Stress: It’s connection to neck and shoulder pain
There is a phrase I often say to patients in clinic: “You really do hold the world on your shoulders.”
I tend to use it when I’m treating someone with persistent neck and shoulder tension, particularly through the upper trapezius muscles, and we start talking about what else is happening in their life. Perhaps work has been particularly demanding, they aren’t sleeping well, they are caring for children or relatives, or they simply have a lot going on and haven’t really stopped to consider how much pressure they are under.
As an osteopath, I find the connection between stress and physical symptoms fascinating because we have a tendency to separate the two. We think of stress as something happening in our minds and neck or shoulder pain as something happening in our muscles and joints, when in reality our nervous system connects the two remarkably closely.
As a working parent myself, I also know that removing stress from life isn't a particularly realistic piece of health advice. There will always be busy weeks, interrupted nights, deadlines, family worries and periods when there simply aren't enough hours in the day. What can be useful, however, is understanding what those periods may be doing physically and recognising some of the signs that your body isn't getting much opportunity to switch off.
Why do we hold tension around our shoulders?
The trapezius is one of the largest superficial muscles of the upper back. It runs from the base of the skull, across the shoulders and down the upper and middle back, with different portions of the muscle involved in movements of the neck, shoulder blades and shoulder girdle.
I sometimes describe the trapezius to patients as a very “emotional” muscle. I don't mean that the muscle itself experiences emotion, of course, but that its activity can reflect how we are feeling.
Think about what happens to your body when you are suddenly startled, worried, cold or under pressure. Your shoulders may creep upwards, your jaw may tighten and your breathing pattern may change. If you are reading this sitting down, try deliberately lifting your shoulders towards your ears and holding them there for a few seconds. You can immediately feel how much work those upper trapezius muscles are doing.
Research supports an association between psychological stress and increased activity of the trapezius muscle. Laboratory studies using electromyography (EMG), which measures electrical activity within muscles, have demonstrated changes in trapezius activity during mentally stressful tasks. This gives us a physiological basis for something many people instinctively recognise: when we are under pressure, our bodies can physically brace.
The occasional stressful day isn't necessarily a problem. Our bodies are designed to respond to challenges. It becomes more relevant when that raised, guarded state occurs repeatedly over weeks or months, particularly when combined with long periods at a desk, driving, reduced exercise or poor sleep.
Over time, muscles can become fatigued and sensitive and the nervous system itself can become more responsive to painful signals. Importantly, this doesn't necessarily mean there is damage to the muscle. Pain is much more complicated than simply finding a damaged structure.
What is happening inside the body when we're stressed?
Our stress response is an essential survival mechanism.
When the brain perceives a threat or challenge, the sympathetic nervous system becomes more active and hormones including adrenaline and cortisol are released. Heart rate and blood pressure may increase, alertness rises and the body prepares itself to respond.
Historically we often describe this as our “fight or flight” response, although the stressors most of us encounter today are rather different from the physical threats this system originally evolved to help us deal with.
A difficult meeting, an overflowing inbox, financial worries, caring responsibilities or being awake at 2am with a child don't require us to physically fight or run away, but our nervous system can still respond to these situations as a form of threat.
Cortisol sometimes gets portrayed as a “bad” hormone, but that isn't really accurate. We need cortisol and it performs many important functions within the body. The issue is more about what happens when our stress systems are repeatedly activated and we don't get enough opportunity for recovery.
Persistent psychological stress has been associated with musculoskeletal pain, and the relationship appears to involve several interacting mechanisms including muscle activity, pain processing, behaviour and sleep.
The stress, sleep and pain triangle
Sleep is something I increasingly ask about when assessing persistent musculoskeletal pain because it can make such a significant difference to how someone feels.
If you're stressed, you may struggle to fall asleep or find yourself waking during the night thinking about things. If you are a parent, good sleep may not always be entirely within your control anyway.
Poor sleep can then affect how the nervous system processes pain. Research has shown a relationship between sleep disturbance and increased pain sensitivity, and importantly the relationship appears to work in both directions. Pain can disturb sleep, but disturbed sleep can also make us more susceptible to pain.
This can create a cycle where stress disrupts sleep, poorer sleep increases pain sensitivity, discomfort makes sleep more difficult and the whole process repeats itself.
This is why, when someone presents to clinic with persistent neck and shoulder pain, I don't only want to know which movements hurt. I want to know how they are sleeping, what their working day looks like, how much they are moving and whether anything significant has changed in their life.
