STRUCTURAL AND MYOFASCIAL CONSIDERATIONS IN CERVICOGENIC PAIN

STRUCTURAL AND MYOFASCIAL CONSIDERATIONS IN CERVICOGENIC PAIN

Notes for the workshop presented at the AMT AGM, April 2008 & again at the AMT Annual Conference, October 2008.
Printed in the AMT Journal "In Good Hands", December 2008
©AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.

Cervicogenic pain is pain that has its origin (genesis) in the neck. Soft tissue pain
in this region can be either local or referred, somatic, autonomic, visceral or neural in origin. In addition to local visceral structures, pain can also refer from viscera in the torso. The main considerations of this paper will be somatic pain from soft tissue structures, primarily the myofascia. Aside from direct trauma to the region, such as whiplash, myofascial dysfunction in the cervical region is generally secondary to structural imbalances below the level of the neck.

Many structures and tissues in the neck can be responsible for pain. Autonomic manifestations would include perturbation of the cervical sympathetic ganglia (just anterior to the vertebral bodies) such as could occur as a result of whiplash or prolonged forward head posture, where vertebral instability creates a cluster of symptoms, as in Barré-Lieou Syndrome (for example.) Somatic pain could originate in either bony tissue (such as facet joint referral)or the soft tissue.

STRUCTURAL CONSIDERATIONS

1. Gravity

“Posture is the distribution of body mass in relation to gravity over a base of support. The base of support includes all structures from the feet to the base of the skull.”
(Kuchera and Kuchera, 1997)

The prime structural consideration is our response to gravity. All posture can be viewed as our response to gravity and subsequent orientation to our environment. All life on Earth responds to the gravitational force of the planet: even birth can only occur in the appropriate gravitational field. While no doubt it may be possible to conceive in zero gravity on a space station, it is impossible to give birth out of Earth's gravitational field. NASA experiments using quails on the space station has proven this many times.

Form follows function: optimal alignment in gravity and to 3 dimensional space has resulted in a structure that has evolved to meet the demands of uprightness in gravity with minimal energy expenditure yet maximum efficiency in movement. Humans are fairly unique in the animal kingdom in that as a species we have evolved to stand and operate upright in gravity. This places unique stresses on our bodies. A snake, a quadruped (like the horse or dog) and another possible biped like the kangaroo will all respond to gravity differently from humans. Bears are another biped, but their response to gravity has resulted from different adaptations to the 3 dimensional environment.

To maintain our upright posture we need to be aligned around our centre of gravity (CoG) over 2 bases of support (the feet) and, from that place, move in, relate to and inter-act with the 3-dimensional space around us. While each of us is unique and our postural pattern can vary slightly from one individual to another, we all conform to major, common patterns that are determined by our form as a species and the relentlessness of the force of gravity on this planet operating upon us.

2. Tensegrity

Twentieth century architect, inventor and philosopher R. Buckminster- Fuller coined the term ‘tensegrity’ as a contraction of ‘tensional integrity’. He used the term to encapsulate the concept of a lightweight, integrated structure that gives great stability with the use of minimal material. A tensegrity structure thus maintains a synergy between balanced tension and compression forces. This means that any applied force can be met evenly by the structure, yielding without disturbing its internal equilibrium.

A tensegrity structure comprises two basic components:

• A compressive structure (such as posts, poles, struts or columns).

• A tensile structure (such as cables, wires, ropes, sheets).

There are some notable architectural examples - Centrepoint Tower and the Sydney Harbour Bridge are both tensegrity structures, In fact, any cantilever bridge or an old-fashioned airplane with struts and guy wires is a tensegrity structure. A tent is another basic example.

To be dynamic, animal bodies need to operate effectively in gravity by minimising the effect of their weight. The tensegrity relationship is one part of achieving this. Thus animals embody the characteristic unison of compressed and tensioned parts that defines a tensegrity structure. The skeleton of an animal is compressive, while the soft tissue, myo-fascial / tendinous and ligamentous structures are tensile.

3. The functional anatomy of the spine.

The human spine is a tensegrity structure. It consists of a series of rigid bones (compressive structures) interposed between deformable, fibro-cartilaginous intervertebral discs (tensile structures). The soft tissue muscles, fascia and ligaments connecting the bones are also tensile structures.

The spine has curves anterior (lordoses) or posterior (kyphoses) in the sagittal plane. Where there are kyphoses, there are bony structures such as the ribs and pelvis enclosing and protecting vital organs. There is also less mobility. Where there are lordoses, there are no bony enclosures and greater mobility.

These spinal curves have a definite relationship to our CoG, sometimes passing through it, sometimes behind it, sometimes anterior to it. Together with the tensegrity relationship within the spine, they allow the spine resilience in movement and stance.

