The Complete Guide to Neck Pain & Cricks

The science of neck pain is undeniably limited, and the science of “crick” sensations specifically is nearly nonexistent.

“The neck is rife with structures that potentially could and probably do cause various painful conditions.”

Janet Travell, David Simons, and Lois Simons, 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 in a variety of ways.

My preferred general explanation49 — not necessarily correct or nuanced enough, but the most useful simplification — is the idea of “minor intervertebral derangement” (MID).5051 A MID is basically a minor mechanical glitch 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. Aging, arthritic joints are probably more vulnerable to MIDs. People who are generally more pain sensitive and/or fearful are also probably more vulnerable to them, and might struggle with a MID that wouldn’t bother someone else at all.

Here are some possible specific examples of MIDs:

• Compression sprain.There are a pair of small, dime-sized joints on either side of every intervertebral joint, the facet joints.52 Their cartilaginous surfaces can be “bruised” when compressed, somewhat like a thumb jam.53 This might happen if you “zigged” when you should have “zagged” — a poorly coordinated movement of the neck.54 Minor compressions of this sort are probably common and mostly painless. Joint surfaces are not especially sensitive to pressure.55
• 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 cartilage, synovial membranes (the lining of the joint capsule) are quite 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” can constitute a minor MID.56
• A nerve pinch. Although less of a problem than most people suppose (much more about this later), irritation of nerves is 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 “alarm” is a big part of what makes things painful, as much as damage.

None of these examples necessarily involve an on-going mechanical problem with the joint — they are all just transient painful disturbances. In most cases, the persistent feeling of a crick is probably not a product of a MID itself, but of its consequences: the irritation of the MID itself could quickly die down, and then replaced by a variety of neurological and muscular reactions.

More to come on the nature of the muscular reaction — it’s the most important idea in the 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 some kind of a mechanical failure of the neck joints, especially the idea that they are “out” of place in some sense. Does that hold up?

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by Gary Lyons

A defining feature of cricks is that something feels out of place or jammed. An “intervertebral derangement” (see previous chapter) is one way to explain that sensation. A “subluxation” is another, much more popular concept.

Spinal joints can get into a few different types of trouble, but “subluxation” and spinal joints being “out” are not defined clearly enough to be useful, and are 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. Many chiropractors attribute great importance to subluxation. Most believe, at the least, that subluxations cause neck and back pain, but — significantly — quite a few of them also believe that subluxations 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, 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 separate article. 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 extremely similar ideas?

Yes, they are. When reader J.B. asked this question, I thought perhaps I’d been caught in a glaring inconsistency.57 Lucky for me, there are some clear differences, and I think exploring them is helpful. Although the chiropractic idea of “subluxation” is a mess, it does have two defining characteristics that have been consistent over the decades:

1. the idea of joints being “out”
2. the idea that they mainly matter because their out-ness has a deleterious effect on nerve roots

The notion of a MID is similar to the first, but avoids the second completely.

Here’s another, trickier difference: chiropractic subluxation is mostly seen as a persistent pathological state of the joint. That is, the joint gets messed up and then stays that way up until “adjusted,” allegedly something that can be identified by feel or seen on an X-ray. (Unfortunately, like dowsers and psychics, chiropractors have trouble demonstrating these skills in controlled tests.585960 So that’s a bit awkward.)

In contrast, a MID is a transient mild trauma — an incident with painful consequences, not a persistent state of affairs. That’s the important distinction.

There is some conceptual overlap. For instance, if you do give yourself a little compression sprain of a zyapophyseal joint, ow, it’s plausible that the consequences would include not just the initial irritation but then also some persistent joint dysfunction: the nervous system trying to move the spine without further compressing the irritated surfaces.

So yes, MIDs and subluxations are indeed similar. But MIDs are a more “humble” concept: just a little injury that probably explains some neck pain, not the holy grail of health, or even spinal health.

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So far in this part of the book we’ve talked about the murky origins of neck pain in general, and two ways of trying to explain the more specific sensation of stuckness, the MID and the subluxation, both referring to some kind of joint dysfunction. And there may indeed be such a dysfunction, a “mechanical” crick. But another fascinating, plausible possibility is that the crick sensation may be where the explanatory buck stops: that is, maybe the joint just feels stuck.

Pain distorts body image — our mental image of our own anatomy. An odd little 2008 paper demonstrated that people with back pain really feel like their vertebrae are deviated to the painful side even when they aren’t.61

This phenomenon could be important. We are used to more or less trusting our sensations. If it feels out, we assume it must be out. But it ain’t necessarily so: sensation can be incredibly deceptive. This could be the main reason for the stuck, janky quality of crick-ish neck pain. Its illusory quality doesn’t make it any less of a problem, of course: there’s still something wrong that’s powering the illusion.

Sensation is impressively sensitive and potent:

• Consider how sensitive we are to the presence of a grain of sand between our teeth: the tiniest obstruction, and we are fully and uncomfortably aware 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 it!
• Or consider how irritating it can be for our freedom of movement to be limited. The feeling of needing to stretch after being stuck in an airline seat can be almost overwhelming.

