The stiff neck dilemma

A large survey of 353,000 Americans revealed 31% of Americans reported experiencing chronic neck or back pain in 2011 (Brown, 2012). Interestingly, rates of individuals experiencing chronic pain increases until the late 50s, when numbers level out and slightly drop, possibly because of morbidity. I began working with a 15 year old basketball player 5 weeks ago specifically because of nagging neck pain. His neck had been an issue for months, and a running drill the team did with their hands overhead for 7 minutes caused a spasm that left him with discomfort in the following weeks.  He rested, avoided movements that bothered it, and asked his mom if he could see me so he could get strong without getting hurt. A quick assessment revealed asymmetries in his thorax and pelvis, as well as a tendency towards inefficient breathing. Research performed by Wirth, suggests improving neck flexor muscle endurance, thoracic spine mobility, chest mobility, and respiratory muscle endurance training for individuals with chronic neck pain. Further, Dimitriadis, compared respiratory strength in 45 individuals with chronic neck pain compared with 45 controls. The researchers found the chronic neck pain group had a statistically significant difference in their respiratory muscle strength and concluded this weakness impaired global and local muscle systems in the neck.

When you look at the anatomy, this makes sense. The primary muscles of inspiration are the intercostals and the diaphragm; the accessory muscles are the sternocleidomastoid, scalenes, and serratus posterior superior and inferior. During respiratory distress, the levator scapulae, pectoralis major and minor, rhomboids, serratus anterior, and latissimus dorsi are also involved (an easy to read chart can be found here: If you glance at the picture above, you will see all of the accessory muscles of inspiration are have attachments at the neck and many of the muscles used during respiratory distress do as well. This, of course, might lead one to wonder if a breathing disorder is causing chronic neck pain or if the chronic neck pain is leading to inefficient breathings patterns? It depends on the person, and individuals that are referred to me because of chronic neck pain fall in the "cleared to exercise, everything else has been checked and is a non-issue" category. In the presence of breathing disorders such as asthma, it is useful to understand the effect this has on stabilization and potential increased activity in the accessory muscles of inspiration. This affects rib cage position and will lead to a decrease in overall stability. When clients are experiencing an increase in asthmatic symptoms because of weather or allergens, I am careful about position and load. Anecdotally, clients that have asthma have reported a decrease in symptoms after 4-6 weeks of regularly implementing breathing exercises into their program. I am not suggesting asthma can be cured by mindful, diaphragmatic breathing, but in my experience, it seems to help the severity of it. 

What I did with the basketball player consisted of three parts. I taught him how to breathe in a more parasympathetic (read, diaphragmatic) manner. This went hand in hand with improving his overall core stability with breathing exercises and bodyweight exercises done in an efficient position. I also made him aware of his shoulder position. He is preparing to participate in a pre-season strength and conditioning program involving olympic lifts. His natural, resting tendency is to have his shoulders up by his ears, which doesn't lead to efficient lifts. This pattern seems to be common in individuals with neck pain and goes along with anteriorly rotated shoulders (which he had). I taught him some techniques to notice where his shoulders were located, and I asked him to "make his neck as long as possible" in a variety of positions. When we first started, he consistently used the strategy of trying to find a way to use his neck to make his neck long. Once he because aware that his shoulder position influenced the length of his neck, he became better able to alter neck position with shoulder position. He was able to bring this increased awareness with him during his daily activities, and I can happily report he is currently participating in all of his pre-season activities (including hours each day of basketball), pain free. Many times, what we do outside the gym matters far more than what we do in the gym.

Yours in health and wellness,


Brown, A., 2012. Chronic pain rates shoot up until Americans reach late 50s. Gallup Well-Being;

Wirth, B., Amstalden, M., Boutellier, U., & Humphries, B.K., (2014). Respiratory dysfunction in patients with chronic neck pain-influence of thoracic spine and chest mobility. Manual Therapy, [Epub ahead of print].

Dimitriadis, Z., Kapreli, E., Strimpakos, N., & Oldham, J., (2013). Respiratory weakness in patients with chronic pain. Manual Therapy, 18(3), pp. 248-53.