The Guide to Neck Pain

Have you ever suffered from neck pain?

Perhaps you woke one morning with a “crick” in your neck, or you’ve been diagnosed with “whiplash” after an accident. Maybe you’ve experienced numbness and tingling in your arms or hands and been told that this is coming from your neck. If these situations sound familiar, then this guide is for you. We will aim to provide clarity about neck pain as well as a practical path forward.

Neck pain is defined as having pain symptoms for at least 24 hours in the cervical spine region, which includes the first 7 bones in the neck known as the C1-C7 vertebrae. Neck pain may also include symptoms that radiate into the arms. Millions of individuals worldwide experience neck pain each year. A recent review found 288 million cases of neck pain worldwide, ranking it in the top 25 leading causes of global disability. Kim 2018 GBD 2019 Safiri 2020 Men between the ages of 45-49 and women between 45-54 experience the highest burden from neck pain (see figure 1). Safiri 2020

While many people assume that neck pain implies that something is wrong with the structure of their neck, it turns out that there are lots of other factors that can influence the experience of neck pain. This is actually good news, since it means that we have lots of things we can work on when experiencing neck pain. In the following sections we will discuss some of these factors that increase or decrease the risk of developing neck pain.

What factors relate to the onset and recurrence of neck pain?

“Risk factors” are variables that can influence the development of a condition like neck pain. There are two main categories of risk factors:

1. modifiable – variables that we can influence, such as obesity, physical activity, nutrition, and smoking. These often represent targets we can work to improve.

2. non-modifiable – variables that we cannot influence, such as age or a prior history of neck pain. These are things that we can’t do anything about

Risk factors that influence the development or recurrence of neck pain can be divided into three general categories: physical, individual, and psycho-social factors. Kim 2017 A discussion of these risk factors can direct our efforts when managing neck pain.

In the following sections we will use numbers to describe the strength of relationship between a given variable and neck pain. A value of 1.0 indicates no relationship between a variable and neck pain, a value less than 1.0 indicates that the variable is associated with a LOWER risk of neck pain (i.e., “protective factor”), and a value greater than 1.0 indicates that the variable is associated with a HIGHER risk of neck pain (i.e., “risk factor”). See table 1 for a summary of these concepts. We will focus on the most influential factors here, although many other variables have been studied as well.

Individual Risk Factors

Individual factors describe things specific to a person that relate to the risk of neck pain. A major contributor to the risk of neck pain in this category is Body Mass Index (BMI). Body mass index is a measure of body size that can be a useful screening tool for overweight and obesity. You can calculate your BMI HERE.

High BMI (> 30 kg/m2) is associated with 2.21 times higher odds of experiencing neck pain, indicating that obesity has a strong relationship with neck pain. Since BMI is a modifiable risk factor, we can focus some attention on this area for aiding the management of neck pain.

Other individual risk factors with moderate-strength relationships include variables that are likely not as tangible for influence such as marital status, family size, and socioeconomic level (see table 2).

Physical Risk Factors

Physical risk factors describe variables specific to the person's body and the demands placed upon it. Factors with moderate influence on the risk of neck pain include workspace setup and demands. For example, not having the ability to adjust sitting positions at work (1.80 times higher odds) and working in sustained or “awkward” positions (1.6 times higher odds) are associated with neck pain. In the research, "awkward" was defined using a questionnaire with questions relating to:

1. Working with hands above shoulder level

2. Lifting greater than 25 kg

3. Using force with arms or hands

4. Bending or turning the torso frequently per hour

5. Working in uncomfortable positions

6. Prolonged work in the same position of the body

7. Repetitive movements with arms or hands frequently per hour Luime 2004

Researchers combined bending or turning the torso frequently per hour and working in uncomfortable postures to define "awkward postures”. The use of “awkward” to describe a posture is subjective and may be based on an individual’s past or current experience of discomfort or fatigue with particular body postures. However, not everyone may share this experience, which makes it difficult to define “awkward” postures that are generalizable to all people. This label further drives expectations and ideas about “correct” or “perfect” postures – which don’t actually exist. Korakakis 2019 Korakakis 2020

Psychosocial Risk Factors

Psychosocial factors include individual psychological characteristics, as well as social and inter-personal variables. Of the variables studied, psychological and social factors seem to hold stronger relationships with the risk of neck pain compared to individual or physical factors. Kim 2018

Many of these factors relate to workplace stressors, such as high perceived job demands (2.14 times higher risk), imbalances between the effort required by the job and the rewards received (1.66 times greater risk), and a perception of low support from co-workers (2.43 times higher risk). Other psychosocial risk factors include:

• “Poor” self-rating of health (2.4 times higher risk)

• High perception of muscular tension (4.0 times higher odds)

• Personal history of neck pain (2.24 times higher odds)

• Depression (3.36 times higher odds)

Another important risk factor is the perception of high “quantitative demand” at work (2.32 times higher odds). “Quantitative demand” describes the amount of work and time pressure a person deals with (e.g., ‘‘do you have too much to do?’’ and ‘‘do you have to work overtime?’’) Christensen 2014 Another major risk factor is high role conflict (2.61 times higher odds of neck pain), assessed by questions like ‘‘do you receive conflicting requests from 2 or more persons?’’ Christensen 2014

Protective Factors

In contrast to the factors discussed above that were associated with increased risk of neck pain, we also have variables that are associated with decreased risk of neck pain (i.e., protective). These are worth reviewing to guide what we can do to mitigate neck pain.

