Neck Pain Tutorial

Neck Pain Tutorial
http://saveyourself.ca/tutorials/neck-pain.php
Save Yourself from Neck Pain!

All your treatment and self-help options for a crick in the neck
explained and reviewed
54,000 words, updated Oct 22nd, 2014 Whats new?
by Paul Ingraham bio
This is not just a web page: it is an online book, more than 60 bite-sized
chapters of well-researched writing for both patients and professionals, plus many
extras. It is devoted to tough cases of chronic neck pain and the phenomenon of
neck cricks that nasty stuck feeling. What makes a neck crick tick? What are
the myths and controversies? What works, what doesnt, and why? Its detailed,
readable, and regularly updated with fresh science.
The neck crick

Common and yet mysterious! Neck
cricks are one of the most familiar
of all aches and pains and yet
baffling and stubborn!
Neck pain is an almost universal human experience, afflicting almost everyone

sooner or later. A particularly detailed neck pain tutorial like this one is probably
overkill if youve just woken up with a stiff neck, and you were just looking for a
little quick advice. Put some heat on your neck, maybe do a little stretching, and
youll probably be right as rain in a couple days. If it gives you any trouble after that well, see you back here in a
couple weeks?
On the other hand, maybe its a real whopper of a neck crick. Maybe you can hardly move! Or maybe its the fifth
crick in the neck youve had this year. Or maybe youve had low-grade but constant, chronic and exasperating
neck stiffness ever since that bicycle accident in 2012. Maybe you are starting to wonder if theres any way to
actually reach into your neck, pull out your cervical spine, and put in a replacement unit! If thats the case, this
tutorial is definitely not overkill: you need plenty of good information, because education and fear-reduction may
actually heal neck pain, 1 2 while therapies, drugs, and surgeries have a generally poor track record. 3
I am a science writer & amateur athlete in Vancouver, Canada. Ive been writing about neck pain for over
a decade & I have suffered more from my own vicious cricks than any other pain problem I write about.
~ Paul Ingraham
Neck pain myths busted here!

Chronic neck pain matters. The seriousness of chronic pain is often expressed in terms of the hair-raising
economic costs of work absenteeism, but it may well be far worse than that a recent Swedish study shows that it
probably even shortens people lives. 4 The stakes are high. If not shortened, the quality of life can be ruined. And
yet there is an enormous amount of misinformation about neck pain. 5 Only low back pain rivals neck trouble for
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the sheer volume of half-baked theories it generates.

For instance, there is a common idea out there that neck pain is related to abnormal cervical spine curvature. So
many doctors and therapists believe this over-rated idea that you could probably get a hundred second opinions in
a row without hearing otherwise. And yet research has virtually proved that the neck posture hypothesis is dead
wrong or at the very least seriously oversimplified and underwhelming.
Abnormal vertebrae? Who cares

Research has shown that abnormal curvature of the cervical
spine is not closely associated with neck pain.
But the news hasnt gotten out, and the bogeyman of

abnormal neck shape continues to be the basis of lots of
expensive manual therapy that doesnt work particularly
well. 6 Such ideas can be amazingly persistent. Neck pain
myths are as stubborn as neck pain itself. I am sure that in
ten years there will still be many professionals fixated on
neck posture.
Attention physicians & therapists Although

addressed to patients, this tutorial is also for
professionals, and covers advanced concepts and recent
research. It is easy reading, but it is not simple. Many
footnotes contain extra, advanced information.
Yes, I do criticize common practices and conventional
wisdom! Let me know if you disagree I often make
changes based on feedback. See my professional reading
guide.
This tutorial carefully debunks many other misconceptions

about neck pain myths about subluxation and the spine
being out, myths about muscle strain and muscle spasm,
myths about arthritis and herniated discs and nerve pinches,
and more and it does it with an extraordinary amount of care to refer to and explain recent scientific
research. 7 Theres not much point in criticizing theories about neck pain if Im just going to push my own
unsupported theories, is there?
By the time you are done this tutorial, you are going to know more about your stiff neck than most therapists or
even your doctor perhaps especially your doctor! Most GPs are not really competent to treat neck pain, or any
other difficult musculoskeletal problem. 8 But before you get too cynical about mainstream medicine and run
off to an alternative professional like a chiropractor or massage therapist, guess what? No one else is really
qualified to treat neck pain either no one at all, anywhere, because there are genuinely deep scientific mysteries
about neck pain.
How can you trust this information about neck pain?

I question everything and I have fun doing it. I assume that anything that sounds too good to be true probably is. I
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make no big promises, and I do not claim to know the one true cause of neck pain. When I dont know
something, I admit it. I actually read scientific journals, I clearly explain the science behind every key point (there
are more than 160 footnotes here), and I always link to the original sources.
But really good information, I hope. Ive worked hard for many years to provide the best information about neck
pain available anywhere not just more of it, but better. I offer a unique combination of clinical experience with
journalistic experience and passion I was a writer long before I was a therapist and a deep respect for science.
Everything I write about rests on a foundation of what is actually known so far, and presented in a clear and
friendly style thats just like coming to my office and having a nice long conversation about it a conversation
where all your questions get answered.
Well, all the questions that can be answered there are strict limits to current scientific knowledge about neck
discomfort. Not much is really known, and not everyone can be helped. There is an alarming lack of honesty in
health care about what actually is and is not known about how neck pain works and how to treat it. 9 The goal of
this tutorial is to help you navigate the maze of medical uncertainty and contradictions. If it was easy to solve,
there would be no need for this tutorial.
Still, if youve been struggling with a bad and/or persistent crick in the neck, there are probably more options than
you realized. Most people who think theyve tried everything have not actually tried everything. This tutorial
does not give you a magic bullet for neck pain, but it usually does provide readers with several minor upgrades
to their approach to the problem put them all together, and the combination can become quite powerful. In fact,
in my experience, that is exactly how good therapy for difficult conditions tends to work: there never was, and
never will be, one thing that works, but a collection of things. With this approach, neck pain can go from being
almost crippling to quite manageable. That may not quite be a cure but its a lot better than unrelenting pain.
Dr. House: You sir, will, research all the causes in the universe of neck pain.
Dr. Chase: The list is like two miles long
Dr. House: Start with the letter A.
Dr. Greg House & Dr. Robert Chase, House, American TV series
Who exactly is this tutorial for?

Head pain, face pain, and neck pain are an enormous topic. Ive narrowed the focus of this tutorial to the concept
of cricks and chronic unexplained neck pain and closely related symptoms in the upper back and shoulders
(upper backs get cricks too).
I have excluded detailed discussion of: face and jaw pain; neck pain with prominent nerve symptoms (tingling,
numbness, zapping pain) in the arm; tension headache and migraine 10 ; and fresh whiplash, or other acute neck
trauma. 11 Some safety information is provided below for the rare cases of neck pain that may be caused by
disease.
However, virtually all kinds of neck pain share similar complications which I do cover in detail here. For instance,
whiplash often leads to chronic neck pain. 12 And this is particularly true if you were suffering from emotional
stress and other aches and pains to begin with 13 a strange, important wrinkle that is relevant to neck pain in
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general. And so, although this is not a whiplash tutorial, if you are still suffering from neck pain long after a neck
injury should have healed, please read on this tutorial certainly has much to offer.
And what about a pinched nerve?

