2.

1 Anatomy of Cervical Spine

The neck consists of seven cervical vertebras which are referred as C1 –C7. The
cervical spine provides stability and mobility features to the head and assists to
connect it to the comparatively immobile thoracic spine. Functionally cervical spine is
classified into two regions: upper cervical spine and lower cervical
spine19.

Figure 2.1 Structure of Cervical Spine

Upper Cervical Spine
The first two cervical vertebrae i.e C1 and C2, are exceptionally specialized and they
are given specific names: atlas (C1) and axis (C2) respectively. Atlas and axis form a
special set of articulations which provide a large degree of mobility to the skull. Atlas
does not have vertebral body and spinous process and acts as a ring or washer sitting
between the occipital condyles and the axis. Atlas cradle the occiput and transmit
force from head to the lower cervical vertebrae. Axis is an odd vertebra, the anterior
component of its body extends inferiorly and superior surface of body projects
vertically which is known as dens that articulates with the atlas. Axis transmits the
combined load of head and atlas to the lower cervical spine. Approximately 50% of
flexion extension of the neck takes place between the occiput and C1and 50% of the

rotation of the neck takes place between C1 and C2 20.

Lower cervical spine

Five cervical vertebras, C3-C7 makes the lower cervical spine. These vertebras are
known as typical vertebrae which similar to each other but they vary from C1 and C2.
Each typical vertebra has pedicles, laminae, spinous process, facet joint and vertebral
body. Superior surface of the vertebral body is concave and inferior surface is convex.
Over the superior surfaces of the vertebral bodies there are raised tactics or hooks
which are known as uncinate processes.
The facet joints of the cervical spine are proper synovial joints with the lax fibrous
capsules to permit large range of motion. The facet joints are inclined at an angle of
45° from the frontal and horizontal planes. This alignment enables to restrict
immoderate anterior translation and is crucial in weight-bearing19, 20.
As compared to the thoracic or lumbar regions of the spine, the cervical spine has
much more mobility. Each cervical vertebra has transverse foramina for the vertebral
arteries which supply blood to the brain.

Neck Muscles

The neck has many muscles which connect the head to the torso of body. The main
function of neck muscles is to provide support for the head, allow various neck
movements and to coordinate with the breathing movements. The major neck muscles
are longus colli, capitis, splenius capitus, splenius cervsi and the semispinalis capitis,
suboccipitalis, trapezius muscles and sternocleidomastoid19, 21.
2.2 Chronic Neck Pain

In the twentieth century neck pain was of secondary interest in relation to low back
pain. However, in the last two decades, there is an increasing interest and research in
the area of neuromusculoskeletal conditions which causes neck pain. Neck pain
currently rivals not only in frequency, but also in financial and social costs21.

International Association for the Study of Pain (IASP) defines the chronic pain as any
pain that last for six weeks and more which is perceived over posterior region of the
cervical spine from the superior nuchal line to the spinous process of first thoracic
vertebrae with hyperalgesia sensation in the skin, ligaments and muscles on palpation
and during the movements of neck and shoulder area22. Potential sources of neck pain
are dysfunctions of muscles around neck, synovial joints in the cervical spine, and
intervertebral disks of the cervical region, along with the cervical dura mater and the
vertebral artery. Noxious stimulation of the cervical zygapophyseal joints has been
found to cause neck pain and referred pain.

2.3 Prevalence

Neck pain is one of the most frequent musculoskeletal complaints following low back
pain and is the second disorder in relation to annual workers compensation costs.
Neck pain prevalence is not found to be different between urban, suburban and rural
areas. However, in urban areas neck pain has a higher prevalence in younger and
middle-aged participants, whereas in rural areas neck pain has a higher prevalence in
older participants. This finding may depict the fact that people in rural areas mostly
work in farms performing more physical work whereas people in cities have more
sedentary occupations. Thus, people in urban areas may have mostly postural neck
pain which appears in younger ages, whereas the work of people in rural areas may
lead to spinal stress and this population may be more prone to arthritis which mostly
develops in older ages23.