Leisure-time physical activity has been associated with a 30-40% reduction in the odds of developing long-term neck pain. Palmlöf 2016 Daily walking is a good example of leisure-time physical activity that can reduce the risk of developing neck pain. For example, one study found that a modest increase in daily step count (8190 steps vs. 7044 steps) decreased the risk of neck pain by 78% over a 6-month period – and this is not to mention all the other health benefits that can be obtained by increasing daily activity through walking. Sitthipornvorakul 2020 These findings have been echoed in other research demonstrating exercise substantially reduces the risk of developing neck pain. de Campos 2018 A 2010 study found that the average daily step count in a group of U.S. adults was 5117 steps per day, indicating that there is room for improvement. Bassett 2010

Neck muscle endurance also appears to relate to the risk of developing chronic neck pain over time. While the effect is modest, having folks directly work on neck muscle endurance is fairly easy to do using an isometric hold for time. See a video HERE for an example of this exercise. Shahidi 2015

There are several protective factors in the context of the workplace as well. A survey of 1200 Norwegian workers found that “empowering leadership” at work was associated with a 68% reduction in odds of neck pain. This was assessed using questions like, “does your immediate superior encourage you to speak up if you disagree?” They similarly found that a “high social climate” was associated with a 55% reduction in odds of neck pain. Social climate describes the culture at work, for example being “relaxed and pleasant”. Christensen 2014 Having a less stressful, more supportive and enjoyable work environment seems to protect against the development of neck pain.

Contrast these findings with the risk factors discussed above, where individuals with high workplace demands, low levels of support, and inter-personal conflict all increased the risk of neck pain. The researchers concluded that,

Overall, this substantiated the hypothesis that non-physical aspects of work can exert considerable influences on pain problems. Christensen 2014

In other words, they found that neck pain is influenced by many factors outside of just neck structure.

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Recap

To close out this section, neck pain is common, with prevalence increasing in our 40s and 50s. Additionally, it can relate to many other factors beyond one simple thing being “wrong” with a person’s physical neck. Many risk factors pertain to the individual, such as how a person views themselves (e.g., poor health), perception of their neck (e.g., neck tension), as well as coping strategies to handle work and financial stressors.

We may not be able to directly influence all risk factors, but there are many where we do have opportunities for improvement. This means that an approach to managing neck pain must look at the whole person and their environment, rather than focusing exclusively on just the neck. The strength of relationships described between the risk and protective factors above can help us focus attention on areas with the largest return on our investment of time and effort.

Since general health factors, such as obesity and one’s self-perception of health, have strong relationships with the risk of neck pain, these are important areas to target. One approach can involve increasing general physical activity through daily walks and other forms of exercise that an individual enjoys and can maintain consistently over time. There are also specific exercise-based treatments targeted to the neck that we will discuss further in subsequent sections of this guide.

Work stressors have strong relationships with neck pain, and include high work demands, interpersonal conflicts, and a mismatch between rewards and the amount of effort required to earn them. This becomes a complex discussion of job enjoyment, having supportive co-workers and leadership, and autonomy within your role to make decisions. It’s easy to tell someone to find a different job if a person feels these standards aren’t met, but things aren't typically that straight forward in the real world. Having coping strategies such as talking to a trusted colleague, human resources, friends, family members, and qualified healthcare professionals may be beneficial for addressing work related stressors.

Additionally, addressing environmental work and physical stressors such as maintaining sustained body positions for prolonged periods of time are important areas of focus. Having the workplace setup to afford various postures throughout the day may help when managing neck pain; more on this later.

In the next part of this guide, we will focus on common ideas about neck pain and posture, in order to dispel myths before moving on to discuss how the healthcare system typically approaches the issue, and how we approach it differently.

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Posture

There are many false narratives surrounding posture and neck pain. Posture is a way we hold our bodies while engaging with the environment. This includes the way we sit, stand, or the positions we assume to execute a movement or task. Our posture fluctuates throughout the day based on multiple factors such as our emotional state, fatigue, physical symptoms such as pain, the demands of the task we are trying to accomplish, and more.

Variability in our posture is important for our adaptability and ability to accomplish tasks. However, many choose to divide posture into “good” vs. “bad”, or “injurious” vs. "safe". This dichotomous view of posture emerges from an outdated, reductionist way of thinking about structure, biomechanics, and pain. Lederman 2011 Korakakis 2019 These beliefs about postural perfection permeate our society and lead folks to seek out “optimal” posture, despite no evidence that such a thing actually exists.