Well, maybe you have a pinched nerve and maybe you dont. As with whiplash, this tutorial is useful to many
people who have a true case of nerve root pain (radiculopathy). Even when nerve pain exists and it does, just
much less commonly than it is feared it may prove to be a surprisingly minor problem that goes away on its
own, perhaps when other neck issues are addressed. Severe cases of nerve pain are not addressed directly in this
book, but I do put the topic in some perspective and that alone can be helpful to many patients, particularly
those who arent too sure about their diagnosis.
Reading on is a great way to settle this unsettling issue in
your mind once and for all. There is a section devoted to the
many common misconceptions about nerve pain; another
section to help you identify nerve pain (or the lack of it); and
a third section about safety issues related to massaging
around nerves in the neck.
Smells a bit too good to be true! Nerve pain goes

away on its own? Come on! But this is about as close as
I get to claiming that there is a miracle cure in this
tutorial and its not that all that miraculous. It simply
wont work for many cases. However, it does for some,
and how cool is that?
If you have significant or persistent tingling and numbness in

the arms and hands, then the tutorial may be interesting and useful to you, but it will not focus on the options for
your problem. Surgery is a more realistic option for patients in this category, but not being a surgeon I do not
discuss surgery much. The value of this tutorial to such patients is that you might discover a way to avoid surgery.
The evidence that tissue pathology does not explain chronic pain
is overwhelming (e.g., in back pain, neck pain, and knee
osteoarthritis).
Teaching people about pain why do we keep beating around
the bush?, by Lorimer Moseley, pp23
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Cricks versus pain

Neck cricks and neck pain often go together, affecting about
50% of adults per year, 14 ranging in severity from trivial to
crippling. In my office, I see as many neck pain cases as low
back pain cases. Almost every scientific paper on the subject
starts by reeling off the ugly statistics about how many
people are afflicted by neck pain, how many dollars it costs
our economy every year, and how medically mysterious and
tricky it is.
For those of you who have both neck and back pain, you
may be more interested in reading Save Yourself from
Low Back Pain! However, several key resources are
shared between the two, and reading either one will get
you some of the same key information.
Crick is an informal term. You wont find it in a medical dictionary, but perhaps you should, because its a major
sub-type of neck pain. It feels like something in a joint is catching or sticking or locking when you try to move, a
seemingly mechanical failure. Many neck crick sufferers insist that the problem is not painful, yet nevertheless
extremely frustrating a sensation of stuckness that is irritating or uncomfortable or stuck or more like an
itch or perhaps a deep itch than an actual pain.
Because a crick often does not hurt, per se, it is often underestimated and neglected, even by the patient. The use
of that word crick can trivialize the problem. When it exceeds a certain degree of badness, no one calls it a
crick anymore the word feels too lightweight.
But never underestimate the power of a neck crick to make a person perfectly miserable. Not all pain is painful. It
is possible to suffer deeply without hurting. But the feeling of stuckness can be every bit as bad as severe pain.
Cricks will nag and irritate to the point of nearly driving people out of their minds. I am not exaggerating. I have
seen people showing every sign of severe chronic psychological distress, unable to function well mentally because
their neck will not stop harassing them.
Ive also experienced that state personally, once.
Although its like comparing apples to orange cars, I have often had the impression that irritating cases are more
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tragic than painful cases, causing more emotional distress

suffering and mental preoccupation than pure pain. There
is something profoundly unsettling about this kind of
discomfort. I get email from readers around the world who
recognize their predicament in these words, and want to
reach out just to say, Yeah, thats me!
Upper backs get cricks, too! Neck pain and neck

cricks routinely blend smoothly into the upper back. The
muscular roots of the neck extend well into the upper
back, and those thoracic joints appear to be nearly as
prone to cricking as the cervical joints. I had a thoracic
crick in the spring of 2009 that turned into my worst
ever.
So cricks make neck pain particularly interesting, in the

sense of the Chinese curse. 15 They are a simple sensation
The low back, however, rarely seems to suffer from
that no one can really explain all that well. Not every case of
cricks. The classic crick sensation is typical only from
neck pain includes a crick, but the terrible neck injuries and
between the shoulder blades and up. This is likely an
pain problems of today often become the persistent cricks of
important clue to their nature.
tomorrow. Pain and nagging stuckness are generally
interwoven and the lines between them thoroughly blurred.
So this tutorial is about both, but with a strong emphasis on the exasperating phenomenon of a crick.
PROGNOSIS
Whats the worst case scenario for neck pain?
In the worst cases, with or without the best treatments available, neck pain and crick can be a life sentence of
moderate to severe pain and/or irritation. As noted above, even a painless neck crick can still cause great
suffering. A severe case can be severe indeed, and seemingly immune to all treatment efforts, without ever having
a clear or certain diagnosis.
There are some limits on the severity. 16 In terms of duration, though, there are no limits: neck pain can last five
minutes, ten hours, several days, weeks or months or forever. Most cricks are mild and resolve spontaneously,
with or without treatment, within a few days or a couple of weeks at the longest. Its important for fresh victims to
know this the reassurance is important and justified. 17
However, neck cricks and neck pain do have the potential to last and last. Most patients interested in this tutorial
probably already think of their neck pain as chronic. Unfortunately, I have seen many patients with cricks that are
essentially permanent. It is something of a myth that neck pain is a temporary problem. Many professionals are
prone to reassuring neck pain patients a little too much, probably because chronic neck pain is less debilitating
than back pain, and isnt taken as seriously. And yet it may be more prone to chronicity. 18 Only about 50% of
patients recovered quickly according to Leaver et al . 19 About 35% of cases of neck pain were persistent
according to a Canadian survey of 1100 randomly selected Saskatchewan adults in 2004. 20 Ct et al wrote in the
journal Pain that, Contrary to prior belief, most individuals with neck pain do not experience complete resolution
of their symptoms and disability.
For example, I know of a case of a mild crick, barely more than annoying, that nevertheless remains unchanged
after about eight years. I also know of a case of serious neck pain that lasted thirty-five years but was then
substantially relieved by just a handful of massages. (His story coming up below.) So it is difficult to say how long
a neck crick lasts, because the skys the limit. For those of you just starting out with your first bad case of neck
pain, please rest assured that the majority of cricks are indeed short-lived. And everyone can be reassured even
the oldest neck cricks still have the potential to be relieved.
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So the worst cricks are rare, but when they occur they can cause enough pain to make normal life difficult, and can
last pretty much forever, but its extremely unpredictable.
Interestingly, women suffer more. Again, according to Ct et al , women are 60% more likely than men to
develop neck pain, and 20% more likely to develop chronic neck pain.
And now for a random amusing quote:

Yesterday I saw a guy who repeatedly mentioned that hes a nurse. When he called he said he was having carpal
tunnel problems. Thats fine, I can handle that. But when he came in, all he wanted to talk about was his neck pain.
I can handle that, too. But I asked him why hed said he was having carpal tunnel problems when he called. He said
because the carpal tunnel is in the neck. When I tried to correct him, he argued with me, then walked out. Said he
was going to find a doctor who knows his damn anatomy.
Dr. Grumpy, Anatomy 101
Three case studies of extreme neck crick horribleness

