Neck Pain Treatment Guide (Advanced)

Introduction

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 evil stuck feeling. What makes a neck crick tick? What are the myths and controversies? What works, what doesn’t, and why? It’s detailed, highly readable, and constantly updated with clear explanations of the latest research.

Neck pain is an almost universal human experience. 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, 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 2011. 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,1 2 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 many footnotes here. Click to make them “pop up” without losing your place. There are two kinds: fun and boring. 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. Peoples lives can be almost ruined, if not shortened. 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! 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.

But the news hasn’t gotten out, and it 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 therapists fixated on neck posture.

This tutorial carefully debunks numerous 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 competent to treat neck pain or any other 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?

What would Adam & Jamie do? You know, if they were doctors?

I’m inspired by the MythBusters approach: I question everything and I have fun doing it. (No explosions, alas.) 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.

I’ve worked for over a decade to provide the best information about neck pain available anywhere — not just more of it, but better researched. 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. I do not sell miracle cures … just excellent information! There is a shocking 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 isn’t to tell you the “secret,” because there is no secret — it’s just to help you navigate the maze of medical uncertainty and contradictions.

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 a simply 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 significant 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 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.

Smells a bit too good to be true! Nerve pain “goes away on its own” when other neck issues are addressed? Come on! But this is about as close as I get to claiming that there is a miracle cure in this tutorial — and it’s not that all that miraculous. It simply won’t work for many cases. However, it does for some, and how cool is that? I have seen many cases of nerve pain almost magically back off as the health of the muscle tissue in the region is addressed, and this is why I chose to work with muscle professionally, and to write a lot about it: it gives good bang for your buck, for many reasons that will be discussed in detail.

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, the 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 in much detail. 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 together are extremely common, 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.

A neck crick is a subcategory of neck pain … a subcategory that is often not particularly painful, but instead is characterized 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 exactly 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 the 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 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, quite literally unable to function well mentally because their neck will not stop harassing them.

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 the thoracic joints appear to be nearly as prone to “cricking” as the cervical joints. Indeed, I developed a thoracic crick myself at T2/T3 in the spring of 2009, which turned into the worst I’ve ever had. Although greatly reduced after a concentrated treatment effort over the summer, it remains with me even now.

The low back, however, does not seem to suffer from cricks — not in the same style that the upper back and neck do, anyway. Perhaps some low back problems are a little bit “cricky” in some ways, but the classic crick sensation is typical only from between the shoulder blades and up.

Although it’s like comparing apples to orange cars, I often have the impression that irritating cases are more tragic than painful cases, causing more emotional distress — suffering — and mental preoccupation than pure pain does. 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!”

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 goes 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 very difficult to say how long a neck crick lasts, because the sky’s the limit. But, 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.

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 greatly relieved by simple rubbing of the muscle tissue around the joint. This is a wonderful 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, that client has now 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 was 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:

it’s been bothering you for more than about 6 weeks
it’s severe and/or not improving, or actually getting worse
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.

END OF FREE INTRODUCTION

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Free second tutorial! When you buy this tutorial, you will also get Save Yourself from Trigger Points and Myofascial Pain Syndrome! — a $1995 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, it’s too large a subject to cover properly here — so I provide SaveYourself.ca’s trigger point tutorial as an essential free companion to the neck pain tutorial.

1 Introduction
Science update Oct 26 '12 +
Science update (Oct 26 '12) — Added evidence that the stakes are high with chronic pain: it may even shorten lives.

1.1 Neck pain myths busted here!
1.2 How can you trust this information about neck pain?
1.3 Who exactly is this tutorial for?
1.4 And what about a pinched nerve?
1.5 What’s a “crick” in the neck, as opposed to neck pain?
2 Prognosis
What’s the worst case scenario for neck pain?
2.1 Three case studies of extreme neck crick horribleness
2.2 “What if there’s something really wrong with my neck?” Safety information!
3 Etiology
The (weird and unclear) nature of the beast
3.1 Why does a crick feel the way it does?
3.2 Subluxation: can your neck be “out”?
3.3 Another possibility: the feeling of stuckness without the fact of stuckness
3.4 Stuck! What limits your range of motion?
3.5 Could it be arthritis? Is your spine degenerating? Probably not, no
3.6 Is it a herniated disc? Does it matter? The herniation myth
3.7 Is it a pinched nerve? I doubt it! The nerve pinch myth
3.8 Does abnormal curvature hurt? Not much! The neck posture myth
3.9 Is it a strain? Probably not! The muscle strain myth
Science update Jul 04 '12
Science update (Jul 4 '12) — 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.

3.10 Is it a spasm? Nope, probably not a spasm either: the muscle spasm myths (plural)
3.11 The most important tissue issue in most neck pain: muscle
Science update Oct 24 '12 +
Science update (Oct 24 '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.