A recent study by Korakakis examined 87 young individuals without any pain or dysfunction and instructed them to adopt whatever they believed to be an “optimal” posture. After this instruction, subjects automatically shifted their habitual (preferred usual posture without influence) sitting posture to a more upright (extended) posture. Korakakis 2021 The authors state:

Social contamination by common beliefs and stereotypes about posture, including that upright sitting is better than slouching, may partially explain these results, as postural behaviours likely reflect beliefs regarding ‘optimal’ [sitting posture]. Unfortunately, healthcare professionals also appear to often provide postural advice based on non-evidence-based opinions.

Part of this “social contamination” includes the prevalent belief that bending the neck while using phones or mobile devices (termed “text neck”) is harmful to neck structures and leads to increased pain and disability. When examining the origins of this belief, the narrative appears to have evolved from a 2014 article by Hansraj. The article makes various claims about head position having detrimental effects on the cervical spine by increasing the mechanical loads distributed across the neck. Specifically, the authors claimed while the head is in a neutral position it weighs 10-12 pounds, but when bent forward, the load on the neck and upper spine increases (see figure 2).

The assumption here is that humans are incapable of adapting to such loads, and that this leads to increased neck damage, degeneration, and pain. One article even asked if text neck is an “…epidemic of the modern era of cell phones?”, and then proceeded to make a series of claims of why the authors think this is the case. Cuéllar 2017 But there’s simply no good data to support these claims or to caution people against looking down at their phones.

The Research

A study by Correia sought to assess the validity of such claims related to “text neck” by examining head position and pain reporting in 582 participants. Interestingly, almost half of the participants reported occasionally worrying about their posture and a third during smartphone use. However, the authors were unable to find any relationship between neck flexion (e.g., looking down) while standing or seated and the prevalence, frequency, or intensity of neck pain. The authors then contradict the claims of the Hansraj et al article cited above:

Our findings contradict the hypothesis raised by the aforementioned Hansraj study. At the average value found in the standing position (34 degrees vs. Hansraj 60 degrees), the simulated load would be much lower (around 40 lb or 18 kg, vs 60 lb or 27 kg). Besides that, data from mechanical load on the necks of cadavers showed a resistance of up to 540 pounds or 244.94 kg, nine times higher than mentioned by Hansraj. Correia 2021

In other words, even if we wanted to focus exclusively on the biomechanical loads, it turns out our necks can handle substantially higher loads than what is incurred by looking down. Furthermore, living humans have the ability to adapt to resist such forces.

Another study of 238 medical students came to a similar conclusion; the authors found 50% of participants were affected by neck pain but no correlations were found between hours spent using a cell phone and posture during cell phone use with neck pain and disability. Bertozzi 2020 On the development of “degeneration” due to text neck, Meziat-Filho et al wrote:

“There is evidence of longitudinal studies with twins that the strongest factor associated with disc degeneration is genetics and the second one is aging. It is also very important to consider that disc degeneration is very common in asymptomatic people, and neck pain is very common in people with no disc degeneration.” Meziat-Filho 2018

Recall from earlier in this guide that when we examine posture as a risk factor for pain or injury, we find a relationship with time spent in sustained positions, rather than any one particular position being inherently “good” or “bad”. Kim 2018 This suggests that we can sit and stand any way we choose based on comfort, tolerance, and necessity to accomplish a task.

A more recent study by Richards et al actually found the opposite of what most folks think regarding “bad posture” leading to pain. The authors conducted a prospective study examining whether neck posture presents a risk for developing chronic neck pain. The authors tracked adolescents from 17 to 22 years of age and assessed multiple variables including depression, activity levels, work physical demands, & subgroups of sitting posture. The authors assessed the presence of persistent neck pain at 17 years of age and re-checked at 22. Their overall findings:

• By 22 years of age, 192 of 686 participants reported chronic neck pain (28%), which significantly increased from age 17 with 152 of 686 (22%).

• Chronic neck pain at age 17 was strongly associated with chronic neck pain at age 22. There was a four-fold increase in the odds of chronic neck pain at age 22 if participants had experienced chronic neck pain at age 17.

• Posture subgroups were not significant for the development of chronic neck pain for men, but were for women. Interestingly, the subgroup most related to neck pain was the group maintaining upright posture, while the least related to neck pain was slumped/forward head posture.

The authors state:

Two of the subgroups in this study were characterised by forward head posture. It has been previously hypothesised that biomechanical load created by the head being more forward of the centre of gravity may lead to a higher prevalence of [neck pain] in people with habitual forward head posture. In contrast, our findings found there was no difference in the presence of neck pain between posture subgroups in men and that in women the lowest prevalence of [neck pain] was in the slumped thorax/forward head posture subgroup, while the subgroup with the highest prevalence of [neck pain] was the upright posture. This finding is also contrary to the beliefs held by health practitioners and in society that sitting up straight is optimal whilst forward head postures are not optimal and a cause of [neck pain]. [emphasis mine] Richards 2021

These longer-term, prospective studies that follow subjects forward through time allow us to draw stronger conclusions compared to studies with cross-sectional (“snapshot in time”) or retrospective (looking backwards in time) designs. Based on the research presented here so far, we can increase our confidence in not stressing over having generalizable recommendations for neck posture in regards to development and sustainment of neck pain. In other words, we should not be pontificating on the internet about how to “fix your shit” or addressing “incorrect” postures in order to avoid neck pain. This is good news, since it means we do not need to concern ourselves with maintaining ergonomically “perfect” positions and workplace habits with neutral head positions, retracted shoulders, and 90-degree bent elbows.

