SaveYourself.ca •Sensible advice for aches, pains & injuries
 

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!

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 Jul 11th, 2014 — What’s new?
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

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 doesn’t, and why? It’s detailed, readable, and regularly updated with fresh science.

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 you’ve 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 you’ll 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 it’s a real whopper of a neck crick. Maybe you can hardly move! Or maybe it’s the fifth crick in the neck you’ve had this year. Or maybe you’ve had low-grade but constant, chronic and exasperating neck stiffness ever since that bicycle accident in 2012. Maybe you are starting to wonder if there’s any way to actually reach into your neck, pull out your cervical spine, and put in a replacement unit! If that’s the case, this tutorial is definitely not overkill: you need plenty of good information, because education and fear-reduction may actually heal neck pain,12 while therapies, drugs, and surgeries have a generally poor track record.3

I am a science writer & amateur athlete in Vancouver, Canada. I’ve 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
About footnotes. There are 156 footnotes in this document. Click to make them “pop up” without losing your place. There are two types: interesting extra content, and boring reference information.1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.

2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman et al. Acupuncture for Chronic Low Back Pain. New England Journal of Medicine. 2010. PubMed #20818865. ← That symbol means a link will open in a new window.
Try one!

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 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.

Abnormal vertebrae? Who cares …

Research has shown that abnormal curvature of the cervical spine is not closely associated with neck pain.

Abnormal vertebrae? Who cares: research has shown that abnormal curvature of the cervical spine is not closely associated with neck pain.

Abnormal vertebrae? Who cares …

Research has shown that abnormal curvature of the cervical spine is not closely associated with neck pain.

But the news hasn’t gotten out, and the bogeyman of abnormal neck shape continues to be the basis of lots of expensive manual therapy that doesn’t 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.

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 There’s not much point in criticizing theories about neck pain if I’m 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 make no big promises, and I do not claim to know the “one true cause” of neck pain. When I don’t 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. I’ve 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 that’s 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 you’ve been struggling with a bad and/or persistent crick in the neck, there are probably more options than you realized. Most people who think they’ve “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 it’s 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. I’ve 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 migraine10; 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 with13 — a strange, important wrinkle that is relevant to neck pain in 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 don’t. As with whiplash, this tutorial is probably quite 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 ultimately prove to be a surprisingly minor problem that goes away on its own when other neck issues are addressed. Severe cases of nerve pain are not addressed directly, but the topic is put in perspective, with potentially great benefit to many patients, particularly those who aren’t 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 whole section about the mythology of nerve pain and the many common misconceptions about it; 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.

However, this tutorial is not ideal for patients with true and serious neurological problems. 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 does not focus on the options for your problem. Surgery is a much 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, pp2–3

What’s a “crick” in the neck, as opposed to neck 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. Pretty much every scientific paper ever written 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 mysterious it remains scientifically.

“Crick” is an informal term. You won’t find it in a medical dictionary. And yet it’s a major sub-type of neck pain … often not particularly painful, but characterized instead by stiffness and a seemingly mechanical limitation of movement in the cervical spine — like something in a joint is catching or sticking or locking when you try to move. 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 treated like a poor cousin to neck pain. The use of that word “crick” tends to trivialize the problem. It’s true, when neck pain exceeds a certain degree of badness, no one calls it a “crick” anymore — the word feels too lightweight.

But it is important to understand that a feeling of stuckness can be every bit as bad as severe pain. 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. Some of the worst neck cricks don’t “hurt,” per se: they 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.

I’ve also experienced that state personally, once.

Although it’s like comparing apples to orange cars, I have often had the impression that irritating cases are more 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, that’s me!”

So cricks make neck pain particularly “interesting,” in the sense of the Chinese curse.15 They are an almost perfect medical mystery: a simple sensation that no one can really explain. Not every case of neck pain includes a crick, but the terrible neck injuries and pain problems of today often become the persistent cricks of 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 phenomenon of a crick.

Part 2

Prognosis

What’s 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, hours, days, weeks, years or decades! Most cricks are mild and resolve spontaneously, with or without treatment, within a few days or a couple of weeks at the longest. It’s important that fresh victims be reassured of this fact. Even neck cricks that seem quite serious at first are quite likely to fade pretty fast.