The lordotic, cervical spine has the greatest mobility within the vertebral column. All mobility comes at the cost of stability and thus this region has a greater propensity for damage and soft tissue adaption / maladaption.

Functionally, the cervical spine has two divisions: the cranio-cervical (Occiput-C2)and the typical cervical (C3-C7) regions, with the C2/C3 motion segment constituting a transitional functional region.

The cranio-cervical region consists of the atlanto-occipital(C0/C1) and atlanto-axial(C1/C2) articulations, which together account for the greatest amount of saggital and transverse motion of any individual vertebrae in the whol spine. Think of the yes and no motions: the yes motion is saggital movement that occurs at C0/C1, while no is transverse movement occurring at C1/C2, the Atlas (C1) rotating around the peg (dens or odontoid process) of C2.

The C2/C3 articulation is functionally unique and quite important, providing the stable base to "anchor" the head and cervico-cranial region to the rest of the spine. The bony articulations of the superior aspect of C3 (large uncinate processes and large, uniquely inclined superior articlar processes) allows a deep, stable socket for articulation with the inferior aspect of C2. This enhanced stability is required to cope with the many muscles (from both above and below) that converge and articulate at this level, all of which play a role in anchoring the atlas.

C3- C7 for the most part conform functionally to the pattern of the rest of the spine below, apart from the following specifically local adaptations:

-bifid spinous processes that allow more muscular attachment sites, as well as preventing the 'kissing spines' effect in extension and thus allowing a safer, greater range of motion in extension.

- Transverse Processes (TPs) with two bony projections that allow two different muscular attachment sites: theanterior pedicles that projects laterally from the vertebral body and theposterior pedicle that projects laterally from the pedicles. A small strut of bone unites these two pedicles; together all three parts are referred to as the transverse process, though this is quite different structurally to TPs elsewhere in the spine.

- Within the transverse process there is the Transverse Foramen, through which the Vertebral Artery passes. This is clinically significant as a potential hazard in doing work on the cervical spine.

- Other clinically unique features worth considering are the orientation of the facets, which allow a large range of motion, the orientation of the pedicles which allows a large, triangular spinal canal, the uncinate processes, which minimize lateral motion and shear and thus protect the Vertebral Artery, and finally the shapeof the intervertebral foramen and the superior groove on the TP, that facilitates the exit of the spinal nerves in a unique way.

MYOFASCIAL CONSIDERATIONS

The myofascial and connective tissue network can be viewed as a tensegrity arrangement within the body. As mentioned in the above paragraph, it is the most mobile part of the axial skeleton; stability here is provided by appropriate relationships in the soft tissue. Like the mast of a sailing ship, the soft tissue of the shoulder girdle, ribs, lower vertebrae and manubrium that connects with the cervical spine, hyoid, mandible and cranium is like a tensegrity mast.

1. Fascia and connective tissue are highly plastic

Fascia is composed of about 30% collagen, 1% elastin and some reticulin fibres in a matrix of water-loving cells. Collagen is the netting that gives fascia its form - it is stronger than steel fibres of the same size. Fascia encloses every structure in the body and is the substance responsible for the form of the body.
It is also highly innervated with sensory nerves and can respond to neural inputs by contracting, relaxing, remodelling and changing its chemical makeup and ratios. When damaged, collagen frays and reconnects wherever it can. This is the basis of scar formation.
Fascia / connective tissue responds to the stress of chronic postural change by:

1. Thickening
2. Shortening
3. Calcifying
4. Eroding

Like bone, fascia is subject to Wolf’s Law: it changes and remodels in response to the forces placed on it. Muscle fibres can contract and relax, unless in spasm. Fascia, on the other hand, can’t relax as readily and will respond to poor usage by remodelling negatively. This can be quite rapid - it doesn’t take much to change its length. However, this plasticity is also a blessing because it doesn’t take much for it remodel to positively either.

Fascia is throughout what is commonly thought of as muscle. A piece of red meat trimmed of all its connective tissue (the white stuff) is approximately 50-60% muscle fibre and 40-50% fascia.

2. Cervical Fascial Anatomy

Once past the partly adipose superficial fascia, here are 4 major layers of deep fascia in the neck:

1. An outer, extrinsic, layer around the sleeve musculature
2. An Inner, intrinsic, deeper layer around the core musculature
3. A visceral layer around the oesophagus and the thyroid / parathyroids.
4. A meningeal layer around the spinal cord.