To be clear: we are not saying that a person won’t report symptoms with a particular posture or behavior, such as looking down. As we’ve previously discussed, in these scenarios it is more likely that the time spent in sustained positions is contributing to pain symptoms, not the positions themselves. This means you may find that you can look down while seated at your workstation for 30 minutes before noticing neck symptoms. Rather than worrying about “optimal” posture (which, again, does not exist in a generalizable way), simply take this as a cue to transition to the next tolerable position – which may be just looking up and positioning the screen in front of your eyes.

In summary, "text neck” is a made-up and unsupported concept that attempts to reduce neck pain to a purely biomechanical problem, and leads to unnecessary interventions to address pain. Slater et al. propose several advantageous beliefs about the topic of posture in their article, Sit Up Straight: Time to Re-evaluate:

1. There is no single “correct” posture. We have no strong evidence that an optimal posture exists or that avoiding “incorrect” postures prevents pain.

2. Differences in posture are a fact of life. We are individuals with differences in make-up and experiences influencing our structural bodies & lived experiences. Pain should not be attributed to relatively “normative” variations.

3. Posture reflects beliefs & mood. Posture may be a window into someone’s beliefs, emotions, thoughts, and body image.

4. It is safe to adopt more comfortable positions. “Comfort” varies between individuals. It’s ok to explore different postures.

5. The spine is robust & can be trusted. – We are NOT machines that “wear out” or “break”; we adapt. Common ergonomic warnings are unnecessary and in fact often harmful if instructing from a point of avoidance.

6. Sitting is not dangerous. You do not have to avoid sitting. However, we are proponents of minimizing sedentary time and being very physically active (anything is better than nothing) for health benefits.

7. One size does not fit all. We do not recommend the common posture and movement screens often offered in the pain and rehabilitative realm. Slater 2019

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Recap

"Text” neck is not something to worry about. Although a person may experience pain with a particular posture, there is no reason to demonize or permanently avoid the position. Rather, think of this from the standpoint that having many options to transition to and from while working is likely advantageous for coping with pain that arises from sustained positions.

In the next part of this guide, we will discuss how the healthcare system typically approaches neck pain, and how we manage the situation differently.

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Neck Pain in Healthcare

The traditional medical approach involves searching for structural issues that are thought to cause neck pain. This often involves using imaging tests like X-rays and MRI scans to find abnormalities that are then labeled as the source of pain. Interventions are then offered to address these structural abnormalities.

The usual reader of our material likely already understands that pain is a more complex experience that is influenced by numerous factors, not just structure (See: What is pain?). With this in mind we will discuss neck pain from a multifactorial perspective, including evidence regarding common beliefs about the causes of neck pain, imaging findings, and their relevance to management.

Framing the issue

When an individual is experiencing neck pain their usual first question is: “What is causing this?” In some situations, there are identifiable factors that relate to the individual’s neck pain, whereas in other situations these can be harder to pin down. The good news is that scenarios requiring further investigation and specific medical interventions are rare. See Figure 1 for findings that warrant further investigation.

It is worth reiterating that these are rare instances in which other symptoms (e.g., fever, headache, dizziness, vision changes, difficulty with walking or balance) are present in addition to neck pain. In these scenarios it is recommended to seek consultation with a healthcare professional as soon as possible to ensure appropriate management. Popescu 2019

The good news is that most folks do not fall into this category of needing urgent medical evaluation and treatment. The majority of neck pain episodes tend to improve on their own over time, almost regardless of what we do. This expected trajectory without any treatment or intervention is known as the “natural history” of a condition.

A recent study demonstrated a natural regression in neck pain over time, with individuals reporting 30%, 35%, and 40% reductions in pain intensity at 3, 6, and 12 months respectively (see figure 3). In this study, complete resolution of pain occurred in 43% of participants by the 12-month follow-up. The subjects observed natural improvements that were similar to those attributed to many medical interventions. Vasseljen 2013

This means that when we healthcare professionals offer many of our interventions du jour, we may simply be entertaining ourselves and our patients while they get better on their own over time. However, as is illustrated in the above figure, a significant number of individuals still report pain and disability up to one year later. One study found that approximately 50% of individuals from general, working, and trauma-related (“whiplash”) populations still reported neck pain months to years later. Bier 2018 These data demonstrate that although many may experience an initial improvement in neck pain without any intervention, others may go on to have persistent and recurrent neck pain and disability.

This raises the question: why does neck pain recur or persist for some individuals?

