Neck Pain Current medical understanding of neck pain. Adapted from: Evidence-Based Management of Acute Musculoskeletal Pain by The National Health and Research Council (NHMRC) Aetiology and Prevalence

• Acute neck pain is most commonly idiopathic or attributed to a whiplash accident; serious causes of acute neck pain are rare (< 1%).

• Degenerative changes, osteoarthrosis or spondylosis of the neck are neither causes nor risk factors for idiopathic neck pain.

• The most consistent determinant of idiopathic neck pain is the social nature of the work environment; occupation and stress at work are weakly associated risk factors.

• Involvement in a motor vehicle accident is not a risk factor for developing neck pain; however individuals who experience neck pain soon after such an event are more likely to develop chronic neck pain.

History

• Attention should be paid to the intensity of pain because regardless of its cause, severe pain is a prognostic risk factor for chronicity and patients with severe pain may require special or more concerted interventions.

• The hallmarks of serious causes of acute neck pain are to be found in the nature and mode of pain onset, its intensity and alerting features.

• Eliciting a history aids the identification of potentially threatening and serious causes of acute neck pain and distinguishes them from non-threatening causes.

Physical Examination

• Physical examination does not provide a pathoanatomic diagnosis of acute idiopathic or whiplash-associated neck pain as clinical tests have poor reliability and lack validity.

• Despite limitations, physical examination is an opportunity to identify features of potentially serious conditions.

• Tenderness and restricted cervical range of movement correlate well with the presence of neck pain, confirming a local cause for the pain.

Ancillary Investigations

• Plain radiography is not indicated for the investigation of acute neck pain in the absence of a history of trauma, or in the absence of clinical features of a possible serious disorder.

• In symptomatic patients with a history of trauma, radiography is indicated

• CT is indicated only when: plain films are positive, suspicious or inadequate; plain films are normal but neurological signs or symptoms are present; screening films suggest injury at the occiput to C2 levels; there is severe head injury; there is severe injury with signs of lower cranial nerve injury, or pain and tenderness in the sub-occipital region.

• Acute neck pain in conjunction with features alerting to the possibility of a serious underlying condition is an indication for MRI.

Terminology Except for serious conditions, precise identification of the cause of neck pain is unnecessary.

• Once serious causes have been recognised or excluded, terms to describe acute neck pain can be either ‘acute idiopathic neck pain’ or ‘acute whiplash-associated neck pain’.

• Approximately 40% of patients recover fully from acute idiopathic neck pain, approximately 30% continue to have mild symptoms and 30% of patients continue to have moderate or severe symptoms.

• Approximately 56% of patients fully recover within three months from onset of acute whiplash associated neck pain, 80% recover fully within one or two years; 15–40% continue to have symptoms and 5% are severely affected.

• Psychosocial factors are not determinants of chronicity in whiplash-associated neck pain.

• Risk factors for chronicity of following whiplash-associated neck pain are older age at time of injury, severity of initial symptoms, past history of headache or head injury.

Evidence of Benefit

• Advice to Stay Active (Activation) — Encouraging resumption of normal activities and movement of the neck is more effective compared to a collar and rest for acute neck pain.

• Exercises — Gentle neck exercises commenced early post-injury are more effective compared to rest and analgesia or information and a collar in acute

neck pain.

• Exercises performed at home are as effective for neck pain as tailored outpatient treatments at two months and appear to be more effective at two years after treatment.

• Multi-Modal Therapy — Multi-modal (combined) treatments inclusive of cervical passive mobilisation in combination with specific exercise alone or specific exercise with other modalities are more effective for acute neck pain in the short term compared to rest, collar use and single modality approaches.

• Acupuncture — Moderate-quality evidence suggests that acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment and at short-term follow-up, and that those who received acupuncture report less pain and disability at short-term follow-up than those on a wait-list. Moderate-quality evidence also indicates that acupuncture is more effective than inactive treatment for relieving pain at short-term follow-up.