3.12 The case for myofascial trigger points as a major neck pain villain
3.13 From the frying pan of injury pain to the fire of trigger point pain
3.14 More about muscle malfunction: what’s going on in a trigger point?
3.15 A recipe for persistent neck pain — what are the risk factors?
3.16 Neck pain versus back pain: some interesting comparisons
4 Diagnosis
How do I know what type of neck pain I have?
4.1 How can I tell if there’s a pinched nerve?
4.2 Nerve blocks (medial branch blocks) as a method of diagnosis
4.3 A poke in the disc! Cervical provocation discography as a method of diagnosis
4.4 Estimating the importance of trigger points in your own case
4.5 “Out of nowhere”: seemingly random episodes of neck pain
4.6 A classic diagnostic sign: “I woke up with it”
4.7 Connections with headaches and migraines
4.8 Miscellaneous medical causes of neck pain and how to stop worrying about them
4.9 What happened to my barber? Neck pain powered by atlantoaxial instability
5 Treatment
What can you do for a crick in the neck?
5.1 Surgical options
5.2 Needles for neck pain: nerve blocks and related treatments
5.3 Anti-inflammatory medications: useful but not a solution
5.4 Is medication overuse a factor?
5.5 A tale of two tutorials
5.6 Introduction to treating your own neck trigger points
5.7 Basic self-massage for neck trigger points
5.8 The role of massage tools in neck massage
5.9 Can you damage neck nerves by self-massaging?
5.10 Heat and ice both provide good bang for buck, but err on the side of heat
Minor update Mar 08 '12
Minor update (Mar 8 '12) — Added some creative problem-solving for hot climates.

5.11 Avoid drafts at night
5.12 Mobilizations or “wiggle therapy”
5.13 Will stretching help neck pain? Much?
5.14 Pull my neck! The (unimpressive) potential of traction
5.15 Relaxation and the confidence cure
5.16 Don’t worry (very much) about exercises to improve neck curvature, posture, coordination or stability
5.17 Does balancing a ball on your head help neck pain? I know you were dying to know …
5.18 Ergonomics are probably more important than posture
5.19 Microbreaking
5.20 Pillow talk: the evidence about pillows is soft
5.21 Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints
5.22 Bracing yourself
5.23 The fascinating case of acupuncture
5.24 Reality checks: some popular treatments that don’t work at all (or not nearly as well as you would hope)
6 Executive Summary
All the treatment options summarized
7 Appendices
7.1 Supplements and downloads
7.2 Acknowledgements
7.3 Reader Comments
7.4 Further Reading
7.5 What’s new in this tutorial?
7.6 Notes

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Part 3.2

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 cricks 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

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.

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 30 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

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.

Product upgrade (Jul 30 '12) — PDF versions of all SaveYourself.ca tutorials are now available. They are ideal for printing and offline reading on e-readers. The online version will always be the “real” version (guaranteed current) and the best way to read the books, but fresh PDF copies will always be available to customers. Announcement on my blog: Finally! PDF versions of my books, and the “technologically interesting” story of how they were made.

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 #5.11) — Added some creative problem-solving for hot climates. See section #5.11, Avoid drafts at night.

Minor update (Dec 14 '11, section #5.18) — Added a minor but odd note about “sensory annoyances” like hats and collars. See section #5.18, 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.

Updated (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 #5.13) — Cited a study about yoga and stretching for back pain. See section #5.13, 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 #5.14) — I can’t believe I didn’t know about inflatable neck extenders until now! See section #5.14, Pull my neck! The (unimpressive) 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 be cleaned up in general, paving the way for efficient conversion to other formats (Kindle, Apple’s iBookstore, etc). Best of all, it is now 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 #5.21) — New artwork from SaveYourself.ca artist Gary Lyons, plus some important new references. See section #5.21, Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.

Updated (Oct 6 '10, section #5.13) — 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 #5.13, 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. The update was inspired by new science on the (significant) risks of spinal manipulative therapy, and by Sam Homola’s excellent article at ScienceBasedMedicine.org, Chiropractic Vertebral Subluxations. 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 #5.24) — Updated with a summary of a bizarre experiment with muscle relaxants that had quite surprising results. See section #5.24, 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 #5.16) — Uupdate with another recent study showing that strength training doesn’t work. See section #5.16, Don’t worry (very much) about exercises to improve neck curvature, posture, coordination or stability.

Major update (Apr 20 '10, section #5.16) — Completely overhauled and substantially expanded, and polished several relevant bibliographic records. See section #5.16, 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 #5.24) — Added an interesting reference about how muscle relaxants are surprisingly ineffective. See section #5.24, 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.

Save Yourself from Neck Pain!

All your treatment and self-help options for a crick in the neck explained and reviewed