Introduction
When my son was eight years old, he came to me with a small cut on the back of his hand and asked me how long it would take to get better. I looked at it and told him that it should be better within two to three days. That night, a scab formed but he picked it off. He continued to pick off the scab every day for the next five days, whereupon he came back to me and told me that I was wrong; it did not get better in two to three days.
I often like to use this story with students, therapists, and clients as a metaphor for the importance of client self-care. Very often, therapists do excellent work toward healing a client’s condition, but the client goes home and metaphorically picks off the scab, negating the work that has been done. To prevent this, it is critically important to give our clients postural self-care advice for when they are at home and work. Neck posture advice is especially important for our clients with cervical spine musculoskeletal conditions.
The most common condition of the cervical spine is hypertonic (tight) extensor musculature of the posterior neck and upper trunk/shoulder regions, including the upper trapezius, levator scapulae, semispinalis capitis, splenius capitis and cervicis, and suboccipital muscles. Unfortunately, there are many postures that can exacerbate this condition and prevent client improvement. Following are the seven most common self-care advice tips for neck posture that we should give our clients/patients.
Figure 1 A, Flexing the neck and head to look at a smartphone in the lap requires isometric contraction of neck extensor muscles to hold the head in an imbalanced posture. B, Bringing the smartphone up to eye level relieves the stress on the neck.
Flexed Head/Neck Posture
So many activities of daily life, whether they are at home or on the job involve working down in front of our body. Examples include reading a book in our lap, working on a smartphone, writing or typing on a keyboard, and tending to a baby. The problem is that if we bring our head and neck into flexion to look down at what we are doing, the center of weight of our head is no longer balanced over our trunk. Instead it is now imbalanced over thin air so that our chin would fall to our chest (i.e., our neck falls all the way into flexion). To prevent this from occurring, we isometrically contract our posterior neck extensor musculature (Figure 1a). When we add up how many hours we are in this posture, it is no wonder that we overuse and abuse these muscles! The key for healthy neck posture, whenever possible, is to bring what we are working on up to our eye level instead of flexing our head/neck down to it (Figure 1b). Note: The same concept is true when reading a book. Instead of reading it in our lap; it should be held up at eye level (a heavier book can be placed on a bookstand).
Figure 2 A, A forward (protracted) head posture also imbalances the head over thin air, placing a stress on neck extensor muscles. B, Clients should be reminded to tuck their chin and bring their neck posteriorly to be over their trunk.
Forward Head Carriage
Similar to a flexed neck posture is a forward carriage (protracted) posture of the head and neck. This involves flexion of the lower neck with extension of the upper neck and head. This also places the center of weight of our head anteriorly over thin air resulting in prolonged isometric contraction of the posterior extensor musculature (Figure 2a). The key to lessening this posture is to remind our clients to tuck in their chin to flex the head, and extend their lower neck back over their trunk (Figure 2b).
Figure 3 A, Holding the arm out to the side or front of the body to work with a computer mouse requires contraction of the upper trapezius as a stabilizer of the scapula. B, Working with the mouse closer to our body allows the (upper) arm to be relaxed and hang vertically at the side of the body, relaxing the upper trapezius.
Abducting the Arm
Holding our arms in abduction to the side of our body, in flexion in front of us, or anywhere in between is also problematic for the neck. Unfortunately, many postures involve holding our arms out in the air like this. The problem is that abduction and/or flexion of the arm at the glenohumeral joint requires scapular stabilization, usually accomplished by isometric contraction of the upper trapezius. Examples include working with a computer mouse or keyboard that is too far away (Figure 3a), or trying to hold a book or magazine up to our eye level when we are reading. To prevent this type of posture, it is important to bring our work closer to our body so that our (upper) arm is relaxed and hanging vertically down by our side (Figure 3b). So healthy neck posture is dependent upon healthy shoulder and shoulder girdle posture.
Figure 4 A, Carrying a purse or bag on the same-side shoulder, regardless of its weight, requires contraction of scapular elevation muscles to prevent the bag from falling off. B, Carrying the bag across the body removes the need to contract muscles to elevate the shoulder girdle.
