Treatment of posterior neck pain in my Boston area Neuromuscular Therapy center always begins with the suboccipitals. For anatomical drawings of the muscles in the following treatment protocol, refer to Neck pain: Understanding the posterior muscles.

To treat the suboccipitals, pressure is held for 8-12 seconds under the skull with fingertips or thumbs to soften the overlying semispinalis muscle of the posterior cervical group. When you feel a release of tension, release pressure and then go deeper to treat the underlying suboccipitals. Cross-fiber friction against the occipital bone is appropriate when pain is tolerable. When you find Trigger Point referrals, spend extra time releasing those nodules with sustained pressure. Pay special attention to the soft tissue between the top two vertabrae where pressure on hard knots can produce headaches as well as neck pain.

Occipital pressure also includes treatment of the splenius capitis lateral to the midline. Pressure is exerted on the soft belly, as it begins to descend diagonally toward the spine, to release the tension that causes neck pain.

Treatment continues with pressure on the layers of posterior cervical muscles in the deep lamina groove on either side of the spine down to the base of the neck. Pay attention to the transverse processes of the top four vertabrae to treat the attachments of the levator scapula and splenius cervicis. The band of connective tissue that attaches the upper trapezius to the spine can also be treated all along the spine with pressure pulling outward to stretch and soften it.

Slow lubricated gliding strokes down the back of the neck milk pain-causing waste products down into the lymphatic system and further soften those myofascial tissues. Include all tissues between the spinous processes and transverse processes.

Extra pressure in the “pocket” at the angle of the neck toward the spine and toward the upper border of the scapula addresses splenius and levator tissue.

Most neck problems include the upper and middle trapezius. Techniques used are pressure against the supraspinatus fossa of the scapula (often with a pressure tool) and slow gliding strokes between acromion process and spine to treat the middle trap and part of the upper trap, and compression of the upper trap between fingers and thumb searching for and treating taut bands and Trigger Point nodules.

For more specific treatment of the lower portion of the levator and splenius muscles and interscapular portions of the middle and lower trapezius, the patient lies face down. Pressure and (if tolerated) cross-fiber friction is used on the lower attachments of the levator scapula on the edge of the scapula bone above the spine of the scapula, and on the attachments of the splenius along the lower cervical and upper thoracic spine. I use pressure bars in both places. Slow lubricated gliding strokes are used diagonally from the base of the neck outward to the scapula to lengthen and “milk” the levator scapula and straight across from the spine to the scapula to treat the middle trapezius.

While the patient is prone, further treatment of the posterior cervical muscles with pressure and gliding can be effective.

Icing, stretching, and drinking lots of water after the treatment for 24 hours is recommended.

Tip for therapists: Since the muscles of the neck work together, when some become dysfunctional, others kick in to help. A thorough treatment should include the SCM and scalene muscles in the anterior neck.