These hair-trigger sensations are powered by a rich sense of position and movement (proprioception, the “sixth sense”), and by a basic physiological need to constantly stimulate all tissues as a basic use-it-or-lose-it requirement of life, essential to health. 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 in 2004). Thus we are programmed to detect and respond strongly to the slightest stagnancy. And this is, in a general way, probably how a joint can be so uncomfortable without actually having anything obviously “mechanically” or even functionally wrong. And even a tiny bit of joint “stuckness” is probably obvious to our nervous systems, just like a grain of sand between teeth.

This could all occur without the slightest visible, palpable or X-rayable problem.

And so, we can almost certainly feel “out” without being “out.” But what about the scenario — routine in neck cricks — where you literally can’t turn your head? That’s a common feature of neck pain, and it certainly seems like more than just a feeling of stuckness.

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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 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 all felt really stuck. And I’ve been stuck that way too.

Many cricks only involve a minor, subjective sensation of stuckness without any literally limited ROM — uncomfortable but full movement. Others are more truly stuck: a genuinely limited range of motion. This often involves relatively little pain, and it is in such cases that the feeling of stuckness is usually the most vivid. 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 …

Sometimes professionals need to experience things to learn about them. Once upon a time, I believed that all neck cricks could probably be explained by “muscle spasm” and resolved with massage. I was inexperienced and overconfident. I had not yet grappled with the unsettlingly huge variety of experiences that people have, and the complexity of the underlying physiology. To wise up, I needed to have an interesting experience with one of my own cricks …

One day I woke up with a neck crick that simply would not respond to massage. I couldn’t relax out of it, not even a little bit. Almost immediately, the theory that it was a muscle spasm seemed deeply wrong. I felt like there was a loose bolt in my gears. It was extremely irritating, but not especially painful.

After two days of aggravation, I received a tractioning treatment, a simple procedure in which the neck is elongated like a Slinky, gently pulling the vertebrae apart. I felt a small pop in my spine — just a tiny little pop, like popping a pinkie-finger knuckle — and I immediately felt a visceral certainty that something quite wrong had suddenly and completely been put right.

And it had: the discomfort in my neck was gone, with only an echo of the muscular reaction left behind: a mild soreness that was trivial compared to the full force of the crick.

Something had been truly “stuck.” Apparently.

This experience changed my tune about mechanical joint dysfunction. Clearly there are cases where something gets stuck, in some sense, and getting it un-stuck works like a charm, if only it can be achieved. Just as clearly, not every case is like this. I have had several more minor cricks since then, and not a single one of them has responded as neatly and obviously to a little joint pop. Each time, I optimistically attempted the same simple therapy … but never again have I felt the same satisfyingly instant, complete relief. This also reflects my clinical experience. Few neck pain patients have ever described an instant-relief scenario to me.

What would cause “stuckness”? What’s actually stuck or jammed or out of place? No one really knows, but here are some of the possibilities:

The unpoppable facet joint. Some people can pop their knuckles, and some people could but don’t because they find it unpleasant, even alarming. If you are willing to pop your knuckles, try this experiment: slowly flex your knuckles until they are just about to pop. Then, as they pop, you will notice that your flexion suddenly goes further — an extra 10˚ or 20˚ right after the pop. The popped knuckle actually has a greater range of movement than the unpopped knuckle. Presumably, the same thing happens with the knuckle-like facet joints of the spine, and yet sometimes you can’t (easily or at all) pop facet joints. They are not as conveniently manipulated as knuckles. You can’t always use brute force to pop them.62 There may be cases where you feel like you “need” to pop a facet joint, but you can’t: you approach the end of the range of motion of the joint, but you are either unwilling and/or unable to pop it to achieve that extended range. In either case, it may feel like an uncomfortable mechanical limitation. The irritation may magnify the effect: the actual limitation could be quite small. Or it could be larger in some cases.

Neurologic inhibition (or nerves telling nerves not to fire). Your brain may be “afraid” to move the joint, for some reason, real or paranoid. For instance, this could occur in the aftermath of a MID. If you have slightly traumatized tissue, your brain may simply refuse to allow you to put stress on it. Nerve signals simply shut down the musculature as you move the neck into the danger zone. Most people find that they can “push it,” but the movement has become indecisive and weak — stuck — and pain sharply increases.63

Subluxation. I lean away from subluxation theory (as discussed above), but I don’t dismiss it entirely. Perhaps subluxations exist in an overt form in a minority of cases. Perhaps a good scientific experiment (which has never been done, as far as I know) would show that people experiencing severe cricks and limited range of motion also consistently have an intervertebral joint that really is “out of place” — jammed at an odd angle, preventing normal movement.64 But you’ve got to keep in mind that chiropractors have failed many tests of their ability to reliably identify subluxations by any means, especially by X-ray and by feel (references provided in the main discussion of subluxation) — and if they can’t identify them, they mostly can’t treat them, even if they do exist.

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If five bees stung you all at once, in one small area on the back of your neck, you would probably think you had been stung by one super-bee. Or maybe that you’d been poked with a cattle prod.

Two sources of pain close together are often felt as one larger painful spot, a neurological effect called “spatial summation.” Pain perception is low resolution and fuzzy, and the brain can merge pains that are up to 20cm apart. Exactly how far depends on many other factors.

