In the last article we discussed one of the ways stress can cause musculoskeletal dysfunction and pain. This is one area of treatment where Remedial Massage comes into its own and a relatively quick fix is usually possible. Not only has massage been shown to improve the physiological effects of stress by promoting physical relaxation, research has demonstrated that massage helps with the reduction of the psychological aspects, including mood improvement and reduced anxiety. We will now look at another cause of neck and shoulder pain – poor posture.
We are all aware that poor posture causes neck and shoulder pain, but what are the processes involved?
The fact is we are designed to be hunter gatherers. In the natural state we would spend a good deal of the time standing, walking, running and generally moving about but in the modern world we spend much of our time sat at a desk, driving a car or slumped in front of the TV. Even if we don’t work at a desk, many of us have jobs that involve us looking down or maintaining the same bent over posture for hours on end (including masseurs I might add). Poor posture can also have a psychological root. Poor self esteem, anxiety and depression can result in this postural pattern. Negative emotions are expressed through flexion of the spine – the desire to curl up into a protective ball. Tall people who don’t wish to stand out from the crowd can also develop the slumped forward head posture. Maintaining the same posture causes unrelenting pressure on the same muscle groups and causes muscle fatigue. Naturally under these circumstances we slump forward, develop rounded shoulders and what is called a forward head posture.
Ask a friend to stand up face forward. Stand to their side and imagine a line drawn vertically downward from their ear. This line should pass directly down from the ear through the shoulder, hip and ankle, but it is possible that the line passes in front of them and the head appears forward of the centre of gravity. When the head is nicely balanced on the neck and shoulders it doesn’t take much effort to hold it in place. The light work of a few ligaments and muscles will maintain stability. The weight of the average human head is around 5kg but in forward head posture due to a fulcrum effect it can have an apparent weight of more than 15kg. Think of the extra strain involved in holding the head up in this situation. Although the head is forward of the centre of gravity the eyes still want to be horizontal so the head, as well as being forward, also needs to tilt upward. This sets off a cascade of events that, in the long term, can cause a great deal of pain and discomfort.
The typical slumped posture with rounded shoulders and forward head is easily recognisable in modern society and, when maintained persistently, the knock on effects can be very widespread and debilitating. It is the soft tissues that suffer first.
- The muscles of the neck and upper back (including the upper trapezius and neck extensors) are in a sustained isometric contraction and become short and tight. The muscles of the chest (pectorals) also become short and tight. Causing generalised aching and more localised trigger points in the muscle.
- The muscles in the front of the neck, the deep neck flexors, are stretched and become weak and inhibited. A number of mid-back muscles (lower trapezius and rhomboids) plus the serratus anterior muscles are also stretched and become weak and inhibited.
- The shoulder muscles (deltoids) roll forward and develop an abnormal torsion.
- A number of ligaments (nuchal ligament) will be placed under excessive stress.
- The normal curve of the upper back becomes exaggerated (thoracic kyphosis).
- The shoulder blades (scapulae) rotate downwards
- The vital capacity of the lungs is decreased with a diminished thoracic cavity.
- The joints of the cervical spine can become partially compressed and the cartilage is exposed to repeated trauma. This compression could potentially lead to nerve root pressure.
- There is a decreased range of movement of the neck and shoulder.
- Tension where the muscle tendons join the back of the skull (occiput) can initiate headaches.
- Chronic pain and discomfort can result in general irritability and poor sleep patterns.
- There is mixed evidence to suggest that compression of the space above and below the collar bone (clavicle) caused by forward head posture could compress the nerve supply and blood flow into the arm (thoracic outlet syndrome) causing numbness and tingling.
- There is mixed evidence to suggest that a forward head posture can also cause temporomandibular joint (jaw) problems.
- There is mixed evidence to suggest a forward head posture and rounded shoulders may help to create or exacerbate impingement syndrome where the tendons of the rotator cuff in the shoulder become irritated and inflamed as they pass through the subacromial space, the passage beneath the collarbone. This can result in pain, weakness and loss of movement at the shoulder.
This list is long enough but unfortunately it doesn’t stop here. Muscles that are chronically contracted disrupt the symmetry of balanced forces acting on the body. This disruption cannot be maintained indefinitely – the body seeks out stability. Changes in one part of the body lead to adaptive changes in other distant parts of the body. The patient may present with widespread problems such as low back, hip or knee dysfunction as well as shoulder and neck pain.The problem escalates as muscles designed to move bones are now given the task of stabilisation and the body sacrifices flexibility for stability. The body finds a new stable state, albeit a noxious one. The body’s natural healing process stalls. In a sense it is stuck in a rut of chronic pain and requires a gentle nudge to reset the balance. Given the opportunity the body will heal itself but sometimes just needs a push in the right direction.
The process of rehabilitation involves awareness and education as much as remedial massage. Massage attempts to break the pain-spasm-pain cycle long enough to initiate self healing and repair.
The massage treatment will also attempt to stretch short tight muscle and activate weak inhibited muscle. Once the body has been prepared for repair the original cause, poor posture, will need to be addressed. The Muscle Clinic offer advice on lifestyle and work changes that can be introduced and we have found that a physical fitness and education system such as Pilates works very well for rebalancing the body. We can recommend Body Care Pilates in Plymouth, Devon. Mixed ability and one-to-one classes are available. Ideal for beginners as well as the more experienced.
In a later article we will discuss in greater depth the Pain-Spasm-Pain cycle and how massage can break this pattern, giving the tissue some much needed breathing space and allows the body to initiate the repair process.
Research and further reading:
Body Care Pilates
Muscle Clinic Blog Post
How Does Stress Cause Neck and Shoulder Pain
Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks.
Influence of forward head posture on scapular upward rotators during isometric shoulder flexion.
Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement.
Relationship of Forward Head Posture and Cervical Backward Bending to Neck Pain
Trigger Points in the Suboccipital Muscles and Forward Head Posture in Tension-Type Headache
Reliability of measuring forward head posture in a clinical setting.
Thoracic outlet syndrome
Body posture evaluations in subjects with internal temporomandibular joint derangement.
Global body posture evaluation in patients with temporomandibular joint disorder.