“Contrary to prior belief, most individuals with neck pain do not experience complete resolution of their symptoms and disability.”

However, neck cricks and neck pain have the potential to last much longer, and most people interested in this tutorial probably already think of their neck pain as chronic. Unfortunately, I have seen many patients whose cricks were essentially permanent. Indeed, it is something of a myth that neck pain is a temporary problem. Doctors are prone to reassuring patients that they will recover — a well-intentioned error.17 Certainly a lot of neck pain does go away, but research has clearly shown that a lot of it doesn’t: in 2004, Côté 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 — according to the conventional wisdom, that’s not how it’s “supposed” to go, but that is exactly how it does go.

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 sky’s 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.

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 it’s extremely unpredictable.

Interestingly, women suffer more. Again, according to Côté 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 he’s a nurse. When he called he said he was having “carpal tunnel problems.” That’s 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 he’d 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 it’s also instructive about the nature of neck cricks. It’s 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 man’s 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.

“Usually my neck would be ‘out’ again before I got home from the chiropractor.”

As of this writing, he has been mostly crickless for a couple of years — for the first time in more than thirty years. “It’s not cured,” he tells me, “but it’s so much less than it used to be. It’s at least 80% gone. It’s mostly a bad memory.”

Of course, therapy doesn’t 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 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 doesn’t 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.” It’s like he’s 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 wasn’t 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 couldn’t 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 doesn’t 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 isn’t 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 that’s really the issue: despite the short term successes in treating her, and despite how valuable she considers that to be, I don’t feel like I’ve really helped her. How can I, when she’s 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 there’s something really wrong with my neck?” Safety information!

“How do you know I’m 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. it’s been bothering you for more than about 6 weeks
  2. it’s severe and/or not improving, or actually getting worse
  3. there is at least one other “red flag” (see note for checklist)18

And there is one (hopefully obvious) situation where there’s no need to wait several weeks before deciding the situation is serious: if you’ve had an accident with forces that may have been sufficient to fracture your spine or tear nerves. I didn’t 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?

Part 3

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. It’s a medical muddle. As with the common cold and flu, we just don’t “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.”19 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 aren’t 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. It’s 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 it’s probably a misleading and potentially anxiety-producing oversimplification to imagine that the joint is partially dislocated or out of place. It’s almost certainly not really like that.

[Massage is one of the single best treatment option for neck pain.]

Because all neck pain is probably at least partially caused by muscle dysfunction, massage is one of the best therapies available. However, we’ll be going over all the treatment options.

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,20 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,21 the medical majority still has a muscle blind spot,22, 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 — neck pain is more common in short people.23 Apparently that’s a fact, but it’s a fact that I can’t 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 I’ve supported it with the best evidence available.

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 ain’t 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? What’s going on in there? We’ll explore this over the next few sections.

After my decade of clinical experience, my preferred explanation24 — not necessarily “correct,” but the most useful explanation for most people, most of the time — is the theory of “minor intervertebral derangement” (MID).2526 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.27 Their cartilaginous surfaces can be “bruised” when compressed, somewhat like a thumb jam.28 This might happen if you “zigged” when you should have “zagged” — a poorly coordinated movement of the neck.29 Minor compressions of this sort are probably extremely common, and mostly painless. Joint surfaces are not particularly sensitive to pressure.30
  • 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 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 patient’s 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 — it’s the single most important idea in this tutorial. But first, let’s make sure that this business of a “mechanical malfunction” component of neck pain is thoroughly addressed. There’s 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.

It’s 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. Let’s 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 book’s section about treating neck pain with spinal adjustment.

Hey, wait a sec… aren’t 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 I’d 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 can’t be completely seperated from the first, but it completely avoids the second.

Here’s 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 that’s 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, it’s 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). There’s 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 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 can’t 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 can’t shoulder check while driving. You can barely move your head to get a shirt on. You can’t tilt your head to shave.

I can’t 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 won’t 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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Part 3.5

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.

