Upper Back and Neck Pain
What you are likely missing in your attempts to alleviate your symptoms and some stuff you can do to help yourself (including exercise tutorials)
Just how common is pain in this area?
According to research, it is estimated that around 22% of people will experience pain in their upper back each year. 1 In certain groups of people, this may be even 50% higher and it is very common for a person with upper back pain to not have significant structural findings on an MRI.
I want to make it clear that there are many potential different things that can cause upper back and neck pain and in today's post I want to talk about pain in this area that is nothing to do with structural injury or visceral related pain.
Today we are talking about those super annoying painful symptoms that plague most people on a regular basis. This is one of the most common areas of complaints that I see in my clinics. In general there are a few reasons that I think this happens and we will dive into each of them today.
Caveat: I cannot be specific to your situation in this blog post so if the reasons I have suggested don’t fit for you, then you likely need more 1 on 1 guided help than I can provide in this format.
For this blog, I’m staying away from blaming anything like posture for these symptoms because as it stands, I’m currently unaware of any research that strongly links posture with pain.
Almost everyone you talk to will immediately blame their posture and that includes most practitioners too.
And if I’m correct in saying that, I’m likely also correct in saying that blaming & targeting posture hasn't really led to much meaningful change for your symptoms long term.
Additionally, many people that are desk based or sit a lot for work will link sitting with pain in their upper back and neck.
I am aware that there is a decent body of research that links time spent sitting with musculoskeletal problems and I also know that by increasing your daily movement (something we can use the exercises in this blog for) we reduce the likelihood of experiencing symptoms.
This is something I have seen with clients too. They aren’t necessarily sitting less each day, but they are moving more than they have been and they often have much reduced symptoms as a result.
All of that aside, here are the most common issues that affect upper back and neck pain. They are written in no particular order and I don’t think I could possibly rank them in order of significance or importance.
1: You haven’t injured yourself recently but might have previously been injured in this area.
It is well supported in the scientific research that previous injury to an area is a solid enough predictor of future painful symptoms and/or future injury in that area.
No-one can predict when in the future those symptoms might show up.
In clinic I have seen that being a few months to potentially years later. For upper back and neck pain, the most common previous injuries are whiplash, disc issues in the cervical spine and concussions.
And yet, the vast majority of people that have upper back and neck pain are not currently injured. They have pain and restricted movement that has usually come on without any identifiable cause.
Most just woke up one day with a stiff neck that progressively got worse or spread to become upper back stiffness and/or pain.
If the last sentence is YOU, I would invite you to consider that despite the presence of pain, it is very very very unlikely that your pain means you have significant structural injury or damage to the area that is painful.
In this study2 of 90 people without pain, they found that 66% of them had “positive anatomical findings” (evidence of structural changes) on MRI, 37% had disc herniations and 29% even had deformation of the spinal cord. And these are regular people without pain.
It is not easy to say with any certainty that pain in your upper back is being caused by degenerative changes or a structural injury. And if you do not have an injured neck/back, your pain is more likely to be a protective response than an injury. Which means you are likely safe to move even if it hurts a bit.
2: You (likely) struggle with disassociation of the neck and torso movement
This one is incredibly common, especially when there has been a whiplash or other neck injury previously. Firstly lets explain disassociation:
Disassociation in movement: the ability to move one body part while avoiding (or limiting) movement in another body part.
Sounds simple right? According to what I see in clinic, it really isn’t!
Most people with neck and upper back pain spend a lot of their day yanking their head around, contorting themselves like a wet dish cloth, trying to stretch the muscles of their neck and torso.
That may provide some short term relief but it doesn’t usually resolve their symptoms.
If there has been a previous injury to the area, it is very common that you may have adopted a “bracing strategy” whilst you were healing. This makes sense. It's much easier to avoid further exacerbation of an injury if you do your best to minimise the load and forces that are passing through those tissues (at least for a short period of time).
FYI: bracing when injured makes some sense….BUT……there are plenty of more recent research studies that suggest that promoting movement as early as is tolerable can help a lot of tissue injuries to improve more quickly than avoiding movement. Gotta love how science keeps us questioning what we think we know…
If a bracing strategy has been employed, it usually means that the movement options around the neck and torso are limited temporarily and that they all “move as one unit” in most movement patterns.
