According to any number of sources, the most common cause of CHRONIC NECK PAIN is WHIPLASH, affecting somewhere between 45 and 50 million Americans on some level. The question, however, is why — why are so many people struggling with Chronic Neck Pain in this age of EVIDENCE-BASED MEDICINE and hi-tech everything? In other words, why are we as a society, not doing a better job of solving this problem for people like BRENDA or LORRIE?
Although the reasons are legion, I think that one of the biggest has to do with the fact that the tissue that is so often injured, yet so misunderstood, is FASCIA. Before we spend some time discussing the anatomy and physiology of the Cervical Fascia, listen to what what Dr RC Schaffer (DC / Ph.D) says in chapter four (Cervical Spine Trauma) of his book, Chiropractic Post-Traumatic Rehabilitation.
The area of cervicothoracic transition is a complex of prevertebral and postvertebral fascia and ligaments subject to shortening. It offers a multitude of attaching and crossing muscles such as the longus colli, trapezius, scaleni, sternocleidomastoid, erector spinae, interspinous and intertransverse, multifidi and rotatores, splenius capitis, splenius cervicis, semispinalis capitis, semispinalis cervicis, longissimus capitis, longissimus cervicis, and the levator costarum and scapula —all subject to spastic shortening and fibrotic changes that tether normal dynamics. There is a rough correlation between the degree of structural damage present and the extent of neurologic deficit.
This is more true in the lower cervical area than in the upper region where severe damage may appear without overt neurologic signs. In either case, it’s doubtful that a deficit would exhibit without an unstable situation existing. It is not unusual for a patient to exhibit a neurologic deficit without static displacement; ie, the vertebral segment has rebounded back into a normal position of rest. Markovich, the renowned neurologist, found that the most common headache is the type caused by neuromuscular skeletal imbalance.
Look at how many muscles are prone to, “spastic shortening and fibrotic changes“. Schaffer then uses a word descriptor that I use a lot when I talk about this problem — “tether“. He is exactly correct; the Scar Tissue that is more appropriately called FIBROSIS, has the ability to TETHER those it gets its claws in. The real problem is that ‘tethering’ always leads to a host of downstream problems that culminate in various sorts of neurological deficits and physical degeneration (HERE). And lest we forget; CHRONIC PAIN.
Despite the fact that Fascia is so often ignored by practitioners of all sorts, it’s not like you could really call it a “fad”. Back in 1950, Dr. ES Meyers published The Deep Cervical Fascia: A Study in Structural, Functional and Applied Anatomy. Not quite a century before that, Henry Gray and Henry VanDyke Carter were publishing their amazing anatomy atlas, Gray’s Anatomy. But even that is nothing new. Back in April of 1489, Leonardo Da Vinci, began writing his book, “On the Human Figure“. Now, over 500 years later, let’s use our computers to take a brief look at some of this anatomy ourselves.
If we were to peel away the skin in the neck region, we would find the Superficial Cervical Fascia, which is continuous with the Fascia from both the deltoid (shoulder) and pectoral (chest) muscles, which travels over the top of the clavicle, and becomes continuous with the PLATYSMA MUSCLE as well. Everything underneath the Superficial Cervical Fascia is considered to be Deep Cervical Fascia.
What’s interesting is the quantum variation in description and layers of the Deep Cervical Fascia (HERE or HERE), which itself is divided into three different layers — superficial (investing), middle (pretracheal), and deep (prevertebral). When studying the attachment points of the investing layer, the most interesting feature I personally found was that it actually attached to the zygomatic arch (cheek bone), which helps to explain certain cases of FACE OR SKULL PAIN — particularly in people who were not actually hit in the face.
While looking at a sharing site, where medical students post their class notes for everyone to see, I found this interesting comment in a long group of notes (Useful Notes on the Deep Cervical Fascia of Human Neck), which other than this sentence, completely stuck to anatomy. “Collection of inflammatory exudate beneath this fascia produces severe radiating pain.” As is always the case, INFLAMMATION, whether systemic or local can be a huge problem, hypersensitizing nerves and potentially leading to TYPE III PAIN and even CENTRAL SENSITIZATION. But this isn’t the only problem related to the Cervical Fascia; not by a long shot!
Because of TISSUE REMODELING, I’ve had several people get their sense of smell back after decades of having lost it (two of them thirty years or more) as well as seeing interesting changes in other special senses. HERE, for instance, is an example of a person who got their hearing back after 40 years of deafness.