Mechanical considerations Ideally the head, one tenth the weight of the entire body, should be perfectly balanced on the spine, requiring only gentle muscular contraction to restore deviations from the ideal to the point of balance. For most of us, major and sustained contraction, usually of the posterior cervical muscles is required to keep our heads up. Two major types of compensation are usually required.

1. Compensation for gross deviation from the ideal – most often the head is anterior to ideal and requires contraction from posterior muscles but lateral and, less commonly, anterior patterns occur.

2. Finer compensation, usually occurring in the upper cervical region, is needed to keep the eyes level and to the front.

The lower cervical segments are the most mobile in the spine (e.g responsible for more than half the rotation that the whole spine is capable of) and as a consequence are the most prone to degenerative change. Patterns of muscular tension can have an emotional, rather than a mechanical basis and nowhere is this more true than the muscles of the neck, shoulder girdle, jaw and throat.

Chinese medicine perspective:

Neck pain, like low back pain, presents in many different forms, so close attention must be paid to the normal diagnostic considerations. Type of stagnation: Predominantly qi stagnation: Use a meridian based treatment with fewer ah shi points and more attention paid to distal points. GB and SJ meridians most likely to be involved. Treat the qi stagnation. Predominantly blood stagnation: Local and ah shi points are main points (unless the condition is predominantly xu, in which case the distal points chosen are also likely to be important) Nature of stagnation: Shi (full): Almost always has a strong mechanical component. Even if it is predominantly qi stagnation there will be a specific area that is affected and local and ah shi points will feature in your treatment. Check for invasion of pathogenic qi (xie qi). Xu (empty): If there is no important internal component, the emptiness will most likely take the form of muscle weakness, best treated with exercise. Internal emptiness will require specific attention. Location of stagnation: Because the somatic system is external, neck pain will have at least some external component. Sometimes however, an internal condition can be an important component and will need to be treated. External: All the yang meridians pass over the neck and all can be involved in the production of neck pain. Most commonly SI is involved if the pain is posterior (the nape), and GB (or SJ) if the pain is at the side of the neck. If there is a substantial anterior component to the dysfunction then Lu 7 seems to work better than LI points.

The following table represents my take on the relationship between the muscle meridian pathways in the neck and the muscles themselves: Small Intestine Rhomboids, Splenius cervicus and capitis (other side) Sanjiao Supraspinatus, Levator scapulae Large Intestine Deltoid, Trapezius, scalenes, platysma Stomach Swallowing muscles Gall Bladder Sternocleidomastoid Bladder Erector spinae, Semispinalis, suboccipitals, Occipito-

frontalis Kidney Anterior spinal muscles Often a structural or anatomically based diagnosis provides the best way of analyzing and treating the external component. Unlike the low back, which often presents with a familiar symptom pattern, neck pain presents in a bewildering variety of patterns. It is helpful to treat the neck as a complex pattern of dysfunction that needs attention at several places at once for a successful outcome. The pattern will be different for every sufferer. The differentiation into myofascial and vertebral patterns is less useful in the neck than in the low back, as components of both are often present together. Tips for anatomically based diagnosis • Myofascial trigger points: follow the usual rules • Joint pain is usually worse at the end of active and passive movement • Upper thoracics almost always involved in low cervical problems • Jaw or front of chest often involved in upper cervical problems • Areas of stagnation can often be best palpated when the neck is being passively moved • Use the Jinjing

Myofascial trigger points (Ah shi pts) refer pain to neck:

Levator scapulae

Lower and mid trapezius

Splenius cervicus refer pain to the shoulder and arm:

Scalenes refer pain to head: upper trapezius sternocleidomastoid - both heads splenius capitis sub-occipitals semispinalis

Uppper trapezius Sternocleidomastoid

Sub-occipitals Semispinalis Vertebral upper T's – UB (esp UB 12), Huato jiaji, Du (esp Du 13) low C's - Bailao mid C’s - Xinshi,St 9 upper C's - GB 20, SJ 16 If there are symptoms of nerve impingement as well as neck pain then more stimulation is needed. Use two ah shi pts on either side of the affected joint then use electrostimulation across them.