The Superficial Cervical Fascia is partly fascia and adipose tissue and is immediately under the dermis. It contains the platysma muscle. After the superficial fascia but before the epimysium of individual muscles lies the deep fascia. There are several layers of deep fascia in the neck:
• Deep Cervical Fascia around the whole neck, with an Investing Layer enclosing interiorly the trapezius and sternocleidomastoid.
• Prevertebral Fascia, superficial to longus colli and scalenes, it continues deep to the Investing Layer to enclose the deep posterior neck muscles.
• A Middle Layer that encloses the infra hyoids anteriorly.
• Visceral fascia that consists of:
a. The Pre Tracheal Fascia enclosing the cervical viscera anteriorly as well as the infra hyoids posteriorly, and
b. Retrovisceral Fascia, enclosing the viscera posteriorly.

The meninges can be viewed as neural fascia enclosing the spinal cord.

Individual muscles are covered with epimysium; perimysium encloses fascicles of muscle fibres and endomysium surrounds individual muscle fibres. These are morphologically no different to fascia. Where the muscle fibs finish, the fascia joins together and continues as the tendon. In other words, fascia is distributed throughout the entire structure.

3. Neuro-Fascial Considerations

As mentioned above, fascia is a heavily innervated material. For example, Golgi Tendon Organs only occur in fascia. As such, they can be found not only in the tendon but also throughout the fascia within the muscle belly. There are proprioceptors, chemoreceptors, mechanoreceptors and thermoreceptors in fascia. Once I would have added nociceptors here as well but recent reading has made me doubt the specific existence of nociceptors - nociception and pain may just be the response to threat or damage, a summation of responses to changes in temperature, ph, chemical environment and pressure. What I will say is that fascial, neural structures are sensory and capable of involvement in pain symptoms.

Proprioceptive feedback alters our cortical response which, in turn, alters our motor patterns … which will then alter structure and biomechanics. If this is prolonged, the fascia responds by changing its internal environment, creating thickenings and adhesions and increasing myofibroblast rather than fibroblast activity, which will further increase the contractile property of fascia.

Sympathetic nervous system activity (fight or flight responses) can shorten fascia. It’s not just prolonged physical overload that creates compromise but also constant low-level, psycho-emotional input: stress from the job/partner/children/bully/tax department/recent injury/that old pain that won’t go away etc. Fear and insecurity can lead to ANS sympathetic involvement as easily as other protective behaviour patterns, be they emotional in origin or physical in origin, such as muscle guarding around immediate physical pain.

Golgi Tendon Organs, Golgi receptors, Pacinian and Ruffini Corpuscles - all present in the fascia – will respond to appropriately to different types of manual therapy and can act to inhibit sympathetic activation of the fascial tonus.

4. Postural and phasic muscles

Structural modification, be it due to poor usage, muscle guarding around pain or sympathetic activation, can lead to an altered relationship to gravity. This can manifest in the muscle fibres as either hypertonicity, hypotonicity or muscle wasting, in the fascia as altered morphology anf tonus. Myofascial structures throughout the body can be divided into tonic or phasic, depending on muscle type and function.

Tonic or postural muscles are the anti-gravity muscles, working constantly to maintain upright stance. Postural muscles are fatigue resistant, Type 1 fibres. In dysfunction these will tend to shorten and can either tighten or weaken.

Phasic muscles are recruited only for specific movements, then rest and restore their energy levels. Phasic muscles are Type 2 fibres, which fatigue easily. Most type II fibres will tend to weaken without shortening in dysfunction

The following list is from Robert Schleip’s website www.somatics.de, a wonderful source of articles on structure and bodywork.

TONIC/ POSTURAL MUSCLES

Hamstrings
Iliopsoas
Rectus femoris
Tensor Fascia Latae
Triceps surae
Pectoralis Major (sternal; clavicular?)
Trapezius (ascending fibres)
Levator Scapulae
Erector Spinae (lumbar and cervical)
(thoracic?)
Quadratus Lumborum
Sartorius
Piriformis
Short Adductors (Magnus and Brevis)
Sternocleidomastoid
B. Brachii (?)
Flexors of hand (?)
Scalenii

PHASIC/ MOBILISER MUSCLES

Tibialis Anterior
Vastus Medialis and Lateralis
Gluteus (Maximus and Minimus)
Rhomboids
Trapezius (ascending and horizontal fibres)
Serratus Anterior
Long adductors
Short hand and foot muscles
Longus Colli and Capitus
Omohyoid (?)
Gluteus Minimus
Pectoralis Major (Costal attachments)
Gluteus Minumus
Triceps Brachii
Scalenii

Note that the scalenes appear in both lists. They are phasic muscles which, if put under the chronic stress of altered posture, become dysfunctional and adapt their fibre type to take on the characteristics of tonic/type 1 fibres.