By far the worst case I have seen in my experience as a massage therapist was a man who had suffered for 35
years, ever since a serious motorcycle accident in his youth. The overall intensity of pain had been frequently
debilitating, but was always greatly aggravated by a maddening sensation of stuckness just under his skull a
whopper of a crick, an itch he had been trying to scratch for three and a half decades by squirming and
wrenching (his word) his neck violently from side to side.
This wrenching was so severe and so habitual that it was a major feature of his personality, like a tic and when
he stopped doing it, friends and family were amazed.
Not only is his story a good example of a worst case scenario for a crick in the neck, but its also instructive about
the nature of neck cricks. Its hard to imagine a more mechanical crick than his, and indeed he had received
hundreds of temporarily effective chiropractic treatments over the years. They always helped, but never for long.
Usually it would be out again before I got home, he explained to me.
And yet! This mans tortured sensation of dislocation was more relieved, and for longer, by simple rubbing of the
muscle tissue around the joint. This is a good demonstration that it is sometimes much easier to change the state
of a joint by massaging muscles than by cracking joints.
As of this writing, he has been mostly crickless for a couple of years for the first time in more than thirty years.
Its not cured, he tells me, but its so much less than it used to be. Its at least 80% gone. Its mostly a bad
memory.
Of course, therapy doesnt always go that well. Skilled therapists can be stumped by cricks, and I have seen several
cases where no intervention made much difference, and some cases where chiropractic adjustment seemed to be
the magic bullet. Although most cricks respond well to massage therapy, what makes some neck cricks come and
go can be quite mysterious.
Another good story is the one about the guy with the painless but invincible crick. As far as I know, this patient
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has been seeking therapy for his problem, from a variety of sources, more or less continuously, for about a decade
now with no results. He has no pain: he has a mildly irritating but completely unchanging sensation of
stuckness in his lower cervical spine. It doesnt hurt, he says. But it drives me nuts.
And nothing seems to touch it. I have worked with this patient a couple dozen times, and have been unable to have
the slightest therapeutic effect. Occasionally it seems as though massaging the muscles in the area gives him some
minor and temporary relief, but the feeling of stuckness remains, indomitable. The extraordinary persistence of it
is what qualifies him as a severe case. Its like hes got hiccoughs or an eyelid twitch that just never went away.
He has a minor problem until it lasts forever.
Another case that comes to mind is the opposite: a woman whose neck pain was so severe that she had
trouble functioning when it flared up. With no history of trauma, this patient was subjected to roughly quarterly
episodes of debilitating stress-induced neck crick, pain and headache. She wasnt merely hurting: she was down
for the count and whimpering. The headache was bad, but secondary: it was primarily the severe pain up one side
of the back of her neck, accompanied by a feeling of stuckness so profound that she couldnt turn her head at all.
It feels completely locked, she said. I thought perhaps it might be too painful to turn, but no: It hurts whether I
turn or not, she explained. It doesnt hurt any more when I try to turn. It just feels stuck.
And yet, despite its severity, this patient seems more treatable than the other severe examples above. She
responds pretty well to massage therapy. She craves pressure on her muscles, and is extremely grateful by the end
of the session, gushing about how much better she feels. She isnt fixed by any means, but she believes that she
gets better much sooner with my help than she would without. Without treatment, she took weeks to recover from
an episode so she reports, from the days before she discovered massage therapy as an option. With massage
therapy, she says she feels much better immediately, and is back to normal within just a few days.
But it also always comes back. And thats really the issue: despite the short term successes in treating her, and
despite how valuable she considers that to be, I dont feel like Ive really helped her. How can I, when shes back
three months later with the next episode? How long will this go on for her? What a curse! This is a great, and sad,
example of how bad neck cricks can be.
What if theres something really wrong with my neck? Safety information!

How do you know Im not seriously hurt?
Could it be cancer? A tumor?
Although much less common than most people realize, anatomical disaster is possible in the neck. And, in rare
cases, neck pain may be an early warning sign of cancer, infection, autoimmune disease, or spinal cord injury.
Fortunately, most such ominous situations cause other nasty signs and symptoms and are likely to be diagnosed
correctly and promptly. If you are aware of the red flags, you can get checked out when the time is right but
not worry excessively before that.
The rule of thumb is that you should start a more thorough medical investigation only when three conditions
are met:
1.
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2. its severe and/or not improving, or actually getting worse

3. there is at least one other red flag (see note for checklist) 21
And there is one (hopefully obvious) situation where theres no need to wait several weeks before deciding the
situation is serious: if youve had an accident with forces that may have been sufficient to fracture your spine or
tear nerves. I didnt really have to tell you that, did I? Well, I did for legal reasons!
In all other cases, you can safely read this tutorial first. Next: how bad can a non-ominous case of neck pain get?
ETIOLOGY
The (weird and unclear) nature of the beast
There is a considerable amount of scientific mystery, debate and controversy about the nature of neck pain, and
the solutions for it. Its a medical muddle. As with the common cold and flu, we just dont get it yet.
A detailed article in the January issue of 2009 of Pain Physician states clearly that very little is known about the
causes of neck pain. 22 No one should ever confidently claim to know the One True Cause of neck pain, because
there are probably many true causes many of them undiagnosable, or not reliably diagnosable because we
cannot (and may never be able to) look deeply into the living neck.
Above all, you should be cautious of the single most popular-yet-vague idea in all of neck pain lore: the idea that
your neck is out. People say my neck is out, and they really mean it: they arent thinking of it as a general term
that might encompass any number of more specific issues. They actually think something is somewhat dislocated,
and this is almost certainly not the case. Its a popular idea, based largely on the chiropractic concept of
subluxation, which will be addressed in detail further along in the tutorial. There can certainly be something
wrong with your neck joints that much is clear but its probably a misleading and potentially anxietyproducing oversimplification to imagine that the joint is partially dislocated or out of place. Its almost certainly
not really like that.
This mess of possible causes is made more confusing by the fact that they
all share at least one thing in common: an equalizing factor which tends
to make them all seem surprisingly similar. No matter what it was that
started the pain, painful muscular dysfunction almost certainly complicates
it, 23 and may even become the dominant problem. Meanwhile, painful
muscle dysfunction itself is poorly understood, and probably
underestimated as a factor by many (or most) health care professionals
even while some medical experts devote their careers to it, 24 the medical
majority still has a muscle blind spot, 25 , and even massage therapists
may overlook it surprisingly, massage therapy training does not go into
much detail about the physiology of muscle pain or treatment methods.
So, nothing is certain, anything is possible, and nothing about neck pain
can surprise me any more: not even the knowledge that and this is so odd
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Because all neck pain is probably at least

partially caused by muscle dysfunction,
massage is one of the best therapies
available. However, well be going over all
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neck pain is more common in short people. 26 Apparently thats a fact,

but its a fact that I cant even begin to explain! In this article I have written
about what seems to be true and useful for most people, most of the time,
and Ive supported it with the best evidence available.
the treatment options.
My chiropractor says this is because the top of my neck attaches

to my head. Is that a common problem?
from the chiropractors say the darndest things file, as reported
by Dr. Grumpy (Only Outside Sleepy Hollow)
Why does a crick feel the way it does?