Neck pain became increasingly prevalent during the last twenty years. In many
countries, neck pain is one of the major causes of morbidity and disability in everyday
life and at work. It affects the physical, social and psychological well being of
individual and thereby contributing to increasing cost on society. Its prevalence in the
world wide varies from 16.7% to 75.1%24.
 Prevalence of 41.1% was reported in office employee because of their large numbers
of working hours, prolonged sitting positions and static postures25. In India, in a study
reported that 28% of computer users were suffering from the neck pain and their
associated complaints like upper limb pain paresthesias were related with their neck
posture26. It is found that out of 33% neck pain reported population, 16% of them was
belong to 18 to 29 Years of age groups because of increasing use of computers,
technological advances and revolutionized way of working27.

2.4 Risk factors for neck pain

There is a large range of factors that have been identified to predispose to neck pain.
These factors may be psychosocial, mechanical or occupational in origin. Stress,
depression, poor general health, females, obesity, neck injury history have been
recognized as significant risk factors for neck pain. Duration of sitting, twisting and
bending as well as high quantitative job demands and low co-worker support have
been also recognize to be related with neck pain occurrence28. Bogduk and McGuirk
recognized educational level, occupation, injury history, working with machines and
stress at work as the most important aetiological factors. There are many conditions
which are recognized as potential source of neck pain: Vertebral tumors, discitis,
septic arthritis, osteomyelitis, meningitis, epidural abscess and epidural hematoma are
considered serious but rare cases of neck pain as their prevalence is estimated to be
below 0.4%. Rheumatoid arthritis, ankylosing spondylitis, crystal arthropathies
including gout, polymyalgia rheumatic, longus colli tendonitis, fractures and synovial
cyst are also unusual cases of neck pain. Some of these diseases are not necessarily
unusual, but they are systemic disorders that rarely affect the neck. Torticollis is a
recognized condition leading to neck pain. Some other potential sources of neck pain
are diffuse idiopathic skeletal hyperostosis, ossification of the posterior longitudinal
ligament, Paget’s disease, spondylosis and osteoarthritis29.

It is estimated that 95% of neck pain patients may have a benign diagnosis such as
mechanical neck pain, postural neck pain, muscular neck pain, neck sprains and
myofascial pain syndrome. However, although such a benign diagnosis may be good
for the patients in terms of mortality, their vagueness may lead patients and clinicians
to search for a more clearly pathological understanding of this pain28. Thus, it seems a
better classification of neck pain could be according to its pathological & anatomical
 causes. However, this diagnosis of neck pain is difficult to perform partially due to the
central convergence phenomenon, the complexity of the innervations as well as the
number of conditions which share similar symptomatology30.

2.5 Manifestations of neck pain

Neck pain is a multidimensional complaint which is accompanied by a number of

other disabling symptoms. Sensory disturbances, changes in cervical muscle function,
alteration of cervical sensorimotor control, disturbances in postural stability and head
and eye movement control and psychosocial distress are usual manifestations of neck
pain.

Sensory function

Local cervical spine hyperalgesia is one of the sensory manifestations in neck pain.
This type of hyperalgesia is attributed either to the sensitization of peripheral
nociceptors located in the injured structures of cervical spine or to the central
sensitization of nociceptive pathways. Allodynia which is the sensation of pain from a
normally non-painful stimulus is also considered a sensory disturbance observed in
neck pain patients. The generalized sensory hypersensitivity and allodynia are
attributed to hyperexcitability of the central nervous system. This hyperexcitability
may be the result of sensitization of the spinal cord or of a loss of endogenous
mechanisms of pain control. Cold hyperalgesia and altered activity of the sympathetic
nervous system are also sensory disturbances that seem to be observed in neck pain23.

Muscle function

Neck pain is associated with multidimensional muscular dysfunction. Patients having

neck pain show reduced muscle strength and endurance of their neck flexors and
extensors groups31. In neck pain it has been also observed that there occur alterations
in cervical motor control. More specifically, in neck pain there is an inhibition of deep
cervical flexors (longus colli, longus capitis), whereas superficial neck flexors
(sternocleidomastoid, anterior scalene) present increased activation. This observation
reveals the compensatory role of superficial neck flexors in impairments of deep neck
flexors32. Although the neck flexors are the muscle group which has been mostly

examined, the muscle activity of neck extensors is also increased33. Patients having
neck pain also present reduced ability to relax their superficial neck flexors and
extensors after activation and this may indicate deficits in the sensory system or a
change of the descending drive to the motor neuron pool34. There is an impaired feed-
forward adjustment in patients with neck pain. More specifically, the ability of
cervical muscles to quickly co-activate after a postural perturbation is impaired, since
superficial and mainly the deep neck flexors have been found to have a delayed onset.
This impairment may finally leave the cervical spine prone to strain and further
injury32.

