Regional Interdependence and Neck Pain

Regional interdependence (RI) can be defined by the influence that a remote dysfunctional movement pattern in one part of the body may have on a client’s primary report of pain and symptoms in another region of the body (Sueki, Cleland, & Wainner, 2013). Such a paradigm shift from a traditional structural perspective, which considers symptoms of pain, allows room for the functional approach, which seeks the origin or source of the pathology/movement dysfunction (Page, Lardner, & Frank, 2010). As a means of exploring RI, the following will review a client case (i.e., post-rehabilitation) implementing RI to understand contributing factors, and solutions, to the client’s movement dysfunction/pain.

The author’s client is a 45-year-old female nurse, who sustained a motor vehicle accident January 4, 2014. The client was diagnosed with a soft tissue injury to the neck/shoulder region, and saw a physical therapist, registered massage therapist, and an occupational therapist prior to being cleared to see the author. The client reported headaches that occur along the left sides of her head (i.e., behind and around the ear) when she overexerts herself at work. Aggravating motions that induce said symptoms are extended periods of overhead reaching and horizontal reaching tasks. Below is a summary of the client’s functional movement screen (FMS):

In addition to the findings on the FMS, the client had poor standing posture before initiating the post-rehab program with the author; she had a forward head posture with a kyphotic curve of the thoracic spine. Such characteristics are known as upper crossed syndrome (UCS) (Page et al., 2010). The following will provide a deeper exploration of UCS, in addition to associated symptoms.

Vladimir Janda, a Czech Neurologist, noticed postural trends, which he defined as upper and lower crossed syndromes in 1979 (Page et al., 2010). Of particular interest was Janda’s upper crossed syndrome (UCS), which can be defined as a crossed relationship between the upper anterior and posterior regions of the body. The pectoralis major and minor are facilitated on the anterior side, as well as the upper trapezius and levator scapulae on the posterior side. Conversely, the deep cervical flexors of the anterior side are inhibited, as well as the lower trapezius and serratus anterior on the posterior side (Page et al., 2010). Such muscle imbalances shift joint positions causing thoracic kyphosis, anteriorly tilted scapulae, and hyperlordosis (i.e., forward head posture) of the cervical vertebrae (Page et al., 2010). A condition known as winged scapula can arise from UCS, and the impairment becomes pronounced during flexion and extension of the arms (Sahrmann, 2002). Please see the attached illustration of UCS:

UCS not only affects posture; such a misalignment of bony segments and muscles also cause changes in breathing patterns (i.e., shallow breathing), since the ribs are unable
to fully expand because of thoracic kyphosis (Muscolino, 2015). Additionally, facilitated upper trapezius and levator scapulae muscles, characteristics of UCS, can contain hypersensitive regions within a taut band of a skeletal muscle, that elicits a referred distant pain, colloquially known as myofascial trigger points (MTRPs) (Fernandez-de-las-Penas, Ge, Alonso-Blanco, Gonzalez-Iglesias, & Arendt-Nielsen, 2010). MTRPs are problematic because they can induce referred pain and headaches along the skull, depending on the location of the MTRP (Fernandez-de-las-Penas et al., 2010). Below is a chart outlining MTRPs and associated referral patterns around the upper back and shoulder regions:

The aforementioned concepts (i.e., UCS, MTRPs, and symptoms) do not necessarily live in a vacuum, and the application of RI can help find common threads between each, providing greater contextualization and meaning to the client’s movement dysfunctions and discomfort. Sueki et al. (2013) stated that RI could be defined by the influence that a remote dysfunctional movement pattern in one part of the body may have on a client’s primary report of pain and symptoms in another region of the body. The aforementioned sections also stated that UCS contains muscle imbalances, whereby some muscles are facilitated (i.e., pectoralis minor, upper trapezius) because other muscles are inhibited (i.e., lower trapezius, deep neck flexors) (Page et al., 2910). Considering that MTRPs can occur in muscle that is facilitated (i.e., MTRPs in a facilitated levator scapulae), it is possible that trigger points can be related to poor postures, as seen in UCS. Therefore, referral patterns from trigger points (i.e., headaches), by implication, might be exacerbated by muscle imbalance/poor postures of the thoracic and cervical spine. Finally, if UCS can be corrected and a neutral thoracic/cervical spine is regained, such changes may help reverse headaches by restoring muscle balance and posture.

Solutions to UCS can be derived by an RI-based approach. McDevitt, Young, Mintken, and Cleland (2015) noted that thoracic manipulation to improve mobility, when compared to a control group, was correlated to reduced pain and symptoms in patients with mechanical neck pain, and shoulder pain. Moreover, spinal manipulation when combined with an exercise intervention, improved symptoms and markers of disability more than manipulations as a stand-alone modality (McDevitt et al., 2015). Thus, improving a proximal region (i.e., thoracic spine) can reduce pain in a more distal (i.e., neck) region, supporting the concept of RI.

Although exercise professionals cannot perform massage therapy or thrusts about the spine, solutions do exist; exercise professionals can refer out to the appropriate medical professional, while performing the corrective exercise/strengthening portions of the rehab program. In this way, a clear division of labor is initiated, while drawing upon the strengths of both professions, and maximizing outcomes for the client.

References

Fernandez-de-las-Penas, C., Ge, H.Y., Alonso-Blanco, C., Gonzalez-Iglesias, J., & Arendt-Nielsen, L. (2010). Referred pain areas of active myofascial trigger points in head, neck, and shoulder muscles, in chronic tension type headache. Journal of Bodywork and Movement Therapies, 14, 392-396.

McDevitt, A., Young, J., Mintken, P., & Cleland, J. (2015). Regional interdependence and manual therapy directed at the thoracic spine. Journal of Manual and Manipulative Therapy, 20(3), 139-146.

Muscolino, J. (2015). Upper crossed syndrome. Journal of the Australian Traditional-Medicine Society, 21(2), 80-85.

Page, P., Lardner, R., & Frank, C. (2010). Assessment and treatment of muscle imbalances: The Janda approach. Champaign, IL: Human Kinetics.

Sahrmann, S. (2002). Diagnosis and treatment of movement impairment syndromes (1^rst ed.). St. Louis, MO: Mosby Inc.

Sueki, D.G., Cleland, J.A., & Wainner, R.S. (2013). A regional interdependence model of musculoskeletal dysfunction: Research, mechanisms, and clinical implications. Journal of Manual and Manipulative Therapy, 21(2), 90-102.

-Michael McIsaac