For some people, those protective movement strategies seem to remain and they do not recover their full movement capacities after an injury.
Without a good assessment of your ability to disassociate these structures from one another, you might not even be aware that this is happening. You likely just feel tightness, stiffness and restricted movement and maybe some pain.
Longer term, recovering the ability to disassociate the neck and torso from each other will offer muscles and joints the opportunity to experience their ranges of motion rather than being held in a braced or protective fashion.
Without those joints and muscles being able to do their thing freely, it can be quite difficult to shift away from tension, restriction and pain.
Towards the end of this blog, I will provide you with video demonstrations for my favourite exercises to begin making improvements to this.
3: You likely can’t move your Thoracic Spine very well
Many people that I meet will struggle with movement in the thoracic spine.
Like every other part of the spine, the thoracic spine is made to flex & extend, side bend left and right and rotate left and right.
The thoracic spine is the area of the spine with the most joint to joint connections. Owing to the 12 pairs of ribs that we have connecting into this area as well as the normal spinal joints, there are a lot of options for movement here. Rib movement (a function of good breathing mechanics) is often overlooked when aiming to improve movement into the thoracic spine.
Most people struggle with at least one of these movements. Perhaps time spent sitting is a factor here but I cannot say this with any degree of certainty. I mean, think about it, a large percentage of us enter this thing called school between the ages of 3-4 and spent upwards of 8-10 hours per day sitting for the rest of our education and working lives.
How could that not have an impact on your movement?
Anyhow, back to the point here. If your thoracic spine is struggling with movement, it may be contributing to upper back, shoulderblade, shoulder or neck problems.
A ribcage and T-Spine that cannot move well usually equate to a set of shoulderblades that won't experience their normal ranges of movement.
Are you one of those people that gets pain underneath or between the shoulderblades and has struggled to alleviate it? Has the movement of your spine been assessed and addressed?
If not, it is possible that all the soft tissue work or manipulation in the world won't solve your symptoms if the underlying movement options never change. You can end up, wound up, in the same old position without much effort.
It's important to note also that the joint mechanics in the thoracic spine are interesting.
In order to rotate the thoracic spine freely there are some conditions that must be present.
When the spine is extending (lifting ribs up towards the sky), the thoracic area should be able to rotate pretty freely without additional requirements.
When the spine is flexing (bending forwards) the thoracic spine must be able to side bend at the same time in order to allow the joints to rotate freely. I have seen many a person with a problem rotating their thoracic spine, pelvis or neck that was happening due to a limitation of spinal side bending, causing many interconnected symptoms.
Check out this quick little video and follow along to feel the differences:
Did you feel what I described in the video? Let me know in the comments section at the end :)
Getting that thoracic spine moving well and communicating well with the shoulderblades and upper limb can lead to fantastic results for people with upper back and neck pain.
4: You have active stressors that affect how you breathe
We all know the old saying : “I’m carrying the weight of the world on my shoulders”
Maybe this is kinda how.
When you start to get stressed out, your respiratory rate is one of the things that will silently shift through the gears without you having much awareness of it happening. Not only will you breathe more quickly, you will likely shift from a more relaxed fuller breath to an upper chest dominant breathing pattern.
Without having spent a lot of time cultivating an awareness to enable you to notice the changes in your breathing, it’s pretty safe to assume that you will not recognise when these changes take place (I am in the same boat as you all, I've just begun working on building more awareness about this).
Breathing is so interesting and I will definitely write more on breathing in the future. The breathing centres in the brain lie right at the junction between structures that are known for conscious and unconscious regulation within the nervous system.
We can consciously attend to our breathing and choose how and when to breathe and we can be breathed by the unconscious side of our nervous system.
Without conscience awareness of our breathing, we are likely to allow our attention to remain on whatever is stressing us out which will drive our respiratory patterns unconsciously.
Allowing your focus to remain on a stressor, might be a requirement of dealing with it so no problem there, but I'd like you to think about those stressors that affect you for much longer than they should. The ones you ruminate on and revisit regularly.
What effect are those having on you?
When our breath shifts to an upper chest dominant breathing pattern and the amount of breaths we take every minute is higher we are likely to start recruiting the accessory muscles of breathing much more than normal.