There are two ways that this might explain why some areas of the body, like the neck and back, are such common places for people to hurt:

1. Maybe the brain can “sum” more widely spaced sources of pain in some places than others.
2. And/or some areas simply have more to sum up, more potential sources of pain.

The first possibility was probably eliminated just recently, by a 2017 study which showed that we have roughly the same perceptual “resolution” for pain everywhere in the body.65 Researchers compared summation in the neck and back to the extremities, and found that it works about the same way: in any area, pain sites as far apart as 15-20cm will be added together by the brain. So the spine is probably not a common trouble spot because we cast a wider summation net there.

This makes it even more likely that there’s probably just more sources of pain in the neck to add up. Spines are super complex anatomically; there are many potential sources of tissue irritation that can be perceptually fused.

For example, if you have one cranky facet joint on the left side of your third cervical vertebra, and another on the right side of your fourth, you might not be able to tell them apart. All you know is that the middle of your neck hurts — and hurts worse than you’d expect from any one minor problem. Because there actually is more than one minor problem. It just feels like one larger problem instead of two lesser ones.

That would also explain some of the chronicity of spinal pain in an elegantly simple way: if you have “one” neck pain problem that’s actually coming from two places, you’re going to think you have the same neck pain problem until both problems calm down … which is inevitably going to take longer than one. If the cranky left C3 facet joint recovers quickly, but the right side facet at C4 carries on twinging, you might not even notice a difference except a drop in intensity and perhaps a shift to the right (and such changes are quite characteristic of neck pain). Two problems with similar locations but different durations could well feel like one longer-lasting problem.

And if you have 4-6 minor sources of discomfort, all constantly easing and flaring up randomly, at least a couple of them active to some degree at any one time? That will probably just feel like one endless pain in the neck with erratic changes in intensity, and an epicentre that drifts around a bit. And that’s going to sound familiar to a lot of neck pain patients.

Paintballs not tumours: the problem of cryptic insults

Brains are not dummies (despite widespread evidence to the contrary): if you can clearly see that you’ve been struck in the chest by two paintballs, 10cm apart, your brain is not going to foolishly assume that you’ve been walloped by one harder paintball strike. The evidence is painted right on your chest, and a brain will use that visual data to achieve higher fidelity perception. Two owies! Not one.

But what if both of them hit you simultaneously in the centre of your back, where you cannot see two splashes of paint? Where there’s no visual data to clarify the situation for your brain? Then you probably will think you got nailed by one paintball from 15 feet away instead of two slower ones from 30 feet away.

“Cryptic insults” sounds like something from a Monty Python sketch.66 But I mean threats to tissues that we can’t see or understand from context. It’s much harder for the brain to know if there’s one or two sources of pain when it can’t see what’s going on, literally or figuratively. It’s also much harder to judge their significance. Internal sources of pain are mostly cryptic, of course. The pain system is all about threat assessment, which is much easier when the cause is obvious from sensory clues and context: “Oh, that’s just a paintball, not cancer!”

But if you have no idea why you’re stinging? Brains tend to assume the worst. The pain system is fine tuned by hundreds of millions of years of animal evolution to err on the side of louder, longer alarms. When in doubt, evolution says, better safe than sorry. Taking tissue insults seriously is a winning strategy for the species. It’s worth the cost of a few false alarms.

It’s extremely likely that a huge percentage of neck pain consists of multiple relatively minor problems being neurologically smushed together into a larger, nastier pain than is really justified. File under “good to know.”

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One of the most common beliefs about all kinds of spinal pain is that it is mostly caused by arthritic degeneration of the spinal joints. But neck pain is extremely common regardless of age. If arthritic degeneration were the major villain in neck pain, or even a significant contributor, then neck pain would steadily get significantly worse with age.

But there is just no such clear pattern! Many young people have severe neck pain, and many older people have little or none.

Surprisingly, even disease-driven erosion of cervical joints can be painless. Rheumatoid arthritis — a nasty disease, quite different from garden variety “wear and tear” osteoarthritis — commonly attacks the joints of the neck, causing significant deformity of the joints (not all varieties of rheumatoid arthritis damage the joints in this way). Although this does often cause severe pain, it doesn’t always: Younes et al found that 17% of 29 patients were completely asymptomatic, even with substantial joint damage.67 In 2015, Brinjikji et al found that 37% of 20-year-olds had disc degeneration without symptoms, and a whopping 96% of 80-year-olds did — so almost everyone! The stats were similar for other degenerative signs like disk bulges and annular fissures (“aging cracks”), all extremely common in people with no pain at all:68

Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.

Of course the truth is in the middle. Degeneration isn’t completely irrelevant to pain! Fascinatingly, the same researchers that brought you that data also published another paper to make exactly that balancing point: degenerative features visible on MRI are nevertheless more prevalent in older adults with pain compared to those without.69 It’s just not nearly as strong a link as everyone assumes, and that is very important to know.