Beliefs about neck pain

This isn’t an easy question to answer directly, but we can start by examining some of the common beliefs people hold about the cause of their neck pain. A recent study asked participants dealing with persistent neck pain to list the 3 most important factors they believed were causing their neck pain (see figure 4). Walton 2012

We will review two of the major themes here.

Theme 1: Posture and Movement

The most prevalent theme for common neck pain triggers was posture and movement. In particular, positions that were sustained or static (e.g., office work, driving, reading, sleeping, and computer usage) and movements including heavy lifting, repetitive, rotation or sudden, and reaching forward/overhead were the most commonly referenced.

Recall from above, there is not a generalizable “optimal” posture or movement that can mitigate the development of neck pain for all people. Instead, sustained postures and movements may relate to an individual’s experience of neck pain. Instead of demonizing postures or movements in general, we can simply use these experiences as cues to add variety into our daily routine. Having opportunities to change positions or vary movement and the amount, type, or intensity of activity can help when coping with neck pain.

Theme 2: Mechanism, Structures, and Tissues

Theme 2 is the set of beliefs most rooted in traditional medical thinking, and relates to issues with general structures (e.g., “stiffness in the neck”), specific tissues (e.g., “bad discs”), and mechanisms of injury causing neck pain (e.g., car accident). Neck pain is commonly attributed to structural concerns such as neck muscle damage, strain, and tightness, joint stiffness, disc issues, nerve damage, ligament damage, and inflammation.

Although we can often find many “abnormalities” on X-rays or MRIs that raise concern, we have good reasons to question the meaningfulness of these imaging findings in usual neck pain situations. Although such findings tend to be the primary focus in healthcare settings, many of these can be more accurately understood as age- and experience-related adaptations, rather than as problems or evidence of disease. Let’s briefly examine a few of these ideas.

Spinal Alignment

Alignment of the cervical spine is a commonly provided explanation for why someone might experience neck pain, and it seems to make intuitive sense to many patients. The cervical spine typically has an inward curve (known as a “lordosis”), however, as we age and have life experiences, this curvature may begin to straighten and transition in the opposite direction. The reversal of this lordotic curvature is known as “kyphosis”. Although kyphosis of the cervical spine is often viewed as a problem, this same type of curvature can be found in 26% of pain-free people in the general population. Kim 2018

When comparing those with and without neck pain, a study by Grob et al found no association between cervical spine alignment and neck pain. The authors state,

We suggest that when so-called ‘abnormalities’ of the sagittal profile are observed in the older patient with neck pain they must be considered coincidental, i.e. not necessarily indicative of the cause of pain. Grob 2007

Although this “alignment” belief seems plausible to many individuals, there are variations in alignment that can naturally develop over time, allowing for individual adaptation to these changes. Generally speaking, these kinds of changes in cervical spinal alignment shouldn’t be labeled as problems requiring specific treatment.

Spinal Degeneration

Cervical spine “degeneration” is a broad term for various findings on imaging tests such as disc herniations, decreased disc space height, bony outgrowths known as “osteophytes”, changes in spinal alignment, and narrowing known as “stenosis”.

Although these findings are often viewed as definitive causes of neck pain, we have evidence of the very same findings in many individuals without neck pain. One study performed MRI scans on 497 volunteers who had no neck pain and found disc degeneration in 17% of males and 12% of females in their 20s, with rates increasing to 86% and 89% among individuals over 60 years of age. To reiterate, none of these individuals had neck pain. Matsumoto 1998

Ten years later, 223 of the original study subjects underwent repeat MRI scan. While 85% (189) of participants demonstrated progression of at least one degenerative finding on the MRI, only 34% had experienced symptoms in the interim (neck pain, stiff shoulders, and numbness in upper extremities). Age was the factor most related to the progression of imaging findings. Okada 2009 20 years later the authors followed up again with 193 participants. Unsurprisingly, the authors found 95% of the participants demonstrated evidence of disc degeneration. At this time, 30 years after the initial study, the only imaging finding that appeared to correlate with symptoms was progression of stenosis. Otherwise, none of the symptoms including stiff shoulders, headache, neck pain, ringing in the ears, or numbness in the arms were correlated with progression of MRI abnormalities. The authors concluded:

.…the degenerative findings on cervical MRI do not appear to be generally associated with the development of clinical symptoms. Thus, we propose that these changes be referred to as ‘age-related changes’ rather than ‘degenerative,’ which implies pathology to patients and families. [emphasis mine] Daimon 2018

Another study of 1211 healthy, pain-free subjects demonstrated similar MRI findings. Despite having no symptoms, 87.6% of participants were found to have disc bulging that increased in frequency and severity by age. Nakashima 2015 Disc bulging, spinal cord compression, and abnormalities in the appearance of the spinal cord all increased throughout the lifespan, with some findings becoming apparent as early as age 20 (see Figure 5).