Pattern of strain • Anterior patterns: Found in many whiplash patients and in other types of patient with neck pain. Check the following muscles and points:

sternocleidoid scalenes subclavius (Ki 27) – needled laterally and a little superiorly pectoralis minor (Lu 1) – needled across the fibres Ren 17

• Posterior pattern: Found in people who sit a lot or older people with collapsed posture. Check the following muscles and points: GB 20 Bailao Semispinalis Upper T’s – HJ, Inner Bl and outer Bl - esp T4 • Whiplash – follow the symptoms around with ah shi points • Pathogenic energies (xie qi) wind - GB 20, LI 4, SJ 5, UB 12, Lu 7, GB 39 cold - ah shi pts. ,moxa, St 36, Ren 6 damp - St 36, St 40, Sp 6, Sp 9 Internal: Stagnant Liver qi - a full condition symptoms come from rising energy: tension anger worse for stress headache GB 20, 21, Liv 3, Bl 18, Bl 19 Blood xu - very tender neck and shoulders

aggravated by massage or heavy manipulation dull headache - esp at end of day tiredness , paleness weak pulse St 36, Bl 17, Bl 20, Bl 21, GB 39 Womens Precious Pills (Ba zhen wan)

Distal Points: Your choice will reflect your diagnosis of course but the following points have the best reputations: S.I 3 — esp. the back of the neck SJ 3 Lu 7 — esp if wind cold SJ 5 — esp if xie qi GB 39 — acute and wind attack or chronic and xu. GB 41 – possibly use opposite side Bl 65 – possibly use opposite side

The Balance method offers a few extra approaches to using distal points. To balance Bladder - when pain is suboccipital just lateral to midline SI 5 and Lu 9 To balance GB meridian sub occipital to trapezius Ht 7 - SJ 4 (incl SI 4&5) Pain near C7/T1 Lu 9, SI 5, Ki 3 Accross shoulder to scapula Ki 5-7, Ht 4-7

Shoulder disorders (Part 1) The shoulder is the upper part of the upper extremity, where our arms connect with our central axis — the spine and ribcage. The humerus is loosely attached to the scapula by the shallow gleno-humeral joint. It is supported and moved by a series of short powerful muscles which have their origin on the scapula. Two larger muscles, Pectoralis major and Latissimus dorsi, run from the spine and ribcage, bypassing the scapula to attach to the humerus. The scapula in turn can move freely over the posterior aspect of the ribcage. It is moved and stabilised by powerful muscles that have their origin on the spine (Trapezius, Rhomboids, Levator scapulae) and ribcage (Pectoralis minor and Serratus anterior). The clavicle performs the major bracing task, helping keep the shoulder at a useful distance from the midline. It is attached to the scapula at the acromio-clavicular joint and to the sternum at the sterno-clavicular joint. This combination of a mobile shoulder joint and a scapula that can move into the optimum position gives the humerus enormous flexibility relative to the spine. This helps us get our hands where we want them so we can feel, manipulate and otherwise interact with the world.

ChineseMedicinePerspectiveAll the arm meridians cross the shoulder. However, most of the important structures of the shoulder are in the lateral and posterior aspects and are thereby governed by the arm yang meridians - Large Intestine, Sanjiao and Small Intestine. Of the yin meridians, only the most superficial (or least yin), the tai yin meridian of the Lung, plays any significant roll in the shoulder. Palpate your own armpit where the Heart and Pericardium meridians pass and feel how little substance there is there. Notice also that the distance between the Lu and Ht meridians is small relative to that between the LI and SI meridians. Thus the LI, SJ and SI (and to a lesser extent the Lu) are those most involved in shoulder problems. The author’s perspective on the sinew channels (jinjing) as they cross the shoulder is:

Jingjin Pathway - elbow to neck/chest

Large Intestine Up lateral intermuscular septum to Deltoid insertion, Deltoid, binds at acromion, Trapezius