These are:
Sternocleidomastoid (SCM)
Scalenes
Upper Trapezius
Serratus Anterior
Intercostal muscles
Pectoral muscles
In this study3 Shahidi et al 2013, they examined the relationship between neck posture, muscle tone and exposure to low and high grade stressors. They demonstrated that acute psychosocial stressors increased the muscle tone of the trapezius muscle during times of stress - with the high stress period increasing the tone in the upper traps the most.
There was another beautiful piece of research done by Bloemsatt et al (2005)4 where they found that the muscles around the head and neck are likely to have increased tension during heightened periods of arousal and stress when compared to the muscle of the arms and hands.
And finally there was another amazing study by Hodges et al 2001 5 that showed that the brain prioritises respiration over spinal stability as respiratory demands increased. The diaphragm is our primary breathing muscle and its secondary function is to provide a stabilisation role to the spine. As breathign demands increase, we lose more and more of the spinal stabilisation to allow the dipahragm to contribute more heavily to its breathing role.
Putting this all together in plain English: your brain adapts your neck and back muscles function from producing movement towards assisting breathing during times of stress. This is quite possibly restricting joint movement as the respiratory rate increases.
That doesn't mean our neck and back muscles STOP controlling our movement. Not at all. They simply do less and contribute more to assisting us with breathing.
(For a second, I'd like you to imagine a world where the neck muscles did stop controlling head movement when breathing rates and/or stressors increased! You'd be walking along and peoples heads would just be randomly flopping down onto their chests all over the place as the various stressors of life affected them! It would be bizarre and likely hilarious to observe 😅)
Anyway, back to neck & back pain.
Might this change in strategy of the neck muscles during times of stress contribute to pain? I cannot definitively prove that it does. I also genuinely so think that it contributes and there is some research to back me up as listed above.
Think back for a second about the last time you had an upper back or neck symptom show up. For a lot of you, this might correlate with a particularly stressful time in life.
It could be when you moved house, started a new job, when a relationship ended. For most of you, it might have showed up exactly when you could have done with it least - aka - when you already have a lot on your plate.
Funny that, isn't it?
You might already have guessed that some focused breathing work may help you out at times like this. I think that it absolutely can help in these types of situations to aid in self regulation and minimising stress responses.
Whilst it isn't a panacea and will not be effective for everyone, breathing exercises in combination with movement exercises as suggested below are often able to reduce the symptoms of upper back or neck pain in most of the clients I work with.
So what can you do to improve this?
First of all, this is a blog post, not an assessment. If you have upper back and neck pain and are worried that you are injured or have something serious going on, please get yourself assessed by a trained professional. The suggestions in this blog are not intended to replace a proper assessment.
Here is what I usually work people through to help them with symptoms in this area. These movement exercises are the lowest level of work I will get someone doing. They are low-load and can be done very regularly without risk of injury.
From that perspective they are perfect for early stage rehab and for building evidence of safety during movement for a brain that might be a little protective right now!
Head still Neck Mobility in Sidebending
It never ceases to amaze me that so many people can move their head on top of their shoulders reasonably well and (often) be completely locked up when you ask them to move their body underneath a head that is kept still.
A common pattern I have noticed in clinic is that a lot of people out there are unable to move the lower cervical spine, upper chest and upper back areas well. I call this area “the dead zone”.
(That is my own little chuckle because if anything it should be called the life zone as it contains our airway, tonnes of nerves and blood vessels and is right above the heart - bet you are wondering now about what sort of weirdo this David guy is if that is what I chuckle about 🤣)
This movement exercise is my attempt to help you to feed some much needed movement into “the dead zone”. You'll be surprised by how much restriction most of you will feel when you do this. The drill asks you to move your pelvis, ribcage and arms through a range of motion before you move your neck.
Most of the movement in the neck happens in the upper 3 joints (C1-C3) so we want to minimise their movement until we have moved the other structures in the neck.
We add a breath in the middle of this to mobilise the ribs and all of those joints too.
The arms and the reach are a key focus also because they allow us to feed movement into the spine without us having to “contract” or “force” the movement to happen. Reach your way into it.
Aim for 15-20 reaches both sides, a few times per day to get yourself moving again.
Head Still Rotation mobility
This exercise follows the same principles as the previous exercise. We want to move the body underneath a head that stays still until the end of the exercise. The “dead zone” as I mentioned above will experience movement before the upper neck is asked to contribute.
