Improving Chronic Neck Pain With Pilates

Pilates exercises may provide relief for clients struggling with chronic neck pain. Neck pain is among the four most common pains affecting Americans (following back pain); it’s also the second leading cause of work absences (Pleis, Ward & Lucas 2010; Albright et al. 2001). The problem occurs most often in middle age and affects women more often than men (Binder 2008).

Causes of neck pain are multiple and are not well understood (Binder 2007). Whiplash is one source; as many as 50% of people with whiplash complain of neck aches a year after injury (Teasell et al. 2010). Posture is another: “In Silicon Valley, computer usage and texting on smart phones are frequent causes of forward-head syndrome and neck pain,” says Mercy Bobias-Lain, owner of Apex Pilates Personal Training in Milpitas, California, whose clientele includes primarily Silicon Valley professionals.

Clinical practice guidelines recommend therapeutic exercises as a treatment; however, most doctors prescribe pain relief medication and rest (Albright et al. 2001). One challenge is that no consensus exists regarding which exercises are best. For clients with neck pain, Pilates experts recommend a whole-body approach with props and modifications. These professionals also suggest using progressions and maintaining clear communication to prevent clients from pushing themselves too far.

Research

Few high-quality studies exist that identify best practices regarding exercise selection for neck pain. Authors of a Cochrane review of 21 exercise trials concluded that “there appears to be a role for exercises in the treatment of chronic neck pain and cervicogenic headache if stretching and strengthening exercises are focused on the neck and shoulder blade region” (Kay et al. 2012). A cervicogenic headache is caused by neck problems such as injury to cervical disks or vertebral joints and may be triggered or made worse by neck movement, a particular neck position, or pressure over parts of the neck (North American Spine Society 2014).

One pilot study has evaluated Pilates for chronic neck pain (Mallin & Murphy 2013). Lead study author Germaine Mallin, MS, chartered physiotherapist and Pilates instructor at Southside Physiotherapy Clinic in Dublin, said, “The reason I decided to look into Pilates was that there were no [Pilates] studies at the time on the subject [of neck pain]. Most were on back pain.”

Subjects in Mallin’s study—12 women and one man aged 37–59, each of whom had suffered neck pain lasting 3 months or longer—participated in a 6-week mat program, attending an hourlong session once weekly. Researchers encouraged subjects to practice at home for 20 minutes at least three times per week. Investigators assessed pain levels and functional disability before the study, after 6 weeks and after 12 weeks. Data analysis showed significant improvement in functional ability after 6 weeks; after 12 weeks, both functional ability and pain levels were significantly better.

“The Pilates exercises used in the study were . . . not specific to the neck only,” says Mallin. “I mainly used stability exercises. You could argue that working on deep-neck-flexor and scapular-stabilizer endurance is also low-level strengthening. There is evidence that improving lumbar-spine posture will also improve neck posture with automatic activation of multifidus and deep-neck-flexor muscles.”

The study included these exercises:

• hip twist, level 1 (supine; single-leg knee-sways with neutral spine)
• double-leg stretch, level 1 (supine; knees bent with rib cage stable and arms overhead)
• double-leg stretch, level 2 (level 1 + alternating heel slides in bent-knee position)
• one-leg stretch, level 1 (supine; arms at sides with alternating heel slides)
• clam, level 1 (side-lying with neutral spine; top knee lifts toward ceiling)
• shoulder bridge, level 1 (supine; hips lift and lower with neutral spine)
• scissors, level 1 (supine; alternating single-knee lifts over hip with neutral spine)
• arm openings, level 1 (side-lying with knees bent; top arm opens to T-position to rotate spine)
• breast stroke prep, level 1 (prone, with forehead supported by towel to maintain neutral spine; shoulder blades glide down while arms lift upward, palms facing down)
• breast stroke prep, level 2 (level 1 + upper-body lift—“chest float”—while keeping neutral spine).

All exercises emphasize maintaining length in the back of the neck.

“I would definitely take a whole-body approach,” says Mallin. “People with neck pain are more likely to have low-back pain than the general population and vice versa, so focusing on core stability of the lumbar spine is important. I also like to add thoracic-mobility exercises, as a stiff thoracic spine can place more load on the spine above and below.” Mallin adds, “Exercises that improve postural awareness and core stability can have an effect on chronic neck pain. Low-level exercises that focus more on technique, rather than strength, can be extremely effective.”

Practical Application

Experienced Pilates practitioners agree with Mallin’s approach to addressing overall alignment. With a longer-term view toward restoring optimal spinal alignment, experts also favor using props and specific exercise modifications. Bobias-Lain additionally recommends educating clients on neck muscle physiology and why strengthening neck extensors is important.

Props can support the neck and start restoring the spine’s natural curves until clients improve their neck strength and gain stability in the core and scapulae. Body awareness is essential for preventing injuries and avoiding pain aggravation. For exercises in the supine position, neck support should be provided with small pillows and rolled towels to reinforce the cervical spine’s natural curves.

Leah Putnam, owner of Spring Training in Mountain View, California, says, “Start by addressing the posterior lateral rib cage as your pinnacle of focus. Take gravity out of the equation by lying supine with posterior bottom ribs in contact with the floor. This can be accomplished by way of pelvic movement, breath, muscular contraction of the external obliques and/or pillowing up the thoracic spine and head.”

She adds, “Once you’ve gained access to this anchoring of the posterior inferior rib cage, try lengthening the cervical spine without disturbing the previous anchoring. The third focus for alignment is opening the chest by pulling shoulders to the floor, while keeping the lower ribs anchored and the back of the neck lengthened.” A way to help open the shoulders is to encourage a palms-up arm and hand position.

“One of the main techniques someone with neck pain needs to master is the ‘chin tuck,’” says Michele Olson, PhD, FACSM, professor of exercise science at Auburn University in Montgomery, Alabama. “Not folding the chin down, but lengthening the back of the neck and then pulling the chin up as if behind the nose. This requires you to use deep flexor muscles in front of the neck, which takes the entire load off the back of the neck muscles. Doing the chin tuck, since it’s not heavily flexion based, will open up the vertebrae and not compress spinal disks, and will provide a [muscle-based] strategy for also stabilizing the neck.” A useful preparatory exercise for increasing body awareness and lengthening the back of the neck is the “neck glide” (described in the sidebar).

For any type of curling or rolling-up movement from supine (e.g., the hundred), clients can support the head—in the chin tuck position—with one or both hands, or they can place a towel under the upper back to create a hammock for their head and neck and hold the hammock with both hands reaching overhead. Cue clients to flex the spine and feel work in the abdominal muscles, not in the neck. As core muscles become stronger, it will be less necessary to provide neck support. If any inversion—like bridging—is involved, a blanket or folded mat can be placed under the back in line with the top of the shoulders to prevent excess neck pressure.

Exercise modifications are essential. Inversions like short spine can be modified so that clients still do the movement but don’t come all the way up into a shoulder stand. Bobias-Lain calls this the “baby short spine.” Avoid exercises with extreme flexion or extension; for example, roll-over, jack-knife and high bridge. For other exercises, clients can do fewer repetitions, use a smaller range of motion, reduce the time spent holding an exercise, use a shorter lever length (e.g., bent knee instead of straight leg, or arms bent at he elbows instead of long arms) and always stop doing an exercise if they feel any neck strain.

While it may take time to stretch tight muscles and strengthen weaker links, your clients will gradually learn how to improve their neck conditions. This experience is very empowering. As Putnam says, “Regaining correct alignment is truly beneficial [for gaining] freedom from pain and [enjoying] enhanced well-being.