Stress doesn't look the same for everybody
One of the interesting things about working in a clinic where I see patients from their twenties through to their eighties is how different the source of stress can be while the physical presentation can look surprisingly similar.
For younger adults it might be long working hours, career pressure, commuting, financial worries or starting a family. For people in their thirties and forties there can be an enormous amount to juggle between children, work, relationships, running a household and sometimes beginning to support ageing parents as well.
Later in life, stress doesn't simply disappear. Caring responsibilities, bereavement, health concerns, retirement, changes in independence and worries about family can all place considerable demands on somebody.
Yet across all these age groups I can see a familiar presentation on the treatment couch: shoulders sitting high, tenderness through the upper trapezius, stiffness around the neck and upper back and sometimes associated headaches or jaw tension.
Occasionally I'll ask someone whether they have been particularly stressed recently and they'll initially say no. Once we start talking about what's actually been happening over the previous few months, however, the answer sometimes changes quite considerably.
Does that mean the pain is “just stress”?
Absolutely not.
This is an important distinction because telling someone their pain is caused by stress can sound dismissive. Neck and shoulder pain still needs to be assessed properly, particularly when symptoms are persistent, worsening or accompanied by other symptoms.
Stress is one part of a much bigger picture. As an osteopath, I'm looking at how the neck and shoulders are moving, muscle tone and sensitivity, joint movement, previous injuries, working position, exercise and general activity alongside sleep, stress and other aspects of someone's health.
Sometimes there is a very obvious mechanical reason for somebody's symptoms. Often there are several contributing factors rather than one single cause. Understanding that stress may be one of them doesn't make the pain any less physical or real.
What can you do if you're holding the world on your shoulders?
Unfortunately, telling someone to “be less stressed” is rarely helpful. Most people would happily choose less stress if it were that simple.
Instead, I tend to encourage small opportunities throughout the day for the body to come out of that guarded position. Occasionally notice where your shoulders are sitting and allow them to drop. Change position regularly if you work at a desk rather than trying to maintain one supposedly perfect posture. Keep the neck and shoulders moving, exercise regularly where possible and look at your workstation if symptoms consistently build during your working day.
Sleep is also worth considering rather than treating it as completely separate from your pain. If you're consistently sleeping badly, addressing why may be just as relevant as stretching the sore muscle.
For some people, hands-on treatment and movement advice can also help settle symptoms and restore comfortable movement, but I think one of the most useful things we can do as clinicians is help somebody understand why their symptoms might be occurring rather than simply treating the painful area.
So the next time you notice your shoulders creeping towards your ears after a difficult day, remember what I so often say in clinic:
“You really do hold the world on your shoulders.”
Sometimes our bodies show us just how much we're carrying before we've consciously acknowledged it ourselves.
How can we help?
If stress is contributing to your aches and pains, that doesn't mean you simply have to put up with them. At The Waterside Practice, we often see how several factors can come together – stress, sleep, working position, reduced movement, changes in activity and the way the body is physically coping with everyday demands.
Our osteopaths can assess persistent neck, shoulder and back pain to understand the different factors that may be contributing to your symptoms. Treatment may include hands-on techniques alongside advice around movement, exercise, working habits and ways of managing the physical load on your body.
Our massage therapists can work with areas of muscular tension and discomfort, including the neck, shoulders and upper back. For someone who has spent weeks feeling as though their shoulders are permanently sitting somewhere near their ears, having time specifically dedicated to reducing muscular tension and encouraging movement can be particularly welcome.
Our foot health practitioners have a different but equally important role in keeping people comfortable and mobile. Painful feet, corns, calluses, nail problems and other foot complaints can make walking and exercise less comfortable, which can affect how much we move. Keeping our feet comfortable helps us to remain active, and regular physical activity itself is an important part of supporting both our physical and mental wellbeing.
One of the advantages of being a multidisciplinary practice is that we don't have to look at the body as a collection of completely separate parts. Sometimes the painful area is only one part of the story, and understanding the wider picture can be just as important as treating where it hurts.
So the next time you notice your shoulders creeping towards your ears after a particularly difficult day, remember what I so often say in clinic:
“You really do hold the world on your shoulders.”
Perhaps it's worth asking what your body has been carrying lately, and whether it might need a little help too.
— The Waterside Practice Team