Sanjiao Up lateral intermuscular septum (with LI) to lateral tubercle, Supraspinatus, Levator scapula

Small Intestine Triceps, Infraspinatus, Teres major and minor, Rhomboids, Serratus posterior superior, contra-lateral Splenius cervicis and capitis

Lung Brachialis and Biceps, Coracobrachialis, binds at coracoid process, Pectoralis minor, subclavius

Pericardium Up medial intermuscular septum to axilla, divides, Subscapularis, Serratus anterior, and Latissimus dorsi, Teres major

Heart Up medial intermuscular septum, Pectoralis major

The arm yang meridians do not seem to have any direct relationship with the organs whose names they bear. They have no points that directly affect those organs, the points that do directly affect them being on other meridians, notably the Bl and St meridians. It is more useful to think of the arm yang meridians as reflecting the yang aspects of the related zang. Therefore, LI meridian relates to yang aspects of Lu SJ “ “ “ “ “ PC SI “ “ “ “ “ Ht

Pointsthataffecttheshoulder The many local points of the shoulder have precise local effects that often depend on precise needling. Choices about direction and depth are particularly important. The anatomy of the target tissue is the main guide. In addition to the meridian points there are several extra points. Even with this many points there are many situations requiring the use of ah shi points. Local points LI15 (Jianyu) Gleno-humeral joint and supraspinatus tendon LI16 (Jugu) Acromio-clavicular joint and supraspinatus SJ 14 (Jianliao) Supraspinatus and infraspinatus tendons SI 9 (Jianzhen) Teres major, Latissimus dorsi SI10 (Naoshu) Infraspinatus SI 11 (Tianzong) Infraspinatus SI 12 (Bingfeng) Supraspinatus muscle SI 14 (Jianweishu) Levator scapulae SI 15 (Jianzhongshu) Splenius cervicis SJ 15 (Tianliao) Trapezius Bl 41 (Pohu) Serratus posterior superior Bl 43 (Gohuangshu) Serratus posterior superior Lu 1 (Zhongfu) Pectoralis major and minor There is little agreement in available texts about the names and locations of extra points around the shoulder. Extra (Jianqian, Taijian, N-UE-11) 1.0 - 1.5 cun anterior to LI 15 below clavicle Gleno-humeral joint Extra (Taijian, Jianshu, N-UE-42)

In the hollow below AC jt, lateral to the tip of the coracoid process. Gleno humeral joint Extra (Jianneiling, Jianqian, M-UE-48) With the arm hanging at the side, midway between the end of the anterior axillary crease and LI15 (Jianyu) Anterior deltoid, short head of Biceps, Coracobrachialis Extra (Jubei) 3 cun above anterior axillary fold. Gleno-humeral joint

Distal points LI 11 (Quchi) The best general point for mechanical shoulder problems Lu 7 (Lieque) Anterior shoulder. Combines well with Lu 2 Lu 5 (Chize) Anterior shoulder pain and qi stagnation Lu 9 (Taiyuan) Bilateral shoulder pain Extra point The most tender point between St 36 and St 38 about two

fingers width from the edge of the tibia. Needled and manipulated while patient moves their shoulder around.

To increase range of movement of stiff shoulder

Examinationoftheshoulder A thorough examination of the shoulder is almost always productive

PatientsittingLook: from the front for asymmetry, swelling etc. Move: Test passive and active resisted movements Passive movements: These test the quality and range of joint movement. You are looking for: differences between the ranges of movement of the two shoulders. Restricted shoulder movement can be caused by tight muscles, contracted ligaments or joint capsules, or bony deformity. an altered quality of the end feel and pain at the end of the (passive) range. In general tight muscles produce little pain at the end of the passive movement and the endfeel is springy. Contracted joint capsules and ligaments, on the other hand are often painful at the end of range and have a more sudden endfeel. A single reduced range of movement is usually a sign of a trigger point in a muscle that performs the opposite action to the restricted movement. For instance, restricted internal rotation can indicate a trigger point in infraspinatus, a major external rotator. Several restricted ranges of movement, on the other hand, usually indicate a disorder of the gleno-humeral joint. Active resisted movements - test a muscle’s integrity and strength.