This exercise can often offer you significant improvement in neck rotation in a short space of time. And like everything else, if done consistently, you will likely keep that improvement long term.
Aim for 12-15 reps in each direction, a few times per day as a astarting point.
Wall COG
This drill is similar to the two before it, in that we will be moving multiple areas of the body at once, but we are not as concerned with limiting movement in the upper neck in this exercise.
I say this to my clients all of the time: this one is an exercise for life. (In fact these 3 exercises are movements for life IMO!)
You can literally use this to move every part of you once you get the hang of it.
It's an amazing exercise to do to break up some time spent sitting, to start or end your day or as part of a warm up for an upper body session in the gym.
We use wall here as a constraint. It provides feedback, limits error and enables you to guide the movement without needing anyone else's help. Hat tip for this one goes to my dear friend and mentor Gary Ward of Anatomy in Motion for introducing this to me and countless clients.
This is called a Wall COG because the way we set this up, it is like a series of cogs turning and influencing each other.
Skull → Ribcage → Breath → Shoulderblades & Arms → Pelvis → Lower Limb.
Syncing this all up can take a little bit of practice, but I guarantee that it will be worth it.
As you become familiar with this exercise, take it away from the wall and you will be able to explore more range of motion through the spine during this exercise.
Aim for 15-20 breaths, a few times per day as a starting point.
Seated Scapula & Spinal COG - people who sit at work I haven’t forgotten about you!
You might not fancy hopping up on the middle of the office and working through the drills above. Your colleagues may start shooting you some (more) funny looks…. (joking, I swear!)…
So this one is a modified version of the Wall COG that should be possible for almost everyone that sits at work. Obviously I do not recommend this for anyone who drives for a living unless the vehicle is parked!
If you were to pair this exercise up with a short walk afterwards, you can absolutely build in A LOT MORE MOVEMENT to your day, like I mentioned way up at the start of this blog post. You might spend virtually the same time sitting, but you can get more movement in, to help alleviate your symptoms.
In this one, we start with pelvis movement which should be fairly easy to feel as we are sitting and have solid contact with the chair or surface beneath us. This should feed movement up into the spine and we then use the shoulderblade movement and the breath to mobilise the upper thoracic spine.
The reverse then occurs with a reach to really open up the upper back and shoulderblades. Lovely stuff for anyone who is desk based.
For most of my clients that sit a lot, I recommend this exercise and a simple alarm on your phone. Set it to go off at whatever schedule suits your day (90 minute intervals seems to work for most) and build some of this beautiful movement into your body to help your upper back and neck to move well and feel much freer.
Wrapping Up
So there you have it. Quite a long post this time and hopefully the context given was useful for you.
Your initial recommendations are to work through these exercises for 1-2 mins each, multiple times per day to help you to really get that upper back and neck moving again more freely.
These exercises cover the three planes of motion (up and down, side to side and rotations) for all the major joints in the upper back and neck and shoulder really help you recover some movement.
I’m currently building out the remaining rehab plans and educational modules for the latest iteration of my self-paced online programme, Move Out Of Pain. This next module that I am building is all about upper back and neck pain and you can bet your next sip of coffee that the exercises and content above will be included in that module.
If you have enjoyed this and felt improvement in your body, I'd love to hear how it has helped you out.
I would love if you could please send this post to everyone you know that suffers with upper back pain. I think this could help literally anyone in any office around the world!
P.S» I am half thinking of turning this into a purchasable E-Book at a later date. If you'd like to be able to purchase something like this, please let me know!
Until next time,
Move Well, and good luck Moving Out Of Pain.
David
Thoracic spine pain in the general population: Prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. Andrew M Briggs, Anne J Smith, and Peter Bragge. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720379/
Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals.
https://pubmed.ncbi.nlm.nih.gov/7593072/
Differential effects of mental concentration and acute psychosocial stress on cervical muscle activity and posture - Bahar Shahidi
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968934/
Differential effects of mental load on proximal and distal arm muscle activity. Bloemsatt et al (2005).
https://pubmed.ncbi.nlm.nih.gov/16078028/
Postural activity of the diaphragm is reduced in humans when respiratory demand increase - Hodges et al 2001
https://pubmed.ncbi.nlm.nih.gov/11744772/