I have a lot of mostly painless arthritis in my own neck

Although I have episodes of neck pain — which is one of the reasons I wrote this book — they do not appear to be much related to the sorry state of my joints shown on a 2015 MRI. My 5^th and 6^th cervical vertebrae are cluttered with growths of extra bone: bone calluses, basically, projecting into the main spinal canal and the exit canal for a spinal nerve root. The joint is arthritic! In fact, it’s quite arthritic, since at least age 43 (though the problem is likely older). The radiologist called it “severe,” and it looks that way: there’s no wiggle room left for my spinal cord or that nerve root. The spinal cord isn’t actually impinged, or only just barely, but the nerve root almost certainly is.

No wiggle room!

MRI image of my own neck at age 45, showing obvious stenosis of the spinal canal at the C5/6 level, but also asymptomatic as far as I can tell. Spinal cords are not necessarily bothered by minor impingement. Click to embiggen.

Despite my deep knowledge of this problem, I was still intimidated by that description — “severe” is not a word you want to see on any radiology report, especially one about your neck. I spent at least a couple weeks boning up on myelopathy symptoms and hypervigilantly monitoring myself. Fun! But even though I know it’s been like this for at least a year (from a previous scan), I’ve never had any symptoms of either radiculopathy (nerve root pinching) or myelopathy (spinal cord pinching). I may in the future, as many people do.70 But for some time now it’s been an example of how arthritic spines can be painless. About 5% of people with no symptoms at all have detectable spinal cord compression.71

Such examples are common and represent the strong pattern with most “structural” problems: the body tolerates minor adversity quite well, and they are usually less of a problem than people fear.

In the back, the spine is often seen as being “fragile,” and my low back pain tutorial goes to great lengths and presents an extraordinary amount of evidence that the back is not actually fragile at all — it is the centerpiece of that tutorial — and that even major structural problems in the lumbar spine are often not painful. The same concern exists with the cervical spine, but requires less rebuttal, because patients are usually less concerned about “fragility” in the neck. (Also, there’s just less evidence to discuss: the question has been very well-studied in the low back, but less so in the neck.)

But this other guy has painful arthritis in his neck… with a twist ending!

This is a fascinating, expectation-defying case report from a colleague of mine, Paul McCambridge, a particularly progressive and admirable chiropractor in the UK. This is about his own neck, not a patient’s. His MRI looks a lot like mine (above), but more dramatic. I have edited his story into a smoother read for this context, but you can also see his original Facebook post.

Paul had vivid neurological symptoms in his left arm — and keep in mind that it was the left arm, an important detail. The problem got steadily worse over a few months. He suffered from constant tingling, buzzing, and numbness in his left hand. It was weak in certain positions. And the pain was nasty, sometimes “excruciating.”

He did all the sensible things. He is an expert, after all. He knows what the prescription is for this kind of thing — not just the conventional wisdom, but everything that integrates the more modern perspective on pain. But none of the usual options helped. He just got worse.

Paul teaches the same ideas I do here. In telling his story, he brought up some of the same citations I have already used in this chapter; he knows that many people have necks that look screwed up but don’t have any symptoms at all. But he also knows that if you do have symptoms, and things keep getting worse, eventually you have to climb into a scanner to see if there are any important clues in there.

So he did that. His MRI showed a classic and significant narrowing at C5/C6, exactly what you might expect based on his symptoms. Textbook. He actually had a badly pinched nerve.

Paul had a strange reaction to the radiologist’s report: it made him laugh out loud. Because the nerve pinch… was on the right side. The wrong side.

The degeneration and compression was much more pronounced on the right side of his spine, but his right arm was completely fine. All of his symptoms — his severe symptoms! — were on the left. And yet the left side of the spine was in relatively fine and dandy condition.

“How difficult it must be for patients to make sense of their pain,” Paul wrote. “If injection or surgery was to be considered, do you address the symptomatic left side, the asymptomatic but structurally worse right side? Or what? Pain is weird! 😂”

Pain is weird indeed. In case it’s not obvious, here is the moral of this story: the condition of the spine is not the only factor in whether or not there’s pain, and probably not the most important factor either.

There surely is such a thing as straightforward spinal arthritis with neurological consequences. There must be. But the longer I do this job, the more I think that such cases are quite rare. Expect the unexpected — do not expect tidy relationships between structure and symptoms.

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What most people think they know about discs in their spine is that they painfully herniate or “slip.” And that’s at least partly true — they do herniate. And when they do, they certainly can hurt, causing many symptoms.72 In rare cases it can be severe. One unfortunate patient was temporarily paralyzed when his disc herniation was aggravated by the position his neck was placed in for an MRI scan to diagnose his problem.73 Don’t worry, he recovered! He was back to normal just a few weeks after surgery. But the incident is an exotic worst-case scenario to make the point: almost anything is possible when an intervertebral disc pushes far enough out of place.

But herniations do not normally cause the symptoms of chronic neck pain. Instead, they mostly cause “nerve root pain” in the shoulders and arms, or a distinctive combo of pain plus other neurological symptoms like weakness and tingling. So the main herniation myth is that disc herniations are a major cause of chronic neck pain. They are not. Although a real problem, they don’t have much to do with most neck pain cases, even chronic neck pain.

The secondary myth is that disc degeneration is a major cause of neck pain. But bulging and fraying and tearing are all mostly asymptomatic, and even many actual herniations are painless as well.