Aside from these two examples, similar findings have been replicated elsewhere, with a recent review of 31 studies showing no meaningful MRI differences between individuals with neck pain versus without. Farrell 2019

Whiplash

The mechanism of how neck pain starts (e.g., after a motor vehicle accident) is another common belief for why neck pain persists. This scenario has been called “Whiplash-Associated Disorder” (WAD) and includes various symptoms such as neck pain, shoulder stiffness, dizziness, and other symptoms occurring after a car crash or other high-velocity injury. Watanabe 2020 It is thought that neck structures stressed by an accident will have increased degeneration, leading to more neck pain and disability throughout life.

Daimon et al did a 20 year follow-up with 81 study participants dealing with whiplash injury. Daimon 2019 Fujimura 1997 The authors found 95% of participants had evidence of disc degeneration, but this shouldn’t be surprising given our discussion above and the expected rates of these changes occurring throughout life. More pertinent to this discussion is that these changes on imaging did not lead to more reporting of symptoms. These study findings suggest that the usual concern about an increased risk of degeneration causing more neck pain throughout life remains largely unfounded. The authors state:

These results suggest that the degenerative changes observed in the intervertebral discs of the cervical spine on MRI at the long-term follow-up represent the physiological aging process rather than pathological changes occurring a long time after a traffic accident. [emphasis mine] Daimon 2019

To drive this point home further, the authors contacted and recruited participants from the pain-free imaging studies and from the whiplash-associated disorder (WAD) studies to compare the two groups 20 years later. The authors compared 75 individuals with WAD and 181 originally pain-free individuals using new MRI scans and symptom questionnaires.

Figure 6 demonstrates the reported symptoms between the two groups. The prevalence of shoulder stiffness, headache, and arm pain were higher in patients dealing with whiplash-associated disorder compared to controls, although reports of neck pain and arm numbness were not statistically different.

The reader may be thinking these data demonstrate something relevant, and indeed they do, but interestingly the symptoms do not align with imaging findings. The prevalence of all analyzed MRI findings were similar between both groups. In other words, at 20 year follow-up, MRI findings did not differ whether individuals originally experienced whiplash or not. In fact, neck pain appeared to be more prevalent in those without significant progression of disc degeneration versus with, and headache was more prevalent in those without progression of posterior disc protrusions than those with. So although a prior history of a whiplash injury was a significant risk factor for certain symptoms (shoulder stiffness, headache, and arm pain), this risk doesn’t seem to align as expected with findings on MRI scans. The authors conclude,

The [cause of] long-lasting symptoms after [whiplash-associated disorder] is still unknown. Watanabe 2020

When a recent study asked participants about their healthcare journey and experience with acute to persistent whiplash associated disorder, several common themes emerged. Many reported the need to “shop around” for healthcare professionals, searching for someone who believed what they were reporting, provided insight into their situation, and had an acceptable treatment plan.

When participants reported lacking such a healthcare professional, confusion arose. One participant stated,

My doctor said to me it’s about time I faced up to the fact that there’s nothing wrong with me, there’s nothing physically wrong. He suggested that I go to a psychiatrist or a psychologist for treatment of the mental side of things and that once that was treated then I would be right. The sooner I’ve faced up to that then the better off I’d be. Ritchie 2017

Others were not keen on the recommendations of more imaging, tests, or medications. Participants reported having to figure out what worked for them over time via trial and error, with some feeling unable to trust the advice of their healthcare professional. We’ve previously discussed the stigmatization that can occur with people experiencing persistent pain. The authors state,

The importance of being believed and validated aligns with previous literature about patient experiences with chronic pain. There is no diagnostic test for WAD so patients may feel a need to prove the existence of their pain resulting in feelings of being judged about the legitimacy of their injury. Ritchie 2017

When these scenarios also involve dealing with insurance companies, financial compensation, and other incentives, folks likely have increased pressure to demonstrate that they are, in fact, injured and deserving of compensation.

Reframing “Degeneration”

Ultimately, the reason for why neck pain persists over time isn't a simple clear explanation. The data we’ve covered so far lead us at Tame Pain to change our language from that of “spinal degeneration” to describing such findings as age- and experience-based adaptations. The hope for shifting our language is to avoid unnecessarily turning such findings into ominous “diseases” that need specific treatment.

A recent study demonstrated just how damaging certain language can be for both patients and healthcare professionals. Rajasekaran 2021 The authors recruited two groups of individuals experiencing low back pain who also had undergone an MRI scan. Group A received their imaging results with usual medical terminology, while group B received re-worded reports that were consistent with current evidence regarding normal age- and experience-based adaptations. Participants were assessed for 1) pain severity, 2) perception of “disease” status, and 3) functional abilities at baseline, after MRI reading, and after 6 weeks of conservative management.

Individuals in group A, who received the usual medical jargon-filled reports, demonstrated a worsening of pain severity, disease perception, and functional status after six weeks of conservative treatment. Whereas Group B, who received reports with modified language to reflect the current best evidence, experienced improvements in these outcomes. In other words, the language provided in the MRI report and how the results were framed had a profound impact on patients’ self-perception and response to treatment.

