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Fibromyalgia & Neck Straightening

by Dr Rob Lamport DC

Students with fibromyalgia present a unique challenge for the yoga teacher or therapist. This post discusses how a straighter neck curvature is a common finding in those with this condition and what you can do.
Background
Fibromyalgia is a condition characterized by chronic widespread musculoskeletal pain. Other symptoms include fatigue, cognitive disturbance, and depression.
 
It affects women more than men, can occur at any age but is typically seen in middle-aged people. Globally It is estimated to affect between 2% and 4% of the general population (Häuser et al., 2022).

What causes it?
The cause of this condition is currently unknown, but various theories exist. One of these is that the nervous system undergoes changes that lead to a heightened sense of pain (Pamares et al., 2017).

Some studies have shown a strong association between reduced vitamin D levels in those with the condition compared to the general population (Makrani et al., 2017). Indeed, this should be tested by a medical professional.

There is also a significant association with a traumatic event in childhood leading to fibromyalgia in adulthood (Kaleycheva et al., 2021).
Fibromyalgia Symptoms
What about changes to the spine?
Structurally one common finding is that there is a loss of the normal neck curvature: the neck will be straighter. In one study (Katz et al., 2022), more than 80% of those with fibromyalgia had a decreased cervical curve. 

Could this be a cause or contributing factor to developing the condition? This we can't say. However, this knowledge should be considered in your therapeutic programs.

What is the Significance of a Straight Neck?
The spine is designed to have natural curves when looking from the side. These curves allow for better weight distribution and shock absorption.

When these curves alter, the load acting through the spine changes, causing added stress to joints, ligaments and muscles. This can manifest as stiffness and pain but may also cause other issues. For example, straighter necks may play an important role in the pathogenesis of tension-type headaches (Nagasawa et al., 1993).

Assessing Changes in Neck Curvature
The most accurate way to assess neck alignment is via an x-ray. However, if this is not available, you may be unsure of the situation. The following points, however, all increase the likelihood of a straighter neck:

  • Thoracic kyphosis: an increased curvature of the upper back is usually associated with a decreased neck curvature. Look for this on the physical assessment.
  • Whiplash: can occur following a road traffic accident, but also many other ways. It can cause various injuries to the neck, which include changes to neck alignment. In the history, ask about car accidents, falls, or any other injuries that may have occurred to the neck.
  • Professions that involve prolonged neck flexion: those that engage in work where the head is bent forward for many hours each day will often have straighter necks. Jewellers and dentists, for example.

If any of the above are present in those with fibromyalgia, altered neck alignment is very likely.

You can, of course, visually assess the neck posture of the student. However, it can be challenging to assess, even for the very experienced.

If you are concerned that the student has straightening of the neck, you can refer to a medical practitioner for further investigation.

If you are not certain of the situation, the following ideas can help ensure the neck is kept both safe and healthy. 
Precautions for those with Straighter necks
Sarvangasana and Halasana (shoulderstand and plough)
Both postures and their modifications require neck flexion, which leads to a temporary neck straightening. This type of movement is likely to aggravate an already reduced curve. Using a blanket under the shoulder will decrease strain on the neck but it is still not advisable.
Sirsasana (headstand)
If appropriate headstand is not a problem. Providing the arms support the vast majority of the weight. Variations of the posture with less arm support should be avoided (the neck tends to buckle and straighten when a load is applied to the head).
Neck flexion
Be mindful of any posture where the head may flex forward, such as during forward bends. Make sure this movement is not forced or causes strain. 
In general, consider that many activities of daily life involve neck flexion. Sweeping the floor, washing up, cooking, brushing teeth etc. All cause the neck to straighten during this action. You will need to explore other movements, including neck extension, which causes the neck to become more curved. Be mindful of this when developing your therapy program.
Beneficial Movements and Practices
  • Explore neck movement. Simple head movements in all directions can bring awareness to the region and improve muscle tone. However, be mindful not to emphasise neck flexion. It is better to explore neck extension movements, as the neck's curvature increases during this movement but decreases during flexion.
  • Improve neck extensor muscle tone. Those with reduced cervical curve tend to have reduced neck extensor muscle strength. This group of muscles move the head into extension (see below for one way to work with these muscles).
  • Support the neck in savasana. This is the easiest and, for me, an essential point to introduce. When lying down in savasana, place a rolled-up, medium-sized towel under the neck. When done correctly, it will help to re-introduce the necks curve. Whilst by itself, this will not permanently solve the issue. It is an important step in helping the student feel correct alignment. Often this support is very comfortable and may help relieve neck pain. (See below for further guidance on this topic).
How to Support the Neck in Savasana Size of Towel
This will vary slightly from person to person. A few points to consider in size selection:

