Fall 1998

OLD PAIN IN THE NECK STORY

“I’m not sticking my neck out for you!”
“You give me a pain in the neck!”
“I got it in the neck.”

Wonder why those and other phrases referring to the vulnerability of that part of the anatomy are so ubiquitous in our language? Think about this unguarded column sticking up between your shoulders and supporting the weight of your head. Starting from the inside there are some pretty vital structures encased by it. In front, just under a thin layer of skin, chock-a-block full of sensory nerve endings (more than on any other body surface) is the thyroid gland, overlying the trachea (windpipe) and the larynx (voice-box.) The next layer encloses the esophagus, and then, more deeply, the vertebral column or spine, this last structure enclosing the spinal cord. Branches of the spinal nerves exit through spaces between the vertebrae and spread out to supply the neck and upper extremity organs, muscles, blood vessels and skin. Major arteries and veins pass from the heart through the neck to branch out in the skull, brain and scalp. In back of the spinal column lie muscles responsible for supporting and moving the head. The overlying skin and scalpare replete with small blood vessels and nerve endings extremely sensitive to touch. 

Nobody has to tell you that your neck is some kind of seriously important, delicate and vulnerable complex. Your brain is aware of this on a subconscious level and on that level is quite protective. The slightest threat is registered and responded to reflexively.  That’s why there’s so much neck pain and related problems with the shoulders and arms going around. 

Your average run-of-the-mill stiff neck: This is usually related to fatigue, stress, to long-standing poor posture or a combination of the aforementioned. Work at the computer or shrugging a phone between the shoulder and the ear can exacerbate the situation. The neck muscles tighten up, partially as a misguided and inappropriate protective mechanism. As often as not, this may be accompanied by a “tension” type headache.

What to do? The acute situation can be addressed through simple measures such as acetaminophen, aspirin, ibuprofen, massage and osteopathic manipulation. That much we can do for you, but more important is what you can do to help yourself, particularly to prevent recurrences. First, ergonomic factors need to be modified: if necessary, a telephone head set; proper positioning of the work space to minimize strain on the eyes and neck. Second, where possible, postural corrections should be made. This can be effected even in people middle-aged or older. Extensive and expensive diagnostic tests are unnecessary. Stiff necks may also be associated with arthritis of the cervical spine, but from the standpoint of treatment there is no essential difference.

Your not so average stiff neck with pain radiating into the upper back, shoulder and/or arm: Several possibilities here. Ranging from less to more serious, they are:

A. Very much the same as above. Poor posture, stress or injury with superimposed inefficient or traumatic movement factors can produce localized areas of muscle irritability known as trigger points. These may be associated with myofascial pain syndromes — muscle pain, spasm, weakness, limited movement — in areas remote from the trigger points. (See previous CSOM newsletters or my web site). Such problems may be partially resolved through some of the same methods outlined above, particularly exercise, postural re-education and ergonomic corrections where indicated.

Other measures may be necessary, including trigger point injection with a local anaesthetic, osteopathic manipulation, ultrasound and electric stimulation, non steroid anti-inflammatory medication and muscle relaxants. Small doses of tricyclic  antidepressants, much too small to have any antidepressant effect, may be extremely effective in ameliorating myofascial pain. There may be many perpetuating factors contributing to these syndromes such as pelvic and low back muscle imbalances, flat or over-pronated feet, etc. These must also be corrected to ensure successful resolution.

“There may be many perpetuating factors... pelvic and low back muscle imbalances, flat or over-pronated feet, etc.” 

B. Myofascial pain may be excruciating, radiating into the head, neck, upper back, shoulder and arm, but it is usually a deep ache and doesn’t follow a specific nerve pathway. This pain can often be relieved by finding a position of comfort. Not so when the source of the pain is irritation of a nerve root due to the impingement of a protruding disc or a bony spur. The pain in this case is sharp, lancinating or boring, often likened to a “toothache in the arm”. It follows a relatively consistent distribution, is often accompanied by pins and needles or numbness very specifically demarcated along the course of the nerve involved. Muscle weakness and atrophy is often noted in the later stages. The pain is usually increased by extending the head to the rear or rotating or bending it to the painful side. It characteristically gets much worse at night, frequently interfering with sleep, particularly in the horizontal position.

Treatment of this “pinched nerve” really depends on:

1. An accurate diagnosis;
2. Supporting the weakened muscles with a cervical collar for a short period;
3. Acupuncture, analgesic and muscle relaxant medication, supplemented by nonsteroid antiinflammatories (NSAIDS);
4. Osteopathic manipulative therapy and physical therapy including cervical traction, myofascial release, ultrasound and electrogalvanic stimulation are often of benefit;
5. More resistant cases may require short-term corticosteroid administration;
6. Very occasionally, neurologic consultation is needed, and even more rarely, spinal surgery;
7. Postural retraining and strengthening exercises are the key to full recovery.