One of the many problems associated with the Deep Cervical Fascia in peer-review is something called Cervical Vertigo (I have also seen it called Positional Vertigo). I guess because I’ve seen this a bunch of times in practice, I always suggest that people struggling with VERTIGO try conservative treatment before going the medical route (in many cases I see these folks after they’ve already been the medical route). Engineer and sufferer Pavel Kotlykov put a well-bibbed website together over at Vertigo Treatment dot org, and in his article Cervical Vertigo Caused by Neck Postures, stated…..
“The etiology of cervicogenic vertigo can be traced to pathophysiological changes in the inner ear, head or neck region. Despite the somewhat ominous-sounding name, “cervicogenic dizziness” is simply a variety of vertigo brought on by conditions related to the neck (or cervico-), and one of several “vestibular” apparatus disorders associated with the inner ear. Among the symptoms commonly associated with this form of vertigo are neck pain and/or stiffness, headache, distorted vision, nausea, ear congestion, sweating, and tinnitus—to varying degrees.”
One of the specific causes mentioned by the authors included,
“Vascular compression of the vertebral arteries in the neck by the vertebrae and other structures (Sakaguchi and Kitagawa et al. 2003), especially, compression due to incongruity of the origin of the vertebral artery, an inconsistent course between the fascicles of either longus coli and bands of deep cervical fascia (Bogduk, 1986) have been shown to be associated with obstruction of blood flow while turning the neck. Spasm of the vertebral arteries can occur due to their close association with the sympathetic trunk (Bogduk, 1986).”
We see here that over three decades ago one of the most renowned WHIPLASH RESEARCHERS of the twentieth century (Nikolai Bogduk) was talking about the relationship between Fascia and THE SYMPATHETIC NERVOUS SYSTEM. The biggest problem with the whole I-think-fascia-may-be-causing-my-problem scenario is that fascia doesn’t show up on tests (HERE) — at least it doesn’t show up on the standard advanced imaging tests commonly used by the medical community after trauma (CT), or after the situation becomes chronic (MRI).
The interesting thing is, there are actually tests available that allow you to image Fascia, but for whatever reasons, they aren’t commonly used. However, as the technology behind Diagnostic Ultrasound continues to improve, practitioners are increasingly able to image Fascial Adhesions (HERE is a really cool example using two 10 second videos for side-by-side comparison).
Last July, the OSTEOPATHIC journal, Research Bank (Reliability of Deep Cervical Fascia and Sternocleidomastoid Thickness Measurements Using Ultrasound Imaging), concluded….
“Recent literature has provided a hypothetical framework for the possible role of fascia within myofascial pain. This hypothesis involves structural alteration of deep cervical fascia within the loose connective tissue layer, as observed through ultrasound imaging (USI). This structural alteration has been termed ‘densification’, and has been associated with increased fascia thickness and reduced tissue compliance.”
The authors came to the conclusion that while it was fairly easy to measure the thickness of the SCM using a novice operator, in order to measure the thickness of the fascia surrounding the SCM required an advanced operator. Oh, and because the authors mentioned the term “DENSIFICATION,” it might behoove you to read the short post I wrote on the topic.
This next study (Ultrasound Assessment of Fascial Connectivity in the Lower Limb During Maximal Cervical Flexion), published in last July’s issue of BMC Sports Science, Medicine & Rehabilitation looked at just how interconnected the body really is because of Fascia. The authors stated, “The fascia provides and transmits forces for connective tissues, thereby regulating human posture and movement. One way to assess the myofascial interaction is a fascia ultrasound recording. The present analyses suggest statistically significant displacement of deep fascia.”
In other words, when subjects sitting in a “kyphotic” or “flexed” posture (bent forward — THE POSTURE OF AGE) moved their chins towards their chests as far as they could go (MAXIMAL CERVICAL FLEXION), it moved the Fascia in their calves enough to be able to measure it. Not only is this very cool for a wide variety of reasons they mentioned in their paper, it proves just how interconnected the body is by fascia (HERE). It also explains why I have had people with chronic neck pain and tethering get relief from working on their THORACOLUMBAR FASCIA.
It also shows that Tom Meyers (ANATOMY TRAINS) and Dr. Janda (UPPER CROSSED SYNDROME / LOWER CROSSED SYNDROME) were right all along, how Fascia is able to act as a second nervous system (HERE), and even how it provides a potential basis for a great deal of sickness and disease (HERE) — not merely pain — when not working properly. If you enjoy posts on fascia, be sure and take a look at my FASCIA SUPER-POST, with all 160+ of our posts on fascia categorized for easy reference. And be sure to like us on FACEBOOK while you’re at it!