  • The student should feel very comfortable
  • The head should be in a neutral position 
  • The necks should appear to be in good alignment
In some cases, the head and neck being in greater extension is also fine and may have a more significant impact on correcting the curvature. However, it is better to maintain a more neutral alignment if you don't know with certainty the curve has changed.
If Thoracic Kyphosis is Present
Those students with rigid thoracic kyphosis may require some support under the back of the head (see examples below). You will see in these students that their heads will extend when they lie down on their backs. A little support under the head will help solve this. Over time address thoracic rigidity by mobilising the upper back. 
Setting up the Student with Good Support and Alignment 
Good Set Up
The rolled-up towel is placed just above the top of the shoulder and is of the correct thickness to support the neck and maintain a neutral head position.












Towel Too Thick
The towel is probably too thick in this example, as the head has extended.  Experiment with a thinner towel and check for rigid thoracic kyphosis (see next image).








Rigid Thoracic Kyphosis
The rigid spine will not straighten when the student lies down, causing the head to extend.








Head Support & Neck Support for those with Rigid Kyphosis
When thoracic rigidity is present (see above), placing a towel under the back of the head may be used in addition to the rolled-up towel under the neck.








Head in Flexion
This image illustrates poorer alignment. Note how the chin is closer to the floor and the bunching up of tissue around the throat. Also, note the space between the back of the neck and the floor. The lesser the area, the straighter the neck.









Building Neck Extensor Endurance and Strength
As mentioned earlier, those with straighter necks tend to have reduced neck extensor muscle endurance and strength. Targeting this muscle group is, therefore, helpful. Here is a safe and straightforward way to do that.

The student should first lie down on the back, with the head supported, as described for savasana (see above). They then very simply, gently, and very slowly push the back of the head into the floor. As this is done, the neck should not move. 

Neck movement will be felt as a change in pressure between the neck support and the neck. Any increased neck flexion or neck extension should be avoided at this stage as it will increase loads acting through the neck. This has the potential to aggravate existing issues.

I recommend incrementally building the amount of this pressure by which the head is pushed into the floor. Start with about 5% of maximum force, hold for a few seconds, and then completely relax. Keep in mind the relaxation stage is as important as the contraction phase. That is due to many people holding excessive tension in the neck. Learning how to relax muscles fully can help to overcome this. Repeat the movement several times, monitoring for any discomfort. If no issue arises, try increasing to 10% of the maximum power.  

Over time, the number of rounds or holds and the force can be increased. For most people, however, 30-40% of the maximum power is sufficient.

What we are doing is essential to understand. We are first aligning the neck, then asking the muscles to contract whilst maintaining the neck's curvature. This ensures no excessive pressure on the neck and, over time, improves stability. This approach is very safe and can typically be practised by anyone.
Other Movements
Certainly, explore other neck movements. Three of my favourite techniques for the neck region are Simha Mudra, Jiva Bandha and Brahma Mudra. If you are unfamiliar with these techniques, you can read about them in my post on sleep apnea here.  

Also, consider the neck's relationship to the shoulders. The shoulders are, in many ways, the foundation of the neck, with many muscles connecting both regions. You can learn more about this topic here.

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References
Häuser, Winfried, and Mary-Ann Fitzcharles. "Facts and myths pertaining to fibromyalgia." Dialogues in clinical neuroscience (2022).

Kaleycheva, Nia, et al. "The role of lifetime stressors in adult fibromyalgia: Systematic review and meta-analysis of case-control studies." Psychological medicine 51.2 (2021): 177-193.

Katz, Robert S., et al. "The Vast Majority of Patients With Fibromyalgia Have a Straight Neck Observed on a Lateral View Radiograph of the Cervical Spine: An Aid in the Diagnosis of Fibromyalgia and a Possible Clue to the Etiology." JCR: Journal of Clinical Rheumatology (2022): 10-1097.

Makrani, Atekeh Hadinezhad, et al. "Vitamin D and fibromyalgia: a meta-analysis." The Korean journal of pain30.4 (2017): 250-257.

Nagasawa, Arata, Toshimasa Sakakibara, and Akira Takahashi. "Roentgenographic Findings of the Cervical Spine in Tension‐Type Headache." Headache: The Journal of Head and Face Pain 33.2 (1993): 90-95.

Pomares, Florence B., et al. "Histological underpinnings of grey matter changes in fibromyalgia investigated using multimodal brain imaging." Journal of Neuroscience 37.5 (2017): 1090-1101.