  • SUPPLEMENT 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
  • SUPPLEMENT 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
  • QRG 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. I’ve 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 it’s mostly under control now just from a little bit of self-treatment of my muscles once every week or two. It’s not “cured,” but it’s about a hundred times less irritating than it was. Thank you!

— Laurie Pappas, Denver, unusually busy home-maker, mother of seven


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. You’re 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 wasn’t ‘structural.’ Even though it felt like something was ‘out,’ that’s not really what was happening. I’d 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 don’t even know me that well are saying to me, ‘Hey, Elliott... you’re not twisting your neck around the way you used to!’ If you’ve got a stiff neck, I can’t recommend Paul Ingraham’s 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 don’t get much better than that.


Further Reading

What’s 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 what’s changed. This tutorial has gotten 38 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

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”?

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 don’t 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 it’s 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 “head-banging” — 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”?

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 that’s 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 can’t believe I didn’t 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 muscle-dominated 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? Here’s 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 don’t 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 doesn’t work. See section #5.17, Don’t worry (very much) about exercises to improve neck curvature, posture, coordination or stability.

Major update (Apr 20 '10, section #5.17)Completely overhauled and substantially expanded, and polished several relevant bibliographic records. See section #5.17, Don’t 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 don’t 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 Fernández-de-Las-Peñas et al, and another paper by Fernández-de-Las-Peñas 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 short-but-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.

    BACK TO TEXT
  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.” BACK TO TEXT
  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. BACK TO TEXT
  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.” It’s 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.

    BACK TO TEXT
  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. BACK TO TEXT
  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 isn’t exactly curing a lot of neck pain. It has “low to moderate quality evidence” that it’s helpful, compared to advice and exercise alone. BACK TO TEXT
  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. BACK TO TEXT
  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.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s 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. BACK TO TEXT
  9. Borenstein. Chronic neck pain: how to approach treatment. Current Pain & Headache Reports. 2007. As recently 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. BACK TO TEXT
  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 Cottrill’s excellent migraine blog. I do have a short tension headache tutorial. BACK TO TEXT
  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. BACK TO TEXT
  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.

    BACK TO TEXT
  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.

    BACK TO TEXT
  14. Bahr et al. Clinical guide to sports injuries. 2004. p106. BACK TO TEXT
  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. BACK TO TEXT
  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 the intensity of an extremely bad headache, but less than a full-blown migraine, child birth or rheumatoid arthritis. BACK TO TEXT
  17. And it’s a difficult choice even in possession of all the facts, since reassurance is almost certainly helpful. BACK TO TEXT
  18. Check all that apply. The more red flags you’ve got, the more worthwhile it is to ask your doctor if it’s possible that there’s 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. BACK TO TEXT
    • Benyamin et al. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. 2009. PubMed #19165300. BACK TO TEXT
    • 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.]”

      BACK TO TEXT
    • 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 world’s most successful back and neck pain clinicians, and in his writings independently develops essentially the same theoretical conclusions as Travell and Simons. Vancouver’s 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 world’s 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. BACK TO TEXT
    • 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). It’s always refreshing to hear medical experts honestly saying “I don’t 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. BACK TO TEXT
    • 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.”

      BACK TO TEXT
    • 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. BACK TO TEXT
    • Maigne. Manipulation of the spine. In Basmajian JV (ed): Manipulation, Traction and Massage, Baltimore: Williams & Wilkins. 1986. BACK TO TEXT
    • Hertling et al. Management of Common Musculoskeletal Disorders, p574.

      Darlene Hertling clearly elucidates Maigne’s 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.

      BACK TO TEXT
    • “Facet” is the easier but technically incorrect term for them. The proper term is one of the gnarliest in all of anatomy: zygapophysial joint. BACK TO TEXT
    • This is sometimes called a compression sprain, though it is not technically a “sprain” and cartilage doesn’t “bruise” because it doesn’t 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. BACK TO TEXT
    • 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 don’t resist movement. And they have to do this fast and in more less perfect harmony. It doesn’t always work out, and one error is all it takes. BACK TO TEXT
    • Indeed, they are so insensitive that only traumatic compression might actually cause a problem. BACK TO TEXT

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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