecs and give her self care treatment/exercises for the pecs. something she can do at home a couple of times a day. she can see a chiro, receive massage, see a personal trainer...but until she does something for herself everyday at home, she's not going to see any fast results. do you have a self-treatment guide/book? if not, pm me and i'll send you some self-massage treatment you can look at and pass on to her (if you like).

 

[xxxobscureabyssxxx]

i think it's her levator scapula. pain on top of shoulder and burning in neck. i prefer to treat it with A.R.T. if the pain is in the right side. seated with you behind client have client raise right shoulder an bring head back with back of head tilted to the right scapula (Lv Scp is shortened). place thumb on top of insertion point on scapula. tell client to lower shoulder while bringing down and arm across to left knee while you are applying an inferior pressure with thumb. then have client drop head chin to chest to the left side (Lv Scp is completely lenghten). at end of movement have them just slightly LOOK to the right side armpit. hold for a few seconds. the most gains come in the very end of the range of motion. i do this 3-4x on both sides. i find they have immediate relief.

 

[susan s]

Ditto with the wall angels and the opinion that Ms. Client is not allowing sufficient time for her bodywork to see lasting or improving results. Two things I didn't see mentioned that I would also check, if she were my client:

What exercises does her PT have her doing for upper body? Often the male PTs (not always, but seems more problematic with them) work the traps WAY too much. Shoulder shrugs, pull-downs, side raises, lunges with a barbell across the sholders...while the traps are not the primary movers for these (except shrugs) they do get engaged. And probably overworked and not sufficiently warmed up or cooled down. She needs to focus while exercising on keeping her shoulders and entire upper body alignment in good form, not just while at the desk.

Secondly, something that was pointed out that I cannot agree more with is the tendency for us to allow our chins to float forward so that the weight of the skull is not balanced evenly over the spine.

A neat little trick for generally releasing the neck as a whole and the extreme upper traps is what I call "chicken neck". t117 Assume good posture with shoulders relaxed, head balanced evenly over the spine and then with the chin LEVEL (not pointing down or tucked) take the index finger of one hand and rest it on the chin, then gently with the neck muscles only press backwards laterally. The purpose of the finger is just to keep the focus on moving the chin levelly BACK, not DOWN. Watch in a 2-angle mirror if needed, the first few times. The movemt is similar to the back-and-forth bob you see a chicken's head do when it walks, but it's all neck and very slow. You want to really feel the movement and hold it before releasing the head to float back naturally to the neutral position. Repeat five or six times, then rest. Repeat throughout the day, especially when driving.

 

[felixeatsmeowmix]

Okay, I almost read the whole thread....skimmed cause I'm tired, but I wanted to throw this in if it hasn't been addressed:

How about PNF exercises for muscle re-education at the end of the massage?

 

[DrummerAdam]

Strength Work

Sounds like the neck is under neural tension and she shrugs her shoulders to releive this tension. She needs more upper body strength inc traps, infasp, cervical retractors.

OffIce

 

[Magic]

I know this reply is a year later BUT no one has mentioned the fact that the ANTERIOR neck need s to be unlocked before posterior work can be done. work scm, infra/supra-hoids, ant/med/post. scalenes, and most importantly, longus coli....then do post. neck, levator, traps, erectors. it's easy work on you too...and the results are amazing...

 

[Magic is Might!]

client with repeated neck pain

Reading through all the good advice given on the subject I could not avoid wondering whether this lady has a problem with something nobody actually mentioned but which is of great importance, i.e. her breathing. A good posture depends much on how a person regulates his/her breathing. Ask her next time to take a deep breath and look where the shoulders go when she does it. If her breathing is correct they should move only very slightly upwards. Correct breathing is being done by the diaphragm, widening the lower part of the ribcage with a constant bit of tension on the Rectus Abdominis. Don't forget to think about your own breathing as well so that your body gets the necessary fresh oxygen in order to function properly. Greetings from Sweden, Adrian

 

[Helios]

According to my rolfer, the adductors have a reciprocity with the cervicals.

Wow. I'm not sure I've every heard this... just made me think of one of my clients, who always requests deep adductor work... he won't even let me touch his neck while supine. Too nervous/uncomfortable.