Which aint saying much, unfortunately. The science is undeniably limited.
The neck is rife with structures that potentially could and probably do cause various painful conditions.
Travell et al , Myofascial Pain and Dysfunction: The Trigger Point Manual, 1999, p247
The amount of crick in a case of neck pain varies, like seasoning in a recipe. However, most cases of neck pain
involve at least some crick and what is that sensation anyway? What makes a crick feel the way it does? Whats
going on in there? Well explore this over the next few sections.
After my decade of clinical experience, my preferred explanation 27 not necessarily correct, but the most
useful explanation for most people, most of the time is the theory of minor intervertebral derangement
(MID). 28 29 A MID is basically a minor mechanical malfunction in your spine, causing pain directly through
mild trauma. A MID is probably not even as painful as a toe stub in most cases, or no more, but certainly painful
enough to provoke a reaction. Here are some possible examples of MIDs:
Compression sprain.There are a pair of small, dime-sized joints on either side of every intervertebral
joint, the facet joints. 30 Their cartilaginous surfaces can be bruised when compressed, somewhat
like a thumb jam. 31 This might happen if you zigged when you should have zagged a poorly
coordinated movement of the neck. 32 Minor compressions of this sort are probably extremely
common, and mostly painless. Joint surfaces are not particularly sensitive to pressure. 33
Synovial membrane pinch. Joint capsules connective tissue wrappings around the facet joints
can probably be pinched between the joint surfaces, basically at random, and probably for the same
reason that compression sprains occur (the zigged when you should have zagged theory). This has
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never been demonstrated scientifically to the best of my knowledge, but it is plausible. Unlike
cartilaginous joint surfaces, synovial membranes (the lining of the capsule) are extremely sensitive.
Violent joint popping. The facet joints also pop, like knuckles. Although many people are used to
the sensation of joint cracking in their necks, for others it is a surprising, uncomfortable, and even
alarming sensation. A violent crack could constitute a minor MID. Your emotional reaction is
relevant: if it scares you, the incident can provoke a cascade of significant neurologic consequences.
Context is everything. Even as a cracky person, used to the sensation, occasionally I have had joint
pops so dramatic that I felt alarmed.
A nerve pinch. Although less of a problem than most people suppose (more about that in a while),
irritation to nerves exiting the cervical spine is certainly possible. Once again, a poorly coordinated
movement can result in a momentary yank or pinch on nerve tissue. The sensation may be more
alarming than actually damaging, but the patients neck may react poorly.
In most cases, the substance of the crick the persistent feeling of the crick is probably not caused by the MID
itself, but by the consequences. The irritation of the MID itself quickly dies down, and is overtaken by a variety of
neurologic and muscular reactions, which are probably dominated by the pain of muscle knots.
More to come on the nature of this muscular reaction its the single most important idea in this tutorial. But
first, lets make sure that this business of a mechanical malfunction component of neck pain is thoroughly
addressed. Theres a strong, intuitive desire to interpret neck pain as a mechanical failure. Is it reasonable?
Subluxation: can your neck be out?

There can certainly be something wrong with your spinal joints there are a few possibilities but subluxation
and spinal joints being out are not defined clearly enough to be useful, and are probably quite misleading.
Subluxation is mainly a chiropractic idea of some kind of spinal joint dysfunction, with many shades of meaning
too many depending on who is talking about it. However, it is inextricably entangled with the idea of a spinal
joint being out of place, and it is this sense of the word that needs some debunking. Some chiropractors attribute
great importance to subluxation. Most believe that subluxations cause neck and back pain, and significantly
many also believe that they cause a wide variety of other health problems and so they use spinal manipulation to
treat visceral disease (Homola). Subluxation theory has been both popular and controversial for many decades
now, and it has never achieved medical respectability. Many experts, including quite a few chiropractors, actually
deny that spinal subluxations exist in any meaningful sense.
Its problematic that spinal manipulative therapy the umbrella term for all kinds of spinal joint adjustment
is so often based on such a confusing and controversial concept. Subluxation has too much baggage to be a useful
term. Lets use more modern and specific terminology, and get away from the idea of spinal joints being out.
The controversies about subluxation theory are described thoroughly in a special supplement to this tutorial,
accessible only to customers. You can also just read some highlights below, in this books section about treating
neck pain with spinal adjustment.
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Does Spinal Manipulative Therapy (SMT) Work? Adjustment, manipulation, and popping of the
~ 12,000 words
spinal joints and the subluxation theory of disease, back pain and neck pain
Hey, wait a sec arent MIDs and subluxations pretty similar ideas?
Reader J.B. asked this question in mid-2014, and I had to chuckle: how could I have missed that? Somehow, over
a period of many years, the similarity of these concepts, and my potential hypocrisy, never once crossed my mind!
How can I be skeptical about subluxations, but use minor intervertebal derangements as a key concept? I was
pretty concerned that Id been caught in a glaring inconsistency!
Lucky for me, there are actually some clear differences (and exploring them should be informative).
Although the chiropractic idea of subluxation is an appalling mess and a slippery target, it does have two
defining characteristics that have been consistent over the decades: first, the idea of joints being out, and
second, the idea that they mainly matter because their out-ness has a profoundly deleterious effect on nerve roots.
The notion of an MID cant be completely seperated from the first, but it completely avoids the second.
Heres the more difficult MID/sublux difference: chiropractors mostly portray subluxation as persistent
pathological state of the joint. That is, the joint gets into and stays in a problematic state, allegedly something they
can feel, or visible on an X-ray, or possibly apparent only with motion. In contrast, a MID is a transient mild
trauma an incident with painful consequences, not a persistent state of affairs.
So thats a clear distinction.
And yet, I concede, there is likely some conceptual overlap. For instance, if you do give yourself a little
compression sprain of a zyapophyseal joint, ow, its certainly plausible that the consequences would include not
just irritation but joint dysfunction as well (e.g. the nervous system trying to move the spine without further
compressing the irritated surfaces). Theres definitely at least a little overlap there between ideas
Another possibility: the feeling of stuckness without the fact of stuckness

Consider how exquisitely sensitive we are to the presence of a grain of sand between the teeth. The tiniest
obstruction, and we are instantly, acutely conscious that something is in the way of our bite.
Or consider that we can detect even the slightest movement in our joints if someone pushes on the tip of your
shoe while your eyes are closed, no matter how gently, you will know. And consider how irritating it can be for our
freedom of movement to be limited! The feeling of needing to stretch your legs after being stuck in an airline seat
can be almost overwhelming.
These sensations are powered by a rich sense of position and movement (proprioception, the sixth sense), and
by a basic physiological need to constantly, physically stimulate all tissues in order to remain healthy. Stagnant
tissues quite literally die bed sores are the obvious example and the stakes are life and death it was an
infected bed sore that killed Christopher Reeve. Thus we are programmed to detect and respond strongly to the
slightest stagnancy. And this is, in a very general way, how a joint dysfunction can be so uncomfortable without
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actually having anything obviously mechanically wrong. Like the grain of sand between your teeth, even a tiny
bit of joint stuckness is probably extremely obvious to our nervous systems. This could all occur without the
slightest visible, palpable or X-rayable problem.
We can almost certainly feel out without being out. So we can have a great feeling of stuckness, without
necessarily having much stuckness. But what about the scenario routine in neck cricks where you literally
cant turn to one side or the other? That seems to be more than just a feeling of stuckness.
Stuck! What limits your range of motion?