Figure 2.5.1 Muscular dysfunctions in neck pain

Psychological states

In patients with neck pain it seems that persistent pain may lead to psychological
distress including anxiety, depression and behavioral abnormalities. Kinesiophobia
and catastrophizing are also psychological states that are believed to be apparent in
patients with neck pain. Although it is not supported by concrete evidence, it is further
believed that the psychologic states of neck pain patients might also be related with
the transition from acute to chronic neck pain23.

Respiratory function

Breathing is unique and one of the most important body functions justifying its
characterization as the primary rhythm of life35. The significance of breathing is also
pondered by the fact that it is the essential function before respiration occurs. The
lungs are the most important anatomical and physiological structures of the
respiratory system to achieve these functions.

Figure 2.5.2 Respiratory Dysfunctions in Neck Pain

According to this model, the deficits accompanying chronic neck pain including
reduced strength and endurance of neck muscles, altered cervical proprioception,
reduced mobility of the cervical area, psychological states as well as pain by itself
may directly influence respiratory muscle function due to the common use of
sternocleidomastoid, trapezius and scaleni or indirectly through a change in rib cage
mechanics. These changes in parallel with the direct effects of pain on ventilation may
finally lead patients with chronic neck pain to respiratory dysfunction. Although all of
these changes in respiratory function of patients with chronic neck pain are supported
by a scientifically valid rationale, they have not been investigated and their
examination remains of high scientific and clinical interest for obtaining a better
insight into the impact of neck pain on the quality of life and health of sufferers. The
proposed mechanisms for the development of this respiratory dysfunction as well as
the existent evidence are described analytically below.
Mechanisms

The existence of each neck pain deficit in patients with chronic idiopathic neck pain
and the potential mechanisms for the development of respiratory dysfunction are
analytically discussed below.
Pain According to the model developed by Kapreli et al pain is one important factor
in patients with chronic neck pain to cause respiratory dysfunction5. Kato et al
observed that acute experimental pain leads to increase of respiration rate, peak
inspiratory/expiratory flows and minute ventilation. However, although sustained pain
was found to have similar effects on respiration, with the exception of respiratory rate
these effects were not different from the respiratory effects of a placebo condition,
suggesting that the respiratory disturbances in sustained pain are attributed mostly to
pain expectation rather that pain itself. The authors explained that this difference
between acute and sustained pain may be justified by the fact that pain experience
leads to an early elicitation of substance P which has stimulatory effects on respiratory
centers, whereas in the sustained pain, respiration may be depressed either by
decreases in the neurokinin-1 mediated effect or by increased availability of opioids
which have depressant effects on respiration36.
Chalaye et al studied the hyperventilation-induced analgesia. In their study it was
observed that slow deep breathing can increase both pain threshold and pain tolerance.
These findings in parallel with increased heart rate variability led the authors to
speculate a potential mechanism for hyperventilation-induced analgesia. According to
them, the stretch-sensitive baroreceptors detect the blood pressure increase due to the
increased intrathoracic pressure and the consequential increased venous return.
Peripheral baroreceptors exert a strong excitatory influence on the pain inhibitory
relays of the nucleus tractus solitarius which is involved in pain modulation and found
on the brainstem. Thus, it seems that hyperventilation has an important role in pain
inhibition which may be intentionally or unintentionally be adopted by pain

sufferers37.

Beside the pain-induced hyperventilation, Kapreli et al also stipulated that respiratory

function associated with chronic neck pain may also be affected by analgesic and anti-
inflammatory drugs which are commonly prescribed in these patients5.
Finally, pain may have indirect effects on respiratory function of neck pain patients.
Pain may influence physical characteristics of patients with chronic neck pain
including neck muscle strength, endurance, ranges of movements, proprioception and
posture. Neck pain is also stipulated to be an important factor associated with the
appearance of psychological states such as anxiety, depression, kinesiophobia and
catastrophizing. Each one of these physical and psychological factors may have its
own unique contribution to a potential respiratory dysfunction and their mechanisms
are discussed in detail in the following subsections.