Pain indicates some sort of inflammation or damage to the musculo tendinous structures responsible for the movement being tested. For instance, painful shoulder abduction can indicate disorder of Supraspinatus, a major abductor. Weakness is more difficult to interpret as it can be caused by neurological phenomena or atrophy from lack of use. Stand behind patient with one hand on the shoulder and the other holding the arm to move or resist. Test flexion & extension abduction & adduction internal & external rotation Feel: Diagnosis of shoulder dysfunction is greatly aided by the accessibility of all the major structures. By palpating these, suspicions derived from the movement tests can be confirmed and areas of dysfunction that produced no positive movement signs can be uncovered. During the palpation the operator tests each structure with appropriate pressure and the patient reports any tenderness elicited. The operator tries to feel the dysfunction Stand behind patient and examine both sides at once. • sterno - clavicular joint • the clavicle (signs of previous fracture) • coracoid process (mainly as a landmark) • coraco-clavicular ligaments (conoid and trapezoid)

• head of the humerus (tenderness - capsule tightness/ inflammation)

• pectoralis minor (muscle belly for trigger points) • pectoralis major (muscle belly for trigger points) • coracobrachialis (muscle belly for trigger points) • anterior deltoid (muscle belly for trigger points) • acromion process, acromio-clavicular joint • bicipital groove (for bicipital tendinopathy and as a landmark) • supraspinatus tendon (for tendinopathy) • infraspinatus / teres minor tendons (for tendinopathy)

• infraspinatus / teres minor muscle bellies (muscle belly for trigger points)

• medial to medial scapula border (upper ribs, serratus post. sup.)

• levator scapula and upper trapezius (muscle belly for trigger points)

• subscapularis (muscle belly for trigger points) Note: If you cannot elicit or aggravate pain in the shoulder region by testing the active and passive movements of the shoulder then the most likely cause of the pain is referred pain from the neck &/or the upper back. Check this by testing neck movements. On the following page I have reproduced a list of the muscles responsible for the various shoulder movements. Keep a copy in your clinic to assist your examination.

Muscles of the Shoulder Movement Primary movers Secondary movers Flexion Anterior Deltoid Pectoralis major Coracobrachialis Biceps brachialis Extension Latissimus dorsi Teres minor Teres major Triceps (long head) Posterior deltoid Abduction Deltoid - middle Deltoid - rest Supraspinatus Serratus anterior Adduction Pectoralis major Teres major Latissimus dorsi External Rotation Infraspinatus Posterior deltoid Teres minor Internal Rotation Subscapularis Anterior deltoid Pectoralis major Latissimus dorsi Teres major Scapular Elevation Trapezius Rhomboids Levator scapulae Scapular Depression Latissimus Dorsi Pectoralis minor Scapular Retraction Rhomboids Trapezius Scapular Protraction Serratus anterior

Myofascial Trigger Points The simplest form of somatic dysfunction in the shoulder is the formation of trigger points. All the muscles of the shoulder can be overloaded through sudden unaccustomed use, chronicoveruse, postural strain, and trigger points are a common consequence of overload. Although mild in terms of pathology, trigger points can cause discomfort equal to that from more serious problems. In addition they can be secondary to more serious disorder but still an important source of symptoms. All trigger points, whether latent or active, will restrict joint movement which can contribute to any of the syndromes described in the following sections. Significant latent trigger points should be found and treated. Active trigger points will produce characteristic patterns of pain distribution which can be recognised; the diagnosis confirmed when the point is located and successfully treated. Trigger points in the shoulder are most commonly found in the following muscles – note how many refer pain to the front of the shoulder: Infraspinatus Refers pain to the front of the shoulder joint

Pushing the hand across the back is usually restricted Anterior deltoid Refers pain to the front of the shoulder joint Coraco brachialis Refers pain to the front of the shoulder jt. Pectoralis minor Refers pain to the front of the shoulder

Pectoralis major Refers pain to the front of the shoulder

Subscapularis in cases of frozen shoulder – pain behind shoulder Supraspinatus usually in association with tendinopathy

In addition to muscles attaching to the scapula or humerus in the shoulder, several muscles of the trunk refer pain to the shoulder and arm. Chief among these are serratus posterior superior and the scalene muscles.