Just seeing a herniation on an MRI is almost meaningless. MRI results on their own, without considering symptoms, are notoriously useless or worse. They are unreliable to begin with — you can easily get different “results” from different radiologists,75 though some are clearly better than others76 — but even verified results are often seriously misleading. False-positives and false-negatives occur “rather frequently,” Kuijper et al wrote in 2011. They looked at 78 scans of people with nerve root compression symptoms but, in many cases, herniations in the “wrong” place or not at all.77

The classic diagnostic disaster is that a patient may have a disc herniation that is not the real source of her pain, but the herniation is falsely accused just because it’s an abnormality visible on an MRI. Most patients, when presented with the impressive high-tech evidence of an MRI picture, find it impossible not to fear it. When you can point at something on a scan and say, “That’s in the wrong place!” the temptation to blame that thing for your pain is overwhelming.

This is a bigger topic in the low back tutorial. Disc herniation in the neck is much less common than it is in the low back, for obvious reasons.78 More importantly, low back herniations are feared far out of proportion to their real seriousness. In my decade treating low back pain as a massage therapist, I met only a handful of patients who arrived at my office already educated about this; most were really not aware that an MRI can be misleading and herniations are about as worrisome as an ankle sprain.79 The trend has continued by email in the years since then: a steady supply of it from readers around the world who have not gotten the memo either.

Evidence that disc bulges and herniations aren’t very scary

Find a hundred happy people without neck pain. These are people who do not have your problem and (even more importantly) never have had your problem: asymptomatic volunteers with completely good necks, happy to stick their head in a big magnetic tube for the sake of scientific curiosity. Guess what? A stunning seventy of those volunteers will turn out to have “annular tears and focal disc protrusions” — not full disc herniations, but the beginnings of them.80

But that number is low, if anything. A much bigger 2015 study, the first big one of this kind for the neck specifically, found bulges in most (90%) of 1200 people without any pain! Even young people are bulging: although bulges were more common in older people, an incredible 75% of people in their 20s had bulges.81

That’s an awful lot of “deformity” without pain. It’s so much that we might even conclude that a little bulging is just a normal state of affairs for intervertebral discs.

And yet many neck pain patients will be overconfidently told that such bulges are the source of their pain. And — more insiduous — many patients will worry about it even if the physician tries to encourage them not to worry about it. Health professionals often underestimate how easily patients are alarmed by hard evidence of a “tear” or “protrusion.” To the average person, if something shows up on a scan, that’s it: it’s gotta hurt. But the evidence clearly shows that it usually does not.

On the other hand, when an MRI shows signs of inflammation around a bulge — increased “signal intensity,” because swelling and inflammation are “reflective” in MRI — that usually does indicate pain. You don’t see much inflammation in people without pain: just 2% of the 1200 folks studied by Nakashima et al. So it’s not that a bulge can’t be associated with pain, it’s just that it usually isn’t.

Actual disc herniations — as opposed to just little bulges and cracks — are relatively rare in asymptomatic volunteers. When a disc truly herniates, it often does hurt. But less often than you’d think. In 2006, D’Antoni and Croft reviewed a handful of studies of this — there aren’t all that many — and concluded that somewhere between 3% and 20% of people without symptoms have disk herniations. So we don’t know exactly how many people with disk herniations are fine, but we definitely know it’s “some,” maybe even quite a few.82 And for every painless case, there are probably twice as many with only minor symptoms.

Herniations are rare to begin with

Herniations usually don’t happen without a trauma,83 often an accident of the sort that sends you to the hospital. So, again, we see that disc herniation plays little or no part in the common chronic neck pain that has no obvious cause. And yet most people are strangely prone to suspecting the consequences of a serious injury without having had an accident! It’s common to see patients speculate about how they hurt themselves. Pro tip: if you have to guess, you probably didn’t hurt yourself badly enough to matter. If your neck hasn’t been suddenly subjected to some nasty forces — an accident causing immediate, severe pain and distress, what we refer to in medical science as an “oh, shit!” moment — then you probably don’t have a herniated disc.

So it’s not that disc herniations are unheard of in chronic neck pain patients, it’s just rare to have a bad one without having noticed the moment of injury (in a big way).

Herniations also heal

Chronic neck pain, by definition, does not go away. Herniations often do: the herniated material is actively absorbed by the body back into the spine.84 They heal, in other words — they may not heal perfectly (for instance, the disc might remain vulnerable to reinjury, like a ligament sprain) — but they do heal, and fairly quickly. Thus we have yet another scenario (there are several like this presented throughout the tutorial) where, even when an injury actually occurs, it’s fairly unlikely to be the cause of chronic pain. An injured patient might well be able to say in the months after a diving injury that they have a herniated disc problem, but after many more months or years it becomes increasingly likely that the disc isn’t really the problem any more, and hasn’t been for a long time — other forces and factors have taken over, and continuing to think in terms of a “disc herniation problem” is no longer meaningful.

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You could have a pinched nerve. But there’s an excellent chance you don’t. Science says so!

This is one of the most common and understandable concerns that people have about pain near any part of their spine, especially the top and the bottom of it, but it is also one of the most overblown of all common medical fears.