C. Less frequently, neck and upper back pain may accompany acute or chronic shoulder pain as inappropriate muscles in the upper back and neck substitute for the injured shoulder muscles. The diagnostic clue is pain and restriction of motion at the gleno-humeral joint between the upper arm and the shoulder blade. Neck and arm pain due to shoulder dysfunction should respond well to management of the shoulder problem. (Once again, see www.bonesdoctor.com or my discussion of shoulder pain in the Spring 1995 issue of this newsletter.) 

Whatever the cause, the odds are pretty good that we’ll find an answer to your neck problem at the Center for Sports & Osteopathic Medicine. 1

Jeannette Kossuth

Worked with us for many years as a massage therapist. Several weeks ago, her husband and young son were run down and killed by a motorist. We extend to her our deepest sympathies. .

CSOM NEWS

Once again, good fortune shines upon us. We have been blessed with the rotations of five superb medical students over the past year. It all started with Marcia Griffin at the end of last year. She served 2 months rotation, and then another one last July. In between, we had the pleasure of Chau Lee’s company, then Jennifer Abeles followed by Rebecca Fishman who generously shared her first two weeks with the returning Marcia. 

Then, just when I thought it was all over, up popped Elizabeth Feldinger who brilliantly continued the streak! I only hope that these wonderful docs & docs-to-be got as much out of their rotations and learned as much from us as we did from them. Marcia was married to Dr. Ken Hansraj on August 1. I wish them endless joy.

In addition to the return of Carolyn Winuk, our Physical Therapy staff has been further enhanced by the addition of Nicole Geschwer and David Cassuto.

Nicole has intensive training in and is expert in many manual techniques, particularly craniosacral manipulation, myofascial release and the manipulative treatment of temporomandibular joint dysfunction. She previously worked as the director of physical therapy in a major pain management facility and has been a great help in expanding and enhancing the pain management aspect of CSOM. She is also expert in “body work”, a discipline which will be further expanded by an intensive course in the Feldenkreis method.

David is expert in the “sports medicine” approach to musculoskeletal injuries. Fix ’em quick and get them back rapidly to the highest possible level of function, whether it be activities of daily living, sports or work.

As an athlete himself, he is eminently qualified in this regard. (He can tell you all about that stuff when he sees you.) Even more important are the manual techniques he has mastered for treatment of back and neck problems.

With the addition of a new medical assistant, Samdai Gonsalves (hereafter known as ANN) from Guyana, the multinational makeup of our staff now includes South Africa, Poland, the former Soviet Union, and France as well as an assortment of multiethnic trash from the good old USA.

And, guess who showed up in the office the other day? Jeanette Micelotta and her husband Neil paid a surprise visit and took the little woman and me out to dinner. Of course it was great seeing them again, but Florida is their home, they’re happy, their lives are great and that’s what counts.

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WHY ME, GOD? AND WHY NOW?

Three years ago, my wife and I were all set for one of our western sojourns: flyfishing, driving, sight-seeing, hiking and intensive eating. We were headed for the Badlands and Black Hills of South Dakota, Mt. Rushmore, Custer National Park, spelunking in Jewel and Wind caves, schlepping in Yellowstone, and fishing the Big Horn River and our usual fishing hole in Montana.

We were both in great physical shape. (In my case, this meant I could walk a couple of miles, some of it up hill, before collapsing). I was working out 3-4 times a week: aerobics, strength training, etc. and my wife was doing even more.

I digress (seemingly). Have you ever noticed yourself going through a super stressful period, walking around with your shoulders in your ears, your breath coming in spastic gasps, your jaw clenched, etc. Then the tsuris (trouble) is over. You can breathe again. Relief is with you! 

It’s Saturday morning and you’ve got the weekend off. Whew! But wait! You awaken with your neck trying to push its way through the base of your skull. Your head is throbbing. Your teeth are trying to grind themselves to a fine powder.Your heart is throbbing like a drum to some bizarre tropical rhythm. What’s going on? It’s called a STRESS! reaction.

You’ve been keeping the lid on like a semi adult. You haven’t lost your cool, mouthed off to your kid, your wife, your boss or smashed the new china. Now the lid is off and all that compacted energy can and does break loose. Who gets it? You do, of course, since you’re basically furious at yourself for not having control of the stress-provoking situation in the first place.