Supraspinatus tendinopathy (Rotator cuff disorder) The rotator cuff is a group of flat tendons which fuse together and surround the front, back, and top of the shoulder joint like a cuff on a shirt sleeve. These tendons are connected individually to short muscles that originate from the scapula. These muscles help rotate the shoulder and help hold the shoulder joint together. Their names and positions in the cuff are: Supraspinatus (superior) Infraspinatus (posterior) Teres minor (posterior) Subscapularis (anterior) Perhaps the most common presenting shoulder problem is a tendinopathy of the supraspinatus tendon. While there are several different causes, the presentation and the core treatment is similar for most cases. The tendon of supraspinatus can be squashed or impinged as it passes under the acromion process (or the coraco-acromial ligament) and it contains a less vascular area near its attachment. Both these weaknesses make it vulnerable to gross and micro trauma in this area. Repeated microtrauma leads to degenerative changes in the tendon (tendinosis) which can result in symptom production (tendinopathy). Anything that puts pressure on either of these weaknesses can contribute to the deterioration of the tendon. Examples are: Repeated or extreme overhead activity, the shape of the the tunnel that the tendon has to pass through (especially if there are irregularities on the underside of the acromion process), weakness of the scapular stabilizers (allowing humeral head to move forward and upwards), nutritional weakness, reflex changes from the neck, hormonal changes (esp. menopausal). There are several pathways involved in producing symptoms and a patient can present with one or any combination of the three:

1. Direct trauma of impingement – can be a single episode or from repeated episodes.

2. Calcium salts being deposited in areas of degeneration caused by microtrauma. Can be very acute and last a few days or can present as a chronic condition

3. The tendon tears, usually in an area of degenerative change caused by repeated microtrauma. The tears can be partial or full thickness. The more

degenerative changes that are present, the less serious the impingement or needs to be to tear the tendon.

Signs and symptoms: Patients will usually present with a history of pain of weeks, months or, occasionally, years. The episode may have been triggered by a specific incident. • Pain - over the deltoid area

- worse for abduction - possible painful arc between 80 and 120 degrees of active abduction - often worse at night when patient lies on either side.

• Weakness – a sign of severity. Resistance testing of the supraspinatus is performed with the arms abducted 90° in the scapular plane (30° anterior to the coronal plane of the body) and internally rotated so that the thumbs point toward the floor. The examiner applies a downward force, while the patient attempts to maintain the arms parallel to the floor. Inability to resist the examiner's downward force demonstrates isolated supraspinatus weakness.

• Usually there is a full passive range of movement • Tenderness over the tendon near its insertion onto the greater tubercle. Examination: Tenderness over the tendon near its insertion is the most constant feature. Weakness and pain on resisted abduction may also be present. Look for associated dysfunction – this can be the difference between success and failure in treatment. Check the following:

• coraco-clavicular ligs

• coracobrachialis near the point Jianneiling

• pectoralis major

• the a-c joint

• the neck and upper back

Treatment: • The simple acupuncture treatment is to use a three point combination that

has a strong effect on the tendon and muscle. The three points are Jianyu (LI15), Jugu (LI 16) and Bingfeng (SI 12) . The patient lies prone (face down)

with the arms hanging off the side of the table or with the hands under the forehead. These positions allow a needle placed in Jianyu (LI 15) to lie alongside the tendon. When in place, the three needles should form a straight line.

• Treat any associated dysfunction

• Cupping over the tendon can be helpful after the needles have been removed

• Techniques of sedation and the choice of appropriate distal points depend on the particulars of the patient’s condition. LI 11 is a common choice.