For all the reasons discussed above (and more below), the pain of a pinched nerve in the neck is less common than most people think, both patients and pros. Many other common causes of pain and altered sensation routinely fool patients and professionals alike into suspecting “some kind of nerve problem.”

And a large percentage of that so-called neuropathy is probably coming from muscle, and is relatively treatable.

Nerves are notorious

I once had a nice older Italian client who would ask me, over and over again, in a thick, sing-songy Italian accent, “So, it’s-a nerve, eh?” No, I would say, it’s probably just a muscle knot, not a nerve. And then — as if we’d never discussed it — five minutes later he would ask again, “So, that’s-a nerve, eh?” He was obsessed with nerves!

Like everyone else is. Sometimes it seems to me as if modern civilization is still getting used to the whole idea of nerves. When people talk about their nerves, it’s like they’re talking about something just revealed by science early last year. They speak with some awe about something barely understood … and feared. Nerves! It could be my nerves!

Nerves just make people nervous. The whole idea of nerves gets people anxious. Could it be a nerve? people are likely to wonder of any puzzling pain. Is this a nerve problem? What if it’s a nerve? Is something pinching my nerve? Something must be pinching a nerve!

The idea of a pinched nerve root particularly is deeply embedded in the public consciousness, thanks to decades of excessive emphasis on the idea in both mainstream and alternative medicine. The aggressive, fraudulent marketing of anticonvulsants is a spectacular and fresh example,85 but chiropractors have promoted this kind of thinking consistently for over a century.86 And now many people think they can hardly get out of bed in the morning without pinching a nerve root.

Nerve roots actually have a lot of wiggle room

It’s surprisingly difficult to pinch nerves! And, even when you do, they are usually surprisingly unbothered by it.

Even the exposed “funny bone” nerve (the ulnar nerve) only hurts when you hit it pretty hard. And people turn their heads painlessly all the time — even though the movements of the vertebrae in normal activity are much more dramatic than the minor subluxations that some chiropractors allege are pinching nerve roots. This is because nerves are typically only sensitive when they are oxygen starved.87 The problem is the vulnerability, not the pinch itself.

Blaming minor nerve pinches for pain is like putting salt in a cut and calling it a salting injury.

To painfully pinch a healthy nerve root as it emerges from the cervical spine, the large hole it passes through has to be significantly narrowed and the nerve has to be significantly oxygen deprived, or otherwise vulnerable. Therefore, you are quite unlikely to have a pinched nerve root for these reasons unless you are at least sixty years old, and/or you’ve recently had a major accident.

And so “pinched nerve pain” is much more rare than other kinds of neck pain, at only 40 to 80 new cases per 100,000 people per year.88 That’s no more than one chance in about 1200 that you’ll get nerve root pain in a given year … easy odds to beat for your whole life! Furthermore, I believe that these figures are probably inflated,89 simply because nerve pain is over-diagnosed: referred pain from muscle knots in the neck is probably routinely mistaken for nerve pain.90 More about this below. Even among people who get tested electrodiagnostically — in people suspected to some degree of having nerve pain, or they wouldn’t be getting tested — only 6% actually turn out to have true nerve impingement.91

The idea that joints can be “out” (already debunked) often intersects with nerve-pinch fear. One of the premises of chiropractic care is that joints can be so far out of whack that they can pinch nerve roots, but this is anatomically impossible. Sam Homola, a chiropractor critical of many practices and ideas in his own profession, describes an experiment in which a dissected spine is mangled by machinery in the attempt to discover just how far you have to bend a healthy spinal joint before its nerve roots are impinged. The answer? Really damned far — you have to bend a spine way beyond its normal limits, severely damaging other joint structures long before you can pinch anything. The holes through which nerve roots exit the spine are quite generous, lots of wiggle room, not at all a tight fit — which makes perfect evolutionary sense, because what animal could thrive in the wild if it was prone to nerve pinches with the slightest misalignment of the spine?

Schematic of nerve root wiggle room

On the left are the approximate proportions of a healthy nerve root & the hole it passes through. When the spine is pulled or compressed, the holes get a little larger or smaller, as shown on the right … but there’s still lots of nerve root room. Click to embiggen.

In the lumbar spine — larger, but similar proportions — the holes between the vertebrae that the nerve roots pass through can be more than a couple centimetres at their widest, while the nerve roots themselves are only about 3-4mm thick.92 If you stretch or compress the spine, the holes do change size a little — as much as 70–130% in the looser neck joints,93 a little less in the low back.94 But even at their smallest, there’s still plenty of room.

“That’s gotta hurt” — but not necessarily

There’s so much space for nerve roots that even traumatic dislocations routinely fail to cause impingement.95 Only significant injury or diseases can result in a seriously pinched nerve root … and often not even then. The patient pictured here, as reported in New England Journal of Medicine, had no “pain, weakness, or parasthesia”!96

If this doesn’t pinch, what does it take?

Click to embiggen. Although this was a serious cervical spine dislocation, the patient was quite healthy & had minimal pain & no neurological symptoms at all. See Akhaddar.