The authors then compiled the usual MRI terminology and substituted out fear- or anxiety-provoking words, and then disseminated two reports with old and new language to spine surgeons, orthopedic surgeons, and physiotherapists. They wanted to see how the language would affect the clinician’s perceptions of disease status and their recommended treatments. The new language report significantly reduced disease severity assessments, and the choice of treatment was downgraded to less aggressive recommendations. This was observed for all professional titles except spine surgeons.

The study demonstrates how the language used on MRI reports affects both patients & healthcare professionals, and influences expectations of treatment. MRI scanning continues to increase for back pain despite practice guidelines and evidence showing significant negative effects from inappropriate overuse. Spinal surgery rates are similarly on the rise; these are not unrelated events. Although this particular study involves patients with low back pain, we see the exact same events unfold in scenarios in which folks are dealing with neck pain.

Given that these imaging findings are readily identified in those without symptoms, we can think of them as incidentalomas. Chojniak 2015 An incidentaloma is something found on an imaging by happenstance, that does not necessarily relate to a patient’s symptoms. The difficulty is that once these are identified, the clinician and/or patient may become worried and seek further investigation or treatments that, by definition, cannot offer benefit, since the finding is not causing any problems in the first place. These downstream consequences happen often enough that we have an acronym for the negative effects: V.O.M.I.T., or “Victims of Modern Imaging Technology”. Hayward 2003

Many of these issues can be mitigated by minimizing inappropriate imaging tests, while also framing neck pain as a multifactorial experience. Since numerous variables can influence the experience of pain, we have many avenues to mitigate symptoms, rather than being confined to a myopic focus on tissue structure alone.

To be clear, this doesn’t mean imaging findings are irrelevant or don’t matter. The increase in frequency/severity of findings does appear coupled to reporting of neck symptoms, but these relationships are highly variable between individuals, making useful generalizations quite difficult. One study goes as far to say,

… it is dangerous to make interventional decisions only by judging degenerative changes using [MRI] images alone. Nakashima 2015

The larger question is: do these imaging findings matter sufficiently to influence or change what we should recommendations for the individual? Most often, the answer here is “no”, but we will explore management of neck pain in next part of our guide with a broader and more inclusive approach to helping those dealing with neck pain.

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Recap

To close, the common healthcare approach to neck pain is overly reductionist for the vast majority of cases. Many healthcare clinicians overutilize imaging in search of structural issues of the neck. However, this approach has risks leading to unnecessary investigations and interventions while perpetuating misinformed beliefs about neck pain. We prefer to take a multifactorial approach to neck pain that will be discussed in our final section of the guide.

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The final section of our neck pain guide will discuss our approach to managing neck pain, Whereas the traditional “impairment-based” approach involves searching for problems in the neck and trying to target them, we will instead advocate for an approach that aims to restore function for a person’s daily activities and individual goals. Worsfold 2020

Once “red flags” situations have been ruled out, we shift away from unnecessarily worrying about the meaning of symptoms, and instead address the unique goals of the person. Many clinicians choose passive approaches to care, where things are done “to” a patient to supposedly treat a specific impairment in the neck. These include things like joint manipulations, massage, TENS therapy, or ultrasound, among others. However, these claims remain largely unsupported. We prefer a more active approach to care, involving the patient in the treatment to aid with symptom reduction, building confidence, and progressing towards desired activities.

We categorize activity goals into daily activities (e.g., looking both ways to cross the street) and extracurricular activities (e.g., overhead pressing, cycling, or rock climbing). Clinical practice guidelines strongly recommend physical activity for neck pain, including whiplash-associated disorder, as well as other forms of neck pain that may include symptoms radiating into the arms. Corp 2020 Lin 2019 Parikh 2019 Blanpied 2017 Kjaer 2017

Although remaining physically active and exercising based on tolerance are strongly recommended management strategies, the best “dosage” of activity remains unknown. de Zoete 2021 We do not view this as a problem; instead, this simply means we should adapt and individualize our activity recommendations according to current symptoms, tolerance level, activity history, and goals. This article will provide general recommendations and guidance for finding an entry point into activity, and slowly building over time. If you are in need of more individualized advice, we recommend contacting a trusted local clinician or reach out to us for remote consultation.

Managing pain is a process that can take time. Recall, most folks experience marked improvements in pain symptoms and function in the weeks to months after onset, but there will be ups and downs throughout the process (see Figure 7). There are also many variables outside of the neck that can influence the experience and intensity of pain such as life stress, sleep, activity demands, and mood or emotional states. As a result, fluctuations in neck pain don’t necessarily mean damage or harm is being done to the neck.

To aid with coping through the process, our usual recommendation is that pain symptoms shouldn’t increase to the point of significantly reduced function or remain exacerbated for several days after a bout of physical activity or exercise. If pain symptoms are regularly increasing during or after activity, modifications to the activity should be made, for example changing the intensity, duration/volume, frequency, or type of activity. Attention should also be paid to the other variables that may be associated with increases in pain intensity such as marked increases in life stress, poor sleep, or other disturbances in mood or emotional states. Fluctuations in these other variables may necessitate alterations in the exercise programming.

Range of Motion

In the early stages of dealing with neck pain, we may need to specifically address range of motion to aid with daily activities. Individuals often notice pain and/or reductions in range of motion when looking up, down, side to side, tilting the head, or with combinations of these movements. Depending on the severity of symptoms, starting rehab may simply involve moving through these ranges of motion based on tolerance. For example, performing 2 sets of 15 repetitions in each direction with 60 seconds rest between sets, done once per day. See Table 4 for a sample program that can be completed at a frequency of 1-3 times per week. It’s important to keep in mind that RPE in this context is a subjective rating of difficulty, fatigue, AND pain. Throughout this process, loading of the neck and upper extremities may be limited by the influence experiencing pain has on RPE, and that’s ok given this will not always be the case.

As time progresses, shifting from range of motion to more functional tasks will be necessary.

Here are a few examples:

• Reversing a vehicle (rotation)

• Tying shoes while seated (flexion/extension)

• Crossing a road (rotation / lateral flexion)

• Washing hair in shower (flexion/extension)

• Picking up an object from the ground in front of the body (deadlifts and squats)

• Shaving the face or applying makeup (rotation)

• Smelling coffee (protraction/retraction)

These task-based approaches help shift away from an internal focus on the neck region, and instead look externally towards completing a particular activity or goal. Worsfold 2020 The above list can even be practiced by mimicking the movements without specifically performing the tasks in the usual setting (e.g. driving a car). The point is to increase volume of the activity over time, while aiding with symptom reduction and task performance.

Resistance Training

As range of motion and symptoms improve, we can add in resistance-based activities. For example, there are three main devices available to directly load the neck and head through specific ranges of motion:

• Neck harness

• Iron neck

• Resistance Bands

The iron neck offers more loading options in various ranges of motion but also involves a higher price tag. Harnesses or bands are perfectly adequate for most purposes as well.

Return to Sport

Many of our readers may be trying to return to specific resistance training movements such as the overhead press, bench press, clean and jerk, or snatch. When individuals are experiencing significant symptoms with these activities, the dosage of these movements should be adjusted throughout this process based on individual tolerance. Upper body exercises play an integral role in the rehabilitation of individuals experiencing neck symptoms that radiate into the arms. In the beginning stages of this process we often advise temporarily transitioning away from explosive, plyometric-type movements (e.g. burpees or handstand push-ups) and other dynamic overhead movements such as push-press, power jerk, split jerk, snatch, etc., with plans for reintroduction later on.

Ideally we can find an entry point into the activities that are relevant for an individual’s goals. Let’s use the example of a strict overhead press. While athletes often warm-up with a barbell, in this situation that may provide too large of an external load at the start. Instead, we might attempt a strict overhead press using dumbbells, since they provide far more loading options. Typically a specific, controlled tempo is applied in this situation to help mitigate excessive loading early on, and many folks find slowing a movement down helps build confidence. We can take a similar approach to barbell bench press by subbing in dumbbell bench presses.

Isolation movements also have utility for individuals experiencing symptoms that radiate into the arms. For example, an individual may be dealing with cervical radiculopathy, a condition characterized by neck pain, as well as numbness/tingling or weakness in a region of the arm(s). Let’s say these symptoms are happening in the triceps. Instead of avoiding any loading of this area, we would have the person use triceps-specific movements as a part of their rehab. There’s no perfect answer for which triceps exercise is best; most decisions around exercise selection relate to the person’s prior training history and equipment availability. A few examples could include, dumbbell “skull-crushers”, single-arm triceps cable press-down, dumbbell kickbacks, bench dips, or close-grip push-ups. Again, we would likely use a controlled tempo for the eccentric portion of each of these movements (for example, a 3-count tempo when lowering the weight). See table 5 for a suggested outline for re-introducing overhead pressing and triceps exercises.

A few important caveats: depending on symptoms, tolerance for loading, and response, the dosage of activity should be altered. This might include changing exercise selection, frequency, volume, and exercise intensity (e.g., via lowering RPE targets).

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Recap

Neck pain (with or without arm symptoms) doesn’t typically require a unique approach from other body regions. Once the ominous “red flag” situations have been ruled out, we can begin working on introducing activity and goal-specific exercises to tolerance. It is relatively rare for these scenarios to require further investigation (e.g. medical imaging) and specific interventions such as passive treatment modalities or surgery. Rather, most folks will experience marked improvements in pain and function in the weeks and months after onset.

Staying active based on individual tolerance is a great self-management approach, but in the beginning stages some movements may need to be regressed or temporarily not programmed. During this time we can focus on staying positive, being patient with the process, and using appropriate programming that progresses back towards desired activities. In addition, this is an opportune time to recognize and work on all the other variables we’ve discussed that can influence our pain experience, such as life, occupation, financial stressors, emotional state, sleep quality and quantity, and many other individual and social factors.

If you are struggling with neck symptoms and need assistance, we’d be happy to consult with you. Please complete our intake paper by clicking "Get Started" below the Consultation header. This wraps up our neck guide, we hope this has been helpful.

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