So you cant shoulder check while driving. You can barely move your head to get a shirt on. You cant tilt your head
to shave.
I cant tell you how many hundreds of times I have heard such descriptions from my patients and readers. And
friends. And family. And bank tellers, and convenience store cashiers. Seemingly anyone who has a neck and the
power of speech has, at some point, had this unpleasant experience and told me about it. They are stuck really
stuck.
Many cricks only involve a minor, vague feeling of stuckness, while others result in a more literal limited range of
motion. Such stuckness may even occur with relatively little pain, and it is in such cases that the feeling of
stuckness is the most vivid it just wont move. Surely there is something truly stuck or outta whack in the neck
when you can barely move it?
Yes, there just might be. In some sense
END OF FREE INTRODUCTION

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from Trigger Points and Myofascial Pain Syndrome! a $19 95 value. Muscular
dysfunction is a factor in nearly all cases of neck pain, and no discussion of neck pain
could ever be complete without also thoroughly exploring the phenomenon of muscle
knots (trigger points). Although basic information about trigger points is provided in
the neck pain tutorial, its too large a subject to cover properly here so I provide SaveYourself.cas
trigger point tutorial as an essential free companion to the neck pain tutorial.
TABLE OF CONTENTS PREVIEW

Introduction
1.1
1.2
1.3
1.4
1.5
Neck pain myths busted here!

How can you trust this information about neck pain?
Who exactly is this tutorial for?
And what about a pinched nerve?
Cricks versus pain
Prognosis
Whats the worst case scenario for neck pain?
2.1
2.2
Minor update Oct 22 '14
Three case studies of extreme neck crick horribleness

What if theres something really wrong with my neck? Safety information!
Etiology
The (weird and unclear) nature of the beast
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
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Why does a crick feel the way it does?

Subluxation: can your neck be out?
Another possibility: the feeling of stuckness without the fact of stuckness
Stuck! What limits your range of motion?
Could it be arthritis? Is your spine degenerating? Probably not, no
Is it a herniated disc? Does it matter? The herniation myth
Is it a pinched nerve? I doubt it! The nerve pinch myth
Does abnormal curvature hurt? Not much! The neck posture myth
More content Jul 11 '14 +
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3.9
3.10
3.11
3.12
3.13
3.14
3.15
3.16
Is it a strain? Probably not! The muscle strain myth

Is it a spasm? Nope, probably not a spasm either: the muscle spasm myths (plural)
The most important tissue issue in most neck pain: muscle
The case for myofascial trigger points as a major neck pain villain
From the frying pan of injury pain to the fire of trigger point pain
More about muscle malfunction: whats going on in a trigger point?
A recipe for persistent neck pain what are the risk factors?
Neck pain versus back pain: some interesting comparisons
Science update Jul 11 '14 +
Diagnosis
How do I know what type of neck pain I have?
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
How can I tell if theres a pinched nerve?

Nerve blocks (medial branch blocks) as a method of diagnosis
A poke in the disc! Cervical provocation discography as a method of diagnosis
Estimating the importance of trigger points in your own case
Out of nowhere: seemingly random episodes of neck pain
A classic diagnostic sign: I woke up with it
Connections with headaches and migraines
Miscellaneous medical causes of neck pain and how to stop worrying about them
What happened to my barber? Neck pain powered by atlantoaxial instability
Digital Motion X-Ray
New Jul 01 '14
Treatment
What can you do for a crick in the neck?
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
5.16
5.17
5.18
5.19
5.20
5.21
5.22
5.23
5.24
5.25
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Surgical options
Needles for neck pain: nerve blocks and related treatments
Anti-inflammatory medications: useful but not a solution
Is medication overuse a factor?
A tale of two tutorials
Introduction to treating your own neck trigger points
Basic self-massage for neck trigger points
A massage success story
The role of massage tools in neck massage
Can you damage neck nerves by self-massaging?
Heat and ice both provide good bang for buck, but err on the side of heat
Avoid drafts at night
Mobilizations or wiggle therapy
Will stretching help neck pain? Much?
Minor yoga update Dec 14 '13 +
Pull my neck! The potential of traction
Relaxation and the confidence cure
Dont worry (very much) about exercises to improve neck curvature, posture, coordination or stability
Does balancing a ball on your head help neck pain? I know you were dying to know
Ergonomics are probably more important than posture
Microbreaking
Pillow talk: the evidence about pillows is soft
Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints
Science update Jul 01 '14 +
Bracing yourself
The fascinating case of acupuncture
Reality checks: some popular treatments that dont work at all (or not nearly as well as you would
Minor update Dec 21 '13 +
hope)
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Executive Summary
All the treatment options summarized
Appendices
7.1
7.2
7.3
7.4
7.5
7.6
Supplements and downloads

Acknowledgements
Reader Comments
Further Reading
Whats new in this tutorial?
Notes

APPENDICES
Supplements and downloads

Customers are entitled to access special supplements and downloads. These documents are just as much a part of
the book as the included chapters, but are seperated so that they can serve as a resource for other books as well.
They contain information that is equally relevant to readers of other books, such as the neck pain or trigger points
books. This section will expand in 2011 as I roll out more special supplements.
Does Spinal Manipulative Therapy (SMT) Work? Adjustment, manipulation, and popping of the
spinal joints and the subluxation theory of disease, back pain and neck pain
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Do Nerve Blocks Work for Neck Pain and Low Back Pain? Analysis of the science of stopping the pain
of facet joint syndrome with nerve blocks, joint injections, and nerve ablation
Trigger Point QRG Quick Reference Guide to Trigger Point Diagnosis and Self-Treatment
Acknowledgements
This document and all of SaveYourself.ca was, for many years, created in my so-called spare time and with a lot
of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and
small, and for being my editor girlfriend; to my parents for (possibly blind) faith in me, and much copyediting;
and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and
obvious). And thanks to all of the above, and many others, for many (many) answers to what do you think of
this? emails.
Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback
and suggestions and stories. Without you, all of this would be pointless.
And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven Novella,
Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.
Reader Comments
Here is what some readers have said about the neck pain tutorial over the years. Feedback is always welcome. I
focus on the positive in this section, but I want to acknowledge that I certainly do receive some criticisms as well.
In many cases I respond by making improvements to the tutorial. However, the vast majority of feedback is
enthusiastic. Thanks, everyone!
I never had severe neck pain except for the occasional bad day, but it was stubborn. Ive never really had any relief
from it ever, always a low grade ache. Every therapist I ever saw told me it was posture, and every doctor said it was
arthritis (even though it started in my 20s). Your tutorial clearly explain several other possibilities, and its mostly
under control now just from a little bit of self-treatment of my muscles once every week or two. Its not cured, but
its about a hundred times less irritating than it was. Thank you!
Laurie Pappas, Denver, unusually busy home-maker, mother of seven
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After Googling neck knot I read an article on some ask-the-clinician site which was pretty useless, and then tried
yours. It was exactly the information I was looking for! Your article affirmed some of my own theories and
enlightened me with more detailed information. Youre a thorough and organized writer.
Cheryl Sosebee, artist
After thirty-five years with severe constant neck pain, I am 80% better, and I feel like I can actually enjoy the rest of
my days. Paul Ingraham helped me understand that the problem with my neck wasnt structural. Even though it
felt like something was out, thats not really what was happening. Id seen every kind of therapist you can imagine,
and no one ever explained it so clearly. I had my doubts at first, but the results of applying his ideas have been
nothing short of miraculous. I used to wrench my neck all day long, always twisting and turning trying to get away
from that damn crick! And now? People who dont even know me that well are saying to me, Hey, Elliott... youre
not twisting your neck around the way you used to! If youve got a stiff neck, I cant recommend Paul Ingrahams
perspective on it strongly enough.
Trevor Elliott, real estate speculator
One more special comment. In the Spring of 2009, I received an incredible endorsement from Jonathon
Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:
I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a
course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst
looking for information about pain for my medical students, and have recommended your tutorials to them. Your
work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular
documented updates, and lack of any commercial promotional material.
Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London
High praise indeed! Thank you, Dr. Tomlinson testimonials just dont get much better than that.
Further Reading
Unexplained episodes of nausea and vomiting, combined with neck pain? See What Happened To My
Barber? Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and
vomiting after massage therapy, with lessons for health care consumers.
Massage Therapy for Tension Headaches Perfect Spot No. 1, in the suboccipital muscles of the neck,
under the back of the skull.
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Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain Perfect Spot No. 4, an
area of common trigger points in the odd scalene muscle group in the neck
Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syndrome Perfect Spot No. 7, the masseter
muscle of the jaw
Save Yourself from Tension Headaches! Simple advice on healing from chronic tension headaches,
also known as fibrositic headaches
Save Yourself from Low Back Pain! Low back pain myths debunked and all your treatment options
reviewed
The Trouble with Chairs Back pain and worse hazards of sitting in chairs way too much
Save Yourself from Trigger Points & Myofascial Pain Syndrome A guide to the science of muscle
pain, with reviews of every possible self-treatment and therapy option, even for the most difficult cases
The Not-So-Humble Healer Cocky theories about the cause of pain are common in massage,
chiropractic, and physical therapy
Singing, Breathing, and Scalenes Connections between singing, breathing and a strange group of
muscles
The Respiration Connection How dysfunctional breathing might be a root cause of a variety of
common upper body pain problems and injuries
Whats new in this tutorial?

The first version of this document was created in 2002. It was upgraded and expanded several times before I
started keeping track of updates put it up for sale in September of 2007. It was revised and expanded to
book-length in the summer 2009, and continues to be updated as new scientific information becomes available,
and in response to reader requests and suggestions.
A major feature of my tutorials is that I actively update them as new science and information becomes available.
Unlike regular books, and even ebooks which can be obsolete by the time they are published, and can go years
between editions this tutorial is updated at least once every three months and often much more. I also log
updates, making it easy for readers to see whats changed. This tutorial has gotten 39 major and minor updates
worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.
Minor update (Oct 22 '14, section #2) Upgraded references on neck pain
recovery rates. See section #2, Prognosis: Whats the worst case scenario for neck
pain?
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Most links to sections

mentioned in the updates
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Science update (Jul 11 '14, section #3.12) Added some important

acknowledgements that the science of trigger points is a bit half-baked, and linked out
to much more information for the curious. See section #3.12, The case for myofascial
trigger points as a major neck pain villain.
More content (Jul 11 '14, section #3.2) Explanation of the difference between a
subluxation and an MID. See section #3.2, Subluxation: can your neck be out?
will work only for customers.

To get access to all sections,
purchase the tutorial for
$19.95. Youll receive the
full version right away.
Science update (Jul 1 '14, section #5.22) Added citation to a key 2012 study of the effectiveness of
adjustment for neck pain. See section #5.22, Spinal manipulative therapy (SMT): Adjustment, manipulation and
cracking of the spinal joints.
New (Jul 1 '14, section #4.10) A new section, but also a summary of an existing free article. See section
#4.10, Digital Motion X-Ray.
Minor update (Dec 21 '13, section #5.25) Added a (fascinating) footnote about the myth of anaesthetic
paralysis. See section #5.25, Reality checks: some popular treatments that dont work at all (or not nearly as
well as you would hope).
Minor yoga update (Dec 14 '13, section #5.14) Added a reference and paragraph about the risks of yoga,
which are minor but real, especially for neck pain. See section #5.14, Will stretching help neck pain? Much?
Minor science update (Jul 20 '13, section #5.14) Added a tiny, flawed study about yoga for neck pain (for
what little its worth). See section #5.14, Will stretching help neck pain? Much?
New evidence (May 29 '13, section #5.16) Rare good news: the first good quality scientific test showing
that reducing fear is actually good medicine. The section got a decent editing as well. See section #5.16, Relaxation
and the confidence cure.
New section (May 29 '13, section #5.8) No notes. Just a new section. See section #5.8, A massage success
story.
Science update (Oct 26 '12, section #1.1) Added evidence that the stakes are high with chronic pain: it may
even shorten lives. See section #1.1, Neck pain myths busted here!
Science update (Oct 24 '12, section #3.12) Added a key reference about the effectiveness of massage for
back pain, with the (safe) assumption that it probably applies to neck pain as well. See section #3.12, The case for
myofascial trigger points as a major neck pain villain.
Science update (Jul 4 '12, section #3.10) A new study shows that massage therapists cannot reliably find
the side of pain by feel good evidence that no gross spasm (or other structural factor) is usually involved. See
section #3.10, Is it a spasm? Nope, probably not a spasm either: the muscle spasm myths (plural).
Minor update (Mar 8 '12, section #5.12) Added some creative problem-solving for hot climates. See
section #5.12, Avoid drafts at night.
Minor update (Dec 14 '11, section #5.19) Added a minor but odd note about sensory annoyances like
hats and collars. See section #5.19, Ergonomics are probably more important than posture.
Minor update (Dec 1 '11, section #3.9) Added some unusual research about the risks heavy metal headbanging a fun example, for perspective. See section #3.9, Is it a strain? Probably not! The muscle strain myth.
More content (Dec 1 '11, section #3.2) Added scientific cases studies, examples, pictures and video of true
dislocation and abnormal anatomy to help drive home the point that even significant spinal joint dysfunction can
be surprisingly harmless never mind subtle joint problems. See section #3.2, Subluxation: can your neck be
out?
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trivial update (Nov 25 '11, section #1.2) Trivial but fun. Added an amusing quote about neck pain
diagnosis from the TV series, House. See section #1.2, How can you trust this information about neck pain?
Minor science update (Nov 4 '11, section #5.14) Cited a study about yoga and stretching for back pain.
See section #5.14, Will stretching help neck pain? Much?
New section (Aug 26 '11, section #3.13) This section is a summary of an important concept thats been
available in a free article since late 2008, but also needed to be emphasized here. Now it finally is. See section
#3.13, From the frying pan of injury pain to the fire of trigger point pain.
Minor update (Jul 29 '11, section #1.1) Added a reference about the poor overall quality of online
information about common injuries. See Starman et al . See section #1.1, Neck pain myths busted here!
Added a fun thing (Jul 15 '11, section #5.15) I cant believe I didnt know about inflatable neck extenders
until now! See section #5.15, Pull my neck! The potential of traction.
New section (Jul 13 '11, section #4.5) More information about an important characteristic of muscledominated neck pain. See section #4.5, Out of nowhere: seemingly random episodes of neck pain.
Major update (Jul 12 '11, section #4.4) Totally renovated section: re-written, reformatted, expanded,
upgraded. A few new checklist items were added, most were expanded, and all were clarified. A separate and
handier quick checklist was added to the existing slow checklist. See section #4.4, Estimating the importance
of trigger points in your own case.
Major update (Jun 21 '11) Major improvements to the table of contents, and the display of information
about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of
the document has really been cleaned up in general, making it significantly easier for me to update the tutorial
which will translate into more good content for readers. Care for more detail? Really? Heres the full
announcement.
Upgraded (Feb 17 '11, section #5.22) New artwork from SaveYourself.ca artist Gary Lyons, plus some
important new references. See section #5.22, Spinal manipulative therapy (SMT): Adjustment, manipulation
and cracking of the spinal joints.
Updated (Oct 6 '10, section #5.14) Updated with an important story about a disastrous example of neck
stretching that backfired. Not just for customers: this particular section is a short version of a new free article. See
section #5.14, Will stretching help neck pain? Much?
Minor update (Oct 5 '10, section #1.1) Some good new science cited in the introduction, about the overall
effectiveness of manual therapies. See D'Sylva et al . See section #1.1, Neck pain myths busted here!
Major Update (Oct 1 '10, section #3.2) Rewriting and expansion of the Special Supplement on spinal
manipulative therapy. See section #3.2, Subluxation: can your neck be out?
Update (Sep 29 '10, section #3.9) New science confirms that helmets do not cause neck injuries they just
keep your head safe. However, minor injury remains likely and problematic. See section #3.9, Is it a strain?
Probably not! The muscle strain myth.
New cover (Aug 6 '10) At last! This e-book finally has a cover.
SHOW
Science update (Jul 7 '10, section #5.25) Updated with a summary of a bizarre experiment with muscle
relaxants that had quite surprising results. See section #5.25, Reality checks: some popular treatments that dont
work at all (or not nearly as well as you would hope).
Minor update (May 24 '10, section #5.17) Uupdate with another recent study showing that strength
training doesnt work. See section #5.17, Dont worry (very much) about exercises to improve neck curvature,
posture, coordination or stability.
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Major update (Apr 20 '10, section #5.17) Completely overhauled and substantially expanded, and