Another case report in the journal Spine describes a man who was born with part of a neck vertebra entirely missing — he also had no serious symptoms until he fell one day, and his unstable spine was dislocated.97 After that he certainly was symptomatic: he had severe pain, but only pain, and no neurological symptoms. No nerve pinch.

I have seen hundreds of cases of people who have been told that their spines were “out,” but only a handful actually had any nerve pain in my opinion, and even that was usually minor. The few neck pain patients who do have serious nerve pain rarely end up in my office: they go to the doctor, because serious nerve pain usually feels like more serious medical business.

So you probably don’t have nerve pain. Just in case, though, there’s a section below devoted to identifying the symptoms of a nerve pinch, so you can confidently deal with this concern.

Nerve pain and sensitization

There are several mechanisms by which nerves can become pathologically over-sensitive after an initial insult, causing the pain to drag on and on. For a long time, no one had any idea why this happened to some people and not others, and it really does seem to be a binary phenomenon: either it happens or it doesn’t. Unfortunately, one likely explanation was identified in 2010: genetics.98 That is not great news, but it is interesting and at least a little bit useful.

So chronic pain could be due to on-going irritation of nerve tissue, but it could also be entirely due to a malfunction of the sensory equipment itself. A fascinating possibility (and a rather bleak one).

The point: be wary of therapeutic wild goose chases looking for mechanical causes of pain. Neuropathy is definitely not just about pinching. The extended suffering could be caused by continuing irritation of a nerve root, or it could be entirely due to a malfunction of the sensory equipment itself.

The relationship to trigger points

If nerve pain is more about biological nerve vulnerability and poor health of tissue around them than physical irritation, what does that say about the role of trigger points? Maybe they are just another symptom of poor tissue health, or could they be a form of “poor tissue health” themselves. Could a nerve passing through/near muscle tissue rotten with trigger points be affected by that? I’m not sure how plausible it is, but it’s not inconceivable.

Maybe this is why treating trigger points sometimes seems to alleviate actual neuropathy.99 If so, it’s yet another way that a back problem that seemingly isn’t about muscle may nevertheless be helped by treating muscle. In this articulate passage, Clair Davies, author of The Trigger Point Therapy Workbook (my review), discussed patterns he observed in private practice as a massage therapist. My experience has been similar over the years …

Interestingly, almost all the people who came to me had some kind of back pain along with whatever other pain complaint they had. Their previous treatments for back pain had always focused on the spine. I heard about injections of papaya or cortisone. People had usually been told they had arthritis or bad disks, or that their cartilage had been worn away. They’d been shown X-rays [or MRIs! — PI] that purported to prove it. Some had already had surgery, and frequently had as much pain after surgery as before. Typically, the surgeon’s last word was always that he was sorry but he’d done all he could. Then he’d renew their prescription for painkillers and dump them off on a physical therapist. I heard these stories over and over again. And over and over, I found that trigger point therapy gave them the relief they’d been seeking for so long. Had trigger points been the problem in the first place? Arthritis? Bad disks? In Travell and Simons’ Myofascial Pain and Dysfunction, I had read that you can have herniated discs and arthritis of the spine and still find that myofascial trigger points are the primary cause of your back pain.

The trigger point therapy workbook, by Clair Davies, p. 13

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As discussed above, it is common for health professionals to blame weakness, curvature, posture, and coordination in the cervical spine — the “neck posture hypothesis,” which has reached its ultimate fear-mongering form in the bogus epidemic of “text neck”: neck pain allegedly caused by constantly looking down at a smart phone to type text messages. Both Richards et al and Damasceno et al have provided good evidence that it’s probably a silly thing to worry about,100101 although it’s worth noting that the effects over many years have not yet been studied, and that might be what matters most.102

What is this “normal” neck posture we may be deviating from anyway? And is too much or too little curve in the spine the cause of pain … or a reaction to it? As Gay wrote in 1993, “a wide range of normal exists in the posture and configuration of the cervical spine,” but “prognostic significance of these variations is claimed by some authors.”103

Certainly the Amazing Owl Man isn’t normal! You don’t see this every day. Enjoy this campy, cringe-inducing bit of news reel about a dude who can “owl” his neck — rotate 180˚ degrees! — if we can believe our eyes:

What are we to make of this? Is this anything more than an eye-popping novelty? I have no idea how he can do that, but can I extract some clinical relevance from it anyway? Natürlich! The man has an outrageously abnormal neck … and no symptoms. And yet we are to believe that slightly bad posture is the cause of dire pain? Shouldn’t someone like Owl Man here be crippled? It’s an absurd example, but there are many more ordinary ones … like the much more straightforward example of the stooped elderly person with obviously awful neck posture, but no particular neck pain.

I have known many patients who were given countless hours of tedious coordination and “neck stabilization” exercises — “core” strengthening for the neck, basically — to fix their allegedly dysfunctional neck posture. Many of them spend years trapped in the belief that their neck pain is due to neck laziness, which can only be repaired with diligent exercise.

The “should” of all that tedious therapeutic exercise hangs over them like a dark cloud.