Carrying a Bag
Another common posture that aggravates the posterior neck musculature is carrying a purse or bag on our shoulder. Even if the bag is empty and therefore very light, because of the natural slope of the shoulder, we need to elevate the scapula/shoulder girdle with contraction of the upper trapezius and levator scapulae to prevent it from sliding off (Figure 4a). This isometric contraction overuses and abuses these muscles of the neck. If the bag is heavy, it is that much worse because it requires a more powerful muscular contraction; and the strap of the bag digs into the musculature of our shoulder, causing direct physical irritation to it and further aggravating it by cutting off local blood circulation. It is better to either wear the bag across the body (Figure 4b) or to use a back-pack, fanny pack, or clutch purse that is held in the hand. Even better is to use a bag that is transported on wheels.
Figure 5 Carrying a weight in the hand, such as a computer bag, requires contraction of scapular elevation muscles to prevent the downward pull on the shoulder girdle by the weight.
Carrying a Weight
Carrying a weight, especially a heavy weight, in our hand is also difficult for the musculature of the neck. Examples include carrying a computer bag, heavy purse, suitcase or other travel bag, or even a bag or sac of groceries. Holding a weight of any kind in the hand creates a traction force on the upper extremity that pulls the shoulder girdle down toward the ground. This must be countered by contraction of the upper trapezius, levator scapulae, and rhomboids as muscles of scapular elevation (Figure 5). To prevent this, heavier weights should either be transported in a bag with wheels or a backpack (especially one that distributes the weight to the hips). When this is not possible, it is better to split the weight between the two hands to even the load.
Figure 6 A, Crimping a phone between the ear and shoulder requires isometric contraction of neck and shoulder girdle musculature. B, holding the phone with the opposite-side hand allows these muscles to relax.
“Crimping” a Phone
“Crimping” a phone between the ear and shoulder is another common neck posture that causes/perpetuates tight musculature of the neck. Crimping requires lateral flexion of the neck and elevation of the shoulder girdle (Figure 6a). Holding this posture requires isometric contraction of all muscles of the neck, but especially the upper trapezius and levator scapulae. An alternative to crimping the phone is to hold it with the opposite-side hand; this leave one hand free if writing is necessary (Figure 6b). Even better is use of a headset.
Figure 7 A and B, Sleeping on the back or side with a pillow that is too thick places the neck in an unhealthy posture. C and D, Using a thinner pillow allows the neck and head to remain in a healthy neutral posture.
Sleep Posture
One other perpetuating factor for tight posterior neck musculature is unhealthy neck posture when sleeping. Given that the average person sleeps between six and eight hours per night, we literally sleep between one quarter and one third of our life. If this posture is unhealthy, it can greatly add to the client’s neck condition. If the client sleeps on their stomach, their neck is forced into a posture of neck rotation for the entire night. If the client sleeps on their back or side with a pillow that is too thick, their neck is forced into excessive flexion or lateral flexion respectively (Figure 7a and b). The healthiest sleep posture is either on the back with a small pillow that supports the normal lordotic curve of the neck, or on the side with a pillow that supports the head and neck in a neutral posture (Figure 7c and d). Note: The pillow shown is a “cervical pillow” that has a depression in the middle, allowing the head to rest down in a neutral anatomic position.
Looking over this long list of postures that can contribute to tight extensor musculature of the posterior neck and top of shoulder, it is easy to see why these muscles are so often tight. Whether the client’s condition is mild or severe, it will never heal if the client does not remove the physical stresses caused by poor postures. We may possess the ideal treatment tools of massage, heat, stretching, and joint mobilization to help these clients, but if we do not involve the client in his/her own care with sound self-care advice, we will find that our results are likely to be temporary and limited at best. If you do not already do so, I recommend that you begin counseling your clients about these seven common postures that affect their neck.
This blog post article was originally published in the massage therapy journal (mtj), spring 2010 issue.
(Click here for a blog post article on Reading, Writing and Posture.)
(Click here for a blog post article on Postural Assessment of the Neck.)
(Click here for a blog post article on Postural Assessment of the Low Back and Pelvis.)