The following list defines the features of the different fibre types (again from www.somatics.de):

TYPE I MUSCLE FIBRES
• Slow twitch
• Contract slowly
• Low stores of glycogen
• High concentrations of myoglobulin and mitochondria
• Fatigue slowly
• Mainly involved in postural and stabilising tasks
• Tonic or postural muscles
• Stress or dysfunction will lead to shortening
• When short/tight, may test either strong or weak

TYPE II MUSCLE FIBRES
• Fast twitch
• Rapid contraction
• Depending on sub-type, mitochondria and myoglobulin concentrations vary
• Generally fatigue rapidly
• Mainly involved in phasic activity
• Also referred to as phasic or mover muscles
• Stress or dysfunction will lead to weakening over their whole length
• Will always test as weak and without shortening

There are 3 subtypes of Type II muscles fibres:

TYPE IIa FIBRES
• “Fast twitch” or “fast white” fibres
• Contract more rapidly than type 1
• Are moderately resistant to fatigue
• High concentrations of mitochondria and myoglobulin compared to other type II fibres


TYPE IIb FIBRES
• “Fast twitch glycolytic” or “fast white”
• Less fatigue resistant
• Depend more on glycolytic sources of energy
• Low levels of mitochondria and myoglobulin

TYPE IIM FIBRES
• “Super fast” fibres
• Found mainly in the jaw muscles
• Depend on a unique myosin
• High glycogen content
• These last two properties differentiate it from other type II muscle fibres

5. The head as a level platform for the senses

The head is the platform for the senses. Due to the Ocular Righting Reflex, the eyes will always seek to look at a level horizon. This feature means that any damage, shortening or change in habitual pattern that occurs to alter the posture of the body will be allowed and compensated for (by involving other structures in the body) as long as the eyes can look at a level horizon. The vestibular system will accommodate the head in a different, dysfunctional position and alter the sense of balance and proprioception, thus perpetuating the new, dysfunctional pattern.

6. Upper Crossed Syndrome

Vladimir Janda’s ‘Crossed Syndromes’ are worth considering in treating the cervical region, specifically the Upper Crossed Syndrome:

• Hypertonic trapezius and levator scapula posteriorly, hypertonic pectoralis major anteriorly

• Hypotonic anterior deep neck flexors and rhomboids and serratus anterior

An appropriate treatment protocol could be to lengthen the upper trapezius, levator scapulae and pec major, accompanied by strengthening exercises and resisted movement for the anterior cervical musculature and rhomboid/ serratus sling.

7. Forward Head Posture

Forward head posture is a very common presentation, with myofascial compensations that are quite similar to upper crossed syndrome.

In forward head posture, we can expect the following:

• The upper traps and levator scap are shortened. This creates an increased cervical lordosis.
• Activation of the Moro (startle) Reflex- increased ANS activity (fight or flight response) – cervical ganglions involved.
• TMJ involvement- retraction of mandible
• Jaw clenched or mouth open, possibly bruxism (grinding)
• The head will double in weight for every 2.5cm it is forward of the CoG, further increasing the load on the musculature (especially the sub occipitals).

The suboccipitals, which should delicately finetune the head’s position in space as the senses respond to stimuli, instead become postural in function.

The TMJ dysfunction affects the body globally by affecting the vestibular function and balance and thus our position space, leading the posterior neck muscles to further shorten and increase their dysfunctionality.

Conclusion

This article is an expansion from workshop notes; that workshop was primarily practical in content. Consequently, it is far from definitive. I have tended to discuss cervicogenic pain primarily in terms of local phenomena. Nothing, however, occurs in isolation in the body. A more global perspective would take into account that the neck is near the top of a chain that commences with the feet. Any other dysfunction in this chain will manifest sooner or later in the neck.

Viewing neck pain as a purely local phenomenon may mean overlooking the genesis of that pain elsewhere in the body. Trigger point pain is very much a local manifestation of a more global pattern. Many trigger points and acupoints correspond to where nerves pass through the fascia. These are very real to the client and offer fairly immediate pain relief when they are deactivated. But they are only a part of the problem. The trick is to make the client aware of what else is contributing and work to prevent recurrence. The body always seems to recruit strength over stability in dysfunction, whereas as the key to true rehabilitation is almost always enhancing stable function.

By way of a closing example, let’s consider Tom Myers’ ‘Anatomy Trains’ concept of the body. Perhaps we could view the involvement of the myofascial meridian or locomotor sling of the Superficial Back Line. The local manifestation of the global pattern could be neck pain or headache. But there will also be tight plantar fascia, perhaps with collapsed arches, genu recurvatum (knee hyperextension), anterior pelvic tilt, either hypo- or hyper- lordosis and definitely cervical hyperlordosis and forward head posture. Any of these more distal dysfunctions could be causing or contributing to the problem and would need addressing to resolve the cervicogenic pain. Or perhaps it could be an issue of core or pelvic stability; involving different myofascial slings again. Any treatment of a client should involve a comprehensive assessment and plan that considers the possibilities of the whole body presenting before you.

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