And yet it seems obvious to me that many people with unusual neck curvatures are fine (or not all that badly off), while people whose necks look normal to me are suffering. This is not a difficult clinical observation to make: neck pain problems are obviously more variable than neck postures. I’m not the only one to notice:

It is not unusual for some individuals to have a straight cervical spine or some reversal of the normal cervical curve and have no symptoms at all. Such deviations from normal may be structural in nature, usually cannot be changed, and are not often significant. A cervical curve can be temporarily altered when neck muscles are in spasm, but the curve (or lack of curve) that is normal for the individual returns when the spasm subsides. When there is no pain or loss of mobility in the neck or cervical spine, no treatment is needed.

Chiropractic gimmickry, Homola (ScienceBasedMedicine.org)

Unfortunately, many clinicians fail to notice the inconsistency (or make anything of it anyway), probably because they want “something to fix” and it pays to pathologize — that is, it’s good for egos and incomes to define “normal” more narrowly and attribute pain problems to deviance from the apex of the bell curve. The neck posture hypothesis is a classic microcosm of structuralism.

“Structuralism” is the excessive focus on crookedness and “mechanical” problems as causes of pain. It has been the dominant way of thinking about how pain works for decades, and yet it is a source of much bogus diagnosis. Structuralism has been criticized by several experts, and many studies confirmed there are no clear connections between biomechanical problems and pain. Many fit, symmetrical people have severe pain problems! And many crooked people have little pain. Certainly there are some structural factors in pain, but they are generally much less important than messy physiology, neurology, psychology. Structuralism remains dominant because it offers comforting, marketable simplicity. For instance, “alignment” is the dubious goal of many major therapy methods, especially chiropractic adjustment and Rolfing. See Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.

But I’ll push the pendulum back in the other direction and say that biomechanics are not completely irrelevant to neck pain.

For instance, it’s more or less a given that there is probably at least some connection between neck posture problems and pain. People with strange neck curvatures do not always have neck pain, but they are at least a little bit predisposed to it. Plenty of research data suggests this. For instance, in 2005 McAviney et al examined 277 neck x-rays and reported a “statistically significant association between cervical pain and lordosis < 20 degrees” — that is, painful necks tended to be flatter necks (about 10˚ flatter than the lower end of what they defined as normal).104 There are others like that.

I don’t give a heck of a lot of weight to studies like that. Mostly they are poor quality, and the only ones “finding” a clear, important connection between posture and pain problems are the sloppy, self-serving ones.105 The rest are reporting only mild correlations,106 and not causation at all — they weren’t designed to tell us if the posture caused the pain or if the pain caused the posture, and they can’t. But more importantly, the file drawer effect is undoubtedly at work here — a tendency to publish studies that seem to support a hypothesis, while failing to publish a discouraging word. Just as therapists want “something to fix,” journals want “something to publish,” and they are more likely to publish papers that report a small but technically statistically significant correlation between neck pain and posture and make a bit too much of it. And it’s quite easy for a small correlational study to find what they are looking for — all the authors have to do is tweak their definition of “normal,” et voila. And so, for decades, journals have been prone to publish these sloppy, low-power studies that confirm everyone’s I-need-something-to-therapize bias.

But — if that’s what’s going on — the truth is hard to hide forever. It usually takes quite a powerful study with a clearly negative result to finally punch through the bias and finally get published, but it happens eventually.107

For instance, in 2007, the European Spine Journal — an excellent journal — published quite a detailed study of this subject by Swiss researchers.108 They examined “the correlation between the presence of neck pain and alterations of the normal cervical lordosis,” and I agree with their assessment that it’s probably “the first study to explicitly examine these relationships in detail.” They x-rayed 54 people with a history of neck pain and 53 without, and then carefully measured their necks. What did they find? Zip, zero, zilch: “No significant difference between the two groups could be found.” Emphasis gleefully mine — the data are excellent, and clearly a blow to the popular hypothesis, which needs the comeuppance. It’s clear from this quality data that people with neck pain simply did not have more dysfunctionally curved cervical spines.

“The presence of such structural abnormalities in the patient with neck pain must be considered coincidental,” the authors concluded.

As Dr. Steven Novella of Science-Based Medicine has often emphasized, “Reliable conclusions come from interpreting the literature as a whole, and not just individual studies.” So there may be some individual studies that show a fairly good correlation between neck pain and posture. But better science — or at least as good — has directly contradicted those findings, showing no correlation at all. So if you look at all the studies together, they all kind of cancel each other out and the net effect is just “meh.”

Of course, who cares about the theory of neck posture if therapy to correct your neck curvature works, right? I’ll tackle that subject below in Don’t worry (very much) about exercises to improve neck curvature, posture, coordination or stability.

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Another popular myth about neck pain is that it is caused by being “strained.” Sometimes this term is used in a generic way: “hurt by being pushed past its limits in some way.” If that’s all you mean by “strained,” that’s fine, carry on.

But if you mean that you think your neck muscles have been torn, we should talk.

It’s all too common for patients to worry unnecessarily about the real definition of “strain”: that is, muscle tissue that’s been damaged by overexertion. This myth is often perpetrated by less well-trained professionals, such as massage therapists with minimal training, or personal trainers. It sets up camp in the minds of patients, a vague anxiety that they have damaged their neck muscles, usually without being quite sure when or how. The misconception that there is “damage” often leads to icing of the neck — an unfortunate choice, since ice