And that’s not the only way of punishing the prime offender. For example, back to the wild west trip. Two weeks before departure, this paragon of physical fitness (me) develops a sharp pain in his left butt which radiates around the front of his hip into his thigh and knee. Walking, sitting, standing, lying down are all untenable activities. Apparently, during my Herculean efforts at strength training, I had succeeded in blowing out a disc. (Is 250 pounds really too much for a 200 pound 65 year old to bench press?) Swell. We’re going hiking in 2 weeks and I can barely walk across the room. Things are looking pretty gloomy. But you ain’t seen nothin’ yet.

Shortly after my symptoms begin, my lovely wife and bearer of baggage complains of pain in her back, radiating into her hip and thigh. The pain is excruciating and she’s unable to walk, stand or sit for any appreciable time. As per her wishes, I examine her and it looks like she either has a herniated disc or bursitis of her hip.

Benjamin Franklin: “The doctor who treats himself has a fool for a patient.” Richard Bachrach: “Doc who treats his own family member deserves what he gets.”

And what I got was a very unhappy wife when I decided in favor of trochanteric bursitis as the correct diagnosis. (Because that was less serious than the other alternative.) Now it is the day before our scheduled departure. I inject her left hip at it’s most tender point and succeed only in causing her greater discomfort.

The two of us are significantly depressed by the prospect of what loomed as a ruined vacation, if any. We decide it a good idea to X-ray her lower back. What I see appears ominous. It looks very much as if her pelvic bones are shot through with cancerous lesions!

I call my radiology consultants at Sutton and tell them what I see. They tell me to bring my wife and her films directly to the hospital. After many consultations, they confirm my conjectures that this may indeed be a more serious problem than a busted western trek. Fear and trembling with much clutching and many tears.

A bone scan and a CT scan are done within an hour. God is not dead! Our suspicions were only that. The scan shows there is a herniated disc, but no cancer! For this our gratitude is unbridled. And our trip? The vacation to which we’d been looking forward for months? After this week from hell we really needed it, pain or no. So, off we go the next morning, saddle bags stuffed with serious pain-killers and anti-inflammatories.

Suffice it to say, we had a wonderful time. Our pains gradually, if erratically, subsided and we were able to do almost everything we had planned. (Even surviving a terrifying fall in one of the caves.) The lesson? What stress can do to us and what we  unconsciously do to ourselves under stressful conditions. Our herniated discs had been sitting there for years like dormant volcanos waiting for the right time to erupt.

What to do? The first step is awareness of the possibility of stress provoking what may appear to be a catastrophic health problem Step 2: Acceptance: This can happen to me. Step 3: If you feel it really needs to be checked out by a physician, then don’t be embarrassed, do it! Step 4: Acknowledgement of the inability to control everything in the world, including, at times, the reactions of your mind and body. Step 5: Coping and acting: do what you have to do to feel better and go on with your life. l Please, please, please!

Don’t wear perfume or cologne when coming to our office. Some of us are highly allergic.

Thank you.

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POSTURE POINTERS

Sitting Whenever possible, choose firm, supportive seats rather than overstuffed chairs or sofas. It is preferable to stand with your knees slightly bent, leaning against a wall or column, shifting balance frequently, rather than to sit on a soft, non-supporting surface. Sit with your knees at hip level, or hips slightly higher, your feet flat on the floor or on a platform. Only your buttocks should touch the back of the chair, and there should be a cushion in the hollow of your back unless the shape of your chair is such that it supports that part of your back. The seat should end 2-3 finger breadths from the back of your knees. Don’t slump!

Never sit for longer than the time it takes for your back to give you the first hint of discomfort. Get up and move around for a minute or two.

Driving
Move the seat forward so that your knees are bent and slightly higher than your hips. Again, the small of your back should be supported.

Standing
Standing for prolonged periods, like doing the dishes (if you’re unable to talk someone else into such onerous tasks): prop one foot up on a stool or platform, allowing your back to assume its natural curve. Contract your buttocks intermittently. When turning to walk from a standing position, shift your feet and eyes in the same direction first, then turn your body.

Sleep Positions
Sleeping on your back: you may be more comfortable keeping a pillow under your knees, and a small pillow or roll under your neck. If you sleep on your stomach, you may want to put a pillow under your belly, and have either a very thin one or none under your head.

“It really doesn’t matter in what position you sleep.”

A pillow between your knees is a good idea if you sleep primarily on your side. Make sure that the pillow under your head fully occupies the space between your head and your shoulder.

Contrary to popular myth, consider the following: It really doesn’t matter in what position, upon what, or with whom you sleep. What counts is enough restorative sleep, no night time pain, and when you awaken you don’t feel worse than when you went to sleep.

DISCLAIMER: The information in this newsletter is for educational and informational purposes ONLY. It should not be regarded or interpreted as anything else. Diagnosis and treatment of disease, injury, pain, or disability is the province of your physician who should be consulted in regard to any medical symptoms or conditions before adopting any course suggested in this newsletter.

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