polished several relevant bibliographic records. See section #5.17, Dont worry (very much) about exercises to
improve neck curvature, posture, coordination or stability.
Rewritten (Apr 20 '10, section #3.8) Completely overhauled and substantially expanded, and polished
several relevant bibliographic records. See section #3.8, Does abnormal curvature hurt? Not much! The neck
posture myth.
Science update (Feb 13 '10, section #5.25) Added an interesting reference about how muscle relaxants are
surprisingly ineffective. See section #5.25, Reality checks: some popular treatments that dont work at all (or not
nearly as well as you would hope).
Minor update (Dec 31 '09, section #3.12) Shored up substantiation of the relationship between migraines
and trigger points. See Fernndez-de-Las-Peas et al , and another paper by Fernndez-de-Las-Peas et al , and
also Calandre et al . See section #3.12, The case for myofascial trigger points as a major neck pain villain.
New section (Dec 16 '09, section #4.3) First new section since the huge update in the fall, a shortbut-useful section. See section #4.3, A poke in the disc! Cervical provocation discography as a method of
diagnosis.
Huge upgrade (Sep 23 '09) Over the past several months, the neck pain tutorial has more than quadrupled
the amount of information it offers, and it is now book-length at more than 40,000 words (not including two
substantive customer-only special supplements). Almost every single section was overhauled, and many new
sections were added. Dozens of references to more recent scientific research were integrated and their significance
explained, including several good new studies less than six months old.
Notes
1. Brison et al . A randomized controlled trial of an educational intervention to prevent the chronic pain of whiplash
associated disorders following rear-end motor vehicle collisions. Spine. 2005. PubMed #16103847.
This is one of a few studies showing a benefit to education for neck pain. The researchers showed a reassuring
educational video to more than 200 patients with whiplash associated disorders (i.e. whiplash injuries that
become chronic neck cricks), and found that they had less severe symptoms than about the same number of
patients who received no educational intervention. The effectiveness of education probably depends a lot on the
type of neck pain and the type of education, making it very hard to study. A recent review of the scientific literature
found that most such studies are negative, but I believe that there are many reasons to be optimistic about
education for pain problems: see Haines for more information.
2. Hurwitz et al . Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010
Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008. PubMed #18204386. For
whiplash-associated disorders, there is evidence that educational videos appear more beneficial than usual care
or physical modalities.
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3. The best recent evidence of this is a 2008 study in Journal of the American Medical Association that showed that
spine-related expenditures have increased substantially from 1997 to 2005, without evidence of corresponding
improvement in self-assessed health status (see Martin). In other words, a lot of expensive medical care is not
helping. This interesting paper was summarized well by Parker-Pope in the New York Times.
4. Jansson et al . Sickness absence because of musculoskeletal diagnoses and risk of all-cause and cause-specific
mortality: A nationwide Swedish cohort study. Pain. 2012. PubMed #22421427.
Can pain shorten your life? A large Swedish study of four million Swedes looked for a correlation between increased
mortality and work absenteeism due to painful musculoskeletal conditions. They found the first ever evidence that
people who have musculoskeletal pain may have an increased risk of premature death. The researchers adjusted
their data for several potential confounders. Its a plausible and disturbing conclusion. The costs of pain are often
expressed in terms of hair-raising stats on the economics of work absenteeism but they may be much greater still.
5. In 2010, the Journal of Bone & Joint Surgery reported that the quality and content of health information on the
internet is highly variable for common sports medicine topics, such as knee pain and low back pain a bit of an
understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30
academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail,
see Starman et al .
6. The standard techniques of physiotherapists, massage therapists, and chiropractors all produce generally poor
results with neck pain: they work a little bit, sometimes, with some people, temporarily. Truly good success stories
are rare. This lacklustre performance was confirmed in 2010 by a new study of studies (a meta-analysis) in Manual
Therapy (see D'Sylva). Although the science is complex and limited and about 75% of studies had to be eliminated
from consideration due to likely bias, one thing was clear: manual therapy isnt exactly curing a lot of neck pain. It
has low to moderate quality evidence that its helpful, compared to advice and exercise alone.
7. We have recently emerged from something of a dark period in the scientific study of neck pain. Always something a
poor cousin to low back pain research, there was a surprising lack of analysis of neck pain research available
perhaps because of a lack of research to analyze. According to the journal Spine in early 1998, No comprehensive
systematic literature reviews have been published on interventions for neck pain and its associated disorders in the
past decade (see Hurwitz). However, since then there have been many important new studies, and much more
analysis. Although this tutorial is many years old, it was significantly renovated throughout 2009 to include this
new science.
8. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems,
especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a
number of studies, like Stockard et al , who found that 82% of medical graduates failed to demonstrate basic
competency in musculoskeletal medicine. Its just not their thing, and people with joint or meaty body pain should
take their family doctors advice with a grain of salt. See Medical Blind Spot for Aches and Pains: Most doctors are
unqualified to care for many common pain and injury problems. Especially the stubborn ones.
9. Borenstein. Chronic neck pain: how to approach treatment. Current Pain & Headache Reports. 2007. As recently
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as 2009, these experts wrote that, despite its frequency as a clinical problem, there are few evidence-based studies
that document efficacy of therapies for neck pain. I agree: the really good studies can practically be counted on
your fingers and toes, and the field is basically still in its infancy. And yet, of course, there are tens of thousands of
doctors and therapists out there who will happily tell you that they know how to treat your chronic neck pain.
Take it with a grain of salt. There are good ideas out there, but no honest professional should feel particularly
confident.
10. Obviously headaches are related to neck pain but this tutorial is already big enough without trying to include
them! If your headache and migraine involve a significant amount of neck pain, the tutorial is worthwhile. For
patients who are experiencing headaches and migraine without clear neck pain, I recommend other resources, such
as Jim Cottrills excellent migraine blog. I do have a short tension headache tutorial.
11. While face and jaw pain often do occur with neck pain, and there is probably a relationship between them, they
involve many special issues. This tutorial does not address them in any detail.
12. Freeman et al . Chronic neck pain and whiplash: A case-control study of the relationship between acute whiplash
injuries and chronic neck pain. Pain Res Manag. 2006. PubMed #16770448.
From the abstract: it is reasonable to infer that a significant proportion of individuals with chronic neck pain in
the general population were originally injured in a motor vehicle accident. See also Atherton.
13. Atherton et al . Predictors of persistent neck pain after whiplash injury. Emerg Med J. 2006. PubMed #16498156.
480 people with neck pain following car accidents completed questionnaires at three follow-up points during the
year after their accident. 128 of them (27%) reported neck pain every time. The greatest predictors of persistent
neck pain relate to psychological distress and aspects of pre-collision health rather than to various attributes of
the collision itself. In other words, people who went into the accident with the most stress and body pain were the
most likely to suffer chronic neck pain. For a short article discussing this research, see A Recipe for Chronic Neck
Pain After Whiplash. See also Freeman.
14. Bahr et al . Clinical guide to sports injuries. 2004. p106.
15. Interestingly, the interesting curse is probably not Chinese, but English or American. According to Wikipedia,
The Chinese language origin of the phrase, if it exists, has not been found, making its authenticity doubtful. Also
interesting, regardlessof its provenance, is that it is the first of three curses, the other two being: (1) may you come
to the attention of those in authority, and (2) may you find what you are looking for.
16. For instance, neck pain does not relentlessly grow worse, building up to a fever pitch of nastiness. Such behaviour!
Neck pain that escalates steadily with little or no relief is unlikely to be just a neck pain problem. Pain that just
keeps getting worse may well be caused by disease. If this is your problem, please review the safety section! Also,
although the worst cases may cause severe pain, I only mean severe for neck pain and not off the scale pain that
blots out the sun and makes it impossible to function or work. The worst non-ominous neck pain is probably about
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the intensity of an extremely bad headache, but less than a full-blown migraine, child birth, or rheumatoid arthritis.
17. Leaver et al . People seeking treatment for a new episode of neck pain typically have rapid improvement in
symptoms: an observational study. J Physiother. 2013. PubMed #23419913. This study of 180 patients who sought
treatment for a new case of neck pain found that 53% of them recovered completely within three months. The
authors believe that physiotherapists should reassure people with a new episode of neck pain that rapid
improvement in symptoms is common, modifying this advice where applicable based on risk factors.
18. I have to equivocate on that difference because, well, bloody stats its nearly impossible to settle on a number,
because there are so many complicated ways of measuring these things. At the most optimistic, back in 1994,
Coste et al reported a back pain recovery much higher than reported in other studies: 90% within two weeks.
Another rather promising example is Costa, which showed that Chronic Low Back Pain Is Not So Chronic. The least
promising recovery data about back pain is about the same as what Ct et al found for neck pain.
19. I cited Leaver above as good news, because half of patients with new cases recover within three months. But its
obviously good-and-bad-news science, because of the other half: almost half of those who seek treatment do not
recover completely within three months. Which is actually quite a high number.
20. Ct et al . The annual incidence and course of neck pain in the general population: a population-based cohort study.
Pain. 2004. PubMed #15561381.
21. Check all that apply. The more red flags youve got, the more worthwhile it is to ask your doctor if its possible that
theres something more serious going on than just neck pain. The great majority of people who check off an item or
two will turn out not to have an ominous health issue. But red flags are reasons to check, not reasons to worry.
Light tapping of the spine is painful.
Benyamin et al . Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain.
Pain Physician. 2009. PubMed #19165300.
Dommerholt. Persistent myalgia following whiplash. Curr Pain Headache Rep. 2005. PubMed #16157061.
From the abstract, Myofascial trigger points may play a crucial role in maintaining sensitization [of muscle tissue after
whiplash.]
Drs. Janet Travell and David Simons devoted their career to the study of soft tissue pain and myofascial pain syndrome,
and published the incredibly authoritative red texts on the subject (Myofascial Pain and Dysfunction). Simons and
Mense have continued that work with the recent text, Muscle Pain. Clair Davies excellent popularization of the red
texts, The Trigger Point Therapy Workbook, has sold extremely well in recent years, is endorsed by a dozen medical
experts, and has generally resulted in patients knowing more about muscle pain than doctors. Dr. John Sarno of New
York is one of the worlds most successful back and neck pain clinicians, and in his writings independently develops
essentially the same theoretical conclusions as Travell and Simons. Vancouvers own Dr. Chan Gunn has spent twenty
years working on an extremely well-reasoned alternative hypothesis for soft tissue pain, and has developed one of the
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worlds more novel and effective therapies for trigger points, intramuscular stimulation. There are many others. These
are all experts who present a compelling case of the importance of muscle pain.
Self-confessed medical ignorance about neck pain is common. One textbook declares, The [neck pain] epidemic is
difficult to explain from a biomechanical perspective. The patient seldom has definite pathophysiological changes or
specific clinical signs. (Clinical guide to sports injuries, p27). Its always refreshing to hear medical experts honestly
saying I dont know, but it is disturbing how ignorant they seem to be of the explanation that follows naturally from
the work of the experts mentioned above (Travell, Simons, Mense, Sarno, Gunn), serious medical researchers and
gifted clinicians who have literally devoted their entire careers to understanding how muscle probably explains the
epidemic of neck and back pain. Their publications seem to be ignored by the medical mainstream.
Poussa et al . Predictors of neck pain: a cohort study of children followed up from the age of 11 to 22 years. Eur J Spine.
2005. PubMed #16133076.
This study examined 430 children over several years and found that short stature at 11 years of age predicted the
incidence of neck pain, and therefore concluded that Short stature may be a risk determinant of neck pain.
The idea of my preferred explanation deserves some clarification. I most certainly do not know exactly what
actually makes a crick feel like a crick. However, I have settled on a working theory over the years, an explanation that
(1) is reasonably consistent with available scientific evidence and my clinical observations, while still leaving plenty of
theoretical leeway for interpretation and anomalies; and (2) is also communicative. This second quality is actually
terribly important in a working theory: as long as it is actually sensible, so much the better if it is also a compelling
piece of imagery that helps readers get it! I also vastly prefer the imagery of the MID to the imagery of the spine being
out, which tends to aggravate patients fears that their spine is fragile.
Maigne. Manipulation of the spine. In Basmajian JV (ed): Manipulation, Traction and Massage, Baltimore: Williams
& Wilkins. 1986.
Hertling et al . Management of Common Musculoskeletal Disorders, p574.

Darlene Hertling clearly elucidates Maignes ideas about MIDs (Maigne), with reference to the thoracic spine. Likely
the idea can be sensibly applied to other sections of the spine as well.
Facet is the easier but technically incorrect term for them. The proper term is one of the gnarliest in all of anatomy:
zygapophysial joint.
This is sometimes called a compression sprain, though it is not technically a sprain and cartilage doesnt bruise
because it doesnt A more common example of this injury is a thumb jam, especially in rugby, where the thumb joint
is bent back and/or harshly slammed together, traumatizing the joint surfaces. In the case of a typical minor MID, the
forces are likely to be much smaller.
When you turn your head, a large number of muscles have to coordinate, literally dozens of them. Some of them have to
contract. Some of them have to relax, so that they dont resist movement. And they have to do this fast and in more less
perfect harmony. It doesnt always work out, and one error is all it takes.
Indeed, they are so insensitive that only traumatic compression might actually cause a problem.
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There are 126 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.

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Neck Pain Tutorial

Save Yourself from Neck Pain!

The neck crick

Neck pain is an almost universal human experience, afflicting almost everyone

Neck pain myths busted here!