Muscle Strength

According to the hypothesis developed by Kapreli et al, the reduction in muscle

strength of cervical muscles may have a serious impact on respiratory function. The
cervical muscle weakness may affect respiratory function by both direct and indirect
way. Trapezius, scaleni and sternocleidomastoid are the global muscles that
participate in both neck motions and inspiration and their potential dysfunction may
affect both systems. Scaleni are active during quiet inspiration and contribute to
breathing even when the pulmonary volumes increase is very small. In contrast,
sternocleidomastoids are relaxed during quiet breathing and activate mainly during
forced inspiration. Although scaleni are found to be more active and have a greater
mechanical advantage, the greater mass of sternocleidomastoid leads both muscles to
similar respiratory effects5. Furthermore, it is mentioned that the topographic
allocation of neural drive to the external intercostals muscles and parasternal muscles
is related to their inspiratory mechanical advantage. Thus, when sternocleidomastoid
and scaleni do not produce sufficient force for the purposes of inspiration, other
respiratory muscles might undergo this extra burden which causes increased in work
of breathing. Considering all of these, it becomes obvious that the weakness of these
cervico-respiratory muscles as a consequence of chronic neck pain may also lead to
respiratory weakness and dysfunction38.
Furthermore, the weakness of these muscles in parallel with the other cervical muscles
and the associated changes in motor control and their intrinsic properties may lead to a
decrease of their passive or active tension, affecting both their dynamic and active
support on the joints, with a consequential decreased ability to produce force and
stability in the joints they control. A weak muscle has also reduced ability to
counteract to the forces applied to the same anatomical area it supports and it is prone
to elongation and strain39. Thus, Kapreli et al support that the dysfunction of these
muscles may lead to changes in functional length and recruitment with a subsequential
over-pull or under-pull during motion altering the length-tension relationship. The
alteration in force-length curves may eventually lead to changes in rib cage mechanics
and ultimately to dysfunction of respiratory muscles5.

Endurance/Fatigue

Kapreli et al suggested that the increased fatigability of superficial neck muscles and
the decreased ability of deep cervical muscles to bear submaximal loads for a
prolonged time may have a serious impact on respiratory function. The reduced
endurance of cervical muscles and especially of the sternocleidomastoid, scaleni and
trapezius may lead them to quickly lose their ability to generate an optimal force and
consequentially this may lead to respiratory dysfunction5. The reduced endurance and
hypo-activity of these deep cervical muscles causes segmental instability not only of
the specific area, but also of their related articulations such as the thoracic spine and
shoulder40. Considering that respiration necessitates a stable spine in order to
appropriately be performed, the spinal instability caused by the local muscular system
may lead to alteration in the rib cage mechanics. This altered thorax biomechanics
which is further compromised by the postural alterations and muscle imbalances due
to the dysfunction of both the global and local muscle system may lead to dysfunction
of other related respiratory muscles such as the diaphragm, intercostals or abdominals
leading to a more generalized respiratory dysfunction5.

Range of Motion

According to the hypothesis developed by Kapreli et al, the reduced cervical ROM
may also contribute to respiratory dysfunction. This assertion seems to be sound when
observing reduced cervical mobility as a result of reduced cervical segmental mobility
or/and muscle shortening. Furthermore, the shortened cervical muscles may change
the length-tension relationships as they present reduced ability for force production.
These changes in segmental mobility, length-tension relationships and the
consequential muscle imbalances and postural changes might finally affect rib cage
mechanics and respiratory function5.
 Proprioception

The model developed by Kapreli et al, also purports that potential deficits in
proprioception may play an important role in changes of respiratory function. It has
been suggested that altered afferent somatosensory input with the subsequential
reorganization of the central nervous system that leads to an altered efferent input to
cervical muscles. These altered efferent may leads both to reduce and inhibit spinal
reflexes leading to dynamic instability of the cervical area or to inhibition of voluntary
movements leading to arthrogenous muscle atrophy. The ultimate outcome of these
changes could also be a reduced functional ability of the cervical area and changes in
motor control patterns. Considering the anatomical connection of cervical area and
respiratory system as well as the previously described potential effects of reduced
strength and segmental instability on respiratory function, these changes may also
cause to alter the rib cage mechanics and a consequential respiratory
dysfunction5.

2.6 Forward head posture

A Forward Head Posture (FHP) can be generally described as the position in which
head is positioned anteriorly and increased normal anterior cervical convexity19. FHP
is the head protrusion accompanied by an upper cervical extension and lower cervical
flexion although Kendall et al support that radiographic evidence shows not only that
there is no flexion in lower cervical spine, but also that that there is an extension more
pronounced than the one of the upper cervical area4. FHP can be evaluated through
different means. FHP is assessed by measuring the craniovertebral angle which is the
made between the line drawn from the tragus of the ear to the 7th cervical vertebra
(C7) spinous process and the horizontal line through C7. Forward Head Posture is
inversely related with craniovertebral angle i.e decreased angle is reflected as an
increased forward head posture. FHP is also measured by the measurement of the
angle between the line extending from the C7 spinous process to the mastoid process
and the line extending from the mastoid process to the outer canthus of the eye. The
rationale of this measurement is the description of head posture in relation to the
external environment. Another method is the measurement of head posture as a
product of both upper cervical extension and lower cervical flexion. The upper
cervical extension (head tilt) is assessed as the angle made between the line drawn
from the forehead to tragus and the Y axis. The lower cervical flexion (neck flexion)
is assessed as the angle made between the line drawn from the C7 to tragus and the Y-
axis41.

In clinical practice FHP was usually considered as a clinical sign of chronic neck pain.
Lau et al, support the adoption of this bad posture by patients with chronic neck
pain42.

It can be summarized that the adoption of FHP during many daily prolonged sitting
activities may lead to a permanent adoption of this bad posture due to muscle
remodeling changes. The deviation of head from body vertical midline necessitates
the development of higher torque in cervical muscles for maintaining static
equilibrium. These high and prolonged contractions lead to reduced blood flow,
fatigue, tissue damage and finally pain41. Furthermore, during the acquisition of this
posture there is an increase in anterior tensile forces and the anterior cervical
structures are stretched. Additionally, there is an increase in posterior compressive
forces and shortening of the related muscles and consequentially the posterior muscles
shorten. Moreover, the cervical discs are stressed increasing the possibility for early
disc degeneration42. These changes of muscle length and activation lead to changes of
their length-tension curve and consequential muscle imbalances.

Considering the changes in superficial and deep muscle activity, the reduced
endurance and strength of cervical muscles, the mobility restrictions and the
consequential muscle imbalances presented in patients with chronic neck pain, the
FHP might be a postural adaptation in order for the cervical and related muscles to
achieve their maximal mechanical advantage.

The developers of the model for explaining neck pain mechanisms leading to
respiratory dysfunctions consider that the contribution of FHP to this dysfunction is
important43. FHP shares similar mechanisms to the other deficits for the development
of respiratory dysfunction as it may be both a cause and effect of changes in muscle
strength, endurance, activity, range of movement, proprioception and muscle
imbalances. However, FHP may also lead to joint overloading and abnormal stresses
on the non-contractile elements of the cervical area41, 43. This excess loading and
stress may cause repetitive micro-trauma to cervical structures. Beside the
 consequential increases in pain with its direct impact on respiration, the excessive
stress and microtrauma to ligaments make them to lose their important function
leading to instability of the cervical spine. Furthermore, microtrauma affecting
mechanoreceptors may further compromise sensorimotor control leading to further
cervical instability44. As it has already been discussed, this segmental instability may
lead to a more generalized instability of the spine and finally to respiratory
dysfunction due to altered rib cage mechanics5, 40.

2.7 Management of Neck Pain

For managing the neck pain physical therapy agents like transcuateous electrical
stimulation, ultrasound, interferential therapy and mobilization, manipulation and
different types of exercise including stretching, neck isometric and dynamic exercises
are commonly employed.

Transcutaneous electrical nerve stimulation (TENS) is one of the most common

electrotherapy modality used in the form of electro analgesia for treating the
musculoskeletal pain. According to the pain gate theory, TENS causes stimulation of
large diameter afferent fibers which inhibits the transmission of pain impulse through
the small nociceptors afferent fibers and thereby helps to reduce the perception of
pain. Maayah M and Jarrah MA in their study found TENS as an effective means for
providing the sustained relief in pain in patients who were complaining neck pain due
to the musculoskeletal disorders when compared with the placebo45. Sharma H and
Patel N in their study found TENS more effective in the rehabilitation of patients
having cervical radiculopathy in terms of reducing neck and arm pain, neck disability
and in improving ADL when given with the neck isometrics exercise as compared to
intermittent cervical traction46.

Ultrasound therapy is widely used to decrease neck pain and increase the muscular
functions. During the ultrasound therapy sonic energy is changed into the heat energy
which produces thermal and non thermal effects. During the application of ultrasound
there occur formation of cavitations, micro streaming and micro massage under the sonic
beam at the cellular level. These changes lead to increased cell membrane permeability,

more diffusion of oxygen and nutrients and removal of pain mediators47. In a study

conducted by Amjad F et al. significant improvements were found in

patients who received ultrasound as compared to those patients who received TENS
in terms of pain intensity and cervical range of motion in the patients having upper
trapezes trigger points48.

Cervical mobilization and manipulation are widely used in the clinical practice for the
management of neck pain. These techniques decrease pain by increasing joint space &
joint range of motion, improving the altered biomechanics and by altering the nerve
activities in afferent fibers and increasing descending inhibition mechanism. Ali H et
al. compared the effectiveness of cervical mobilization and cervical traction along
with the standard care of treatment in subjects with the non-specific neck pain. They
found that cervical mobilization was more effective in terms of reducing pain and
disability49. In a study done by Buyukturan O et al. significant effects were found by
mulligan mobilization technique on reducing pain, improving range of motion,
functional level and quality of life in the older adults with neck pain when compared
with the traditional physiotherapy 50.

It has been found that there occurs reduction in maximal isometric strength and
isometric endurance of the cervical flexor muscles in patients with neck pain51.
Therefore with the intention to gain muscle strength, flexibility and endurance,
to repair injured tissues and to make
capable to preserve normal lifestyles activities, exercise is one of the most often used
intervention in the rehabilitation of subjects with neck pain52. Different
exercise programmes are incorporated for managing neck pain which ranges with
regard to duration of protocol, frequency of training, intensity, and type of exercise.
Isometric exercises and strength training has been found to be effective on neck pain.
Initially neck stabilization exercises were introduced in treatment programme to
reduce pain, improve function, and prevent further injury. Cervical stabilization
exercises are designed to improve the inborn mechanisms by which balance is
furnished to the cervical spine and an injury free state is provided. These stabilization
exercises act like their counterpart in the lumbar spine.

Yesim D et al confirmed the positive effects of the neck stabilization exercises with
some advantages in terms of pain and disability as compared with isometric and
flexibility exercises with physical therapy agents for the treatment of neck pain11.
Asghar Akbari eta al suggested from the results of a
comparative study of effectiveness of muscles specific
stabilization exercises and dynamic exercises on chronic neck
pain and disability that neck specific stabilization exercises
improves more range of motion and reduces pain and
disability compared to the dynamic exercises53.

Gupta B D et al. in their study found deep cervical flexor

exercises to be more effective in reducing pain, disability and
correcting the forward head posture than the conventional
isometric training in the dentists having chronic neck pain1.

Study by Akodu AK et al found neck stabilization exercises

effective in reducing neck pain, forward head posture,
depression and anxiety in individuals with non specific
chronic neck pain. The mechanism of pain reduction is
suggested to be increased activation of motor pathways which
suppresses the pain centre in the brain. There was also an
improvement in functional status of the patients54.

Lee K et al in their study have found that exercises that target

to correct the posture and strength of deep neck muscles
increases cervical angle and improves pulmonary function13.
Sustained natural apophyseal glides (SNAGS) were found to
be effective
in improving neck posture and pulmonary functions in
patients with forward head posture55.

In a study of Chan –Woo- Nam et al, it has been observed that

cervical stabilization exercises with breathing retraining
yielded significant improvement in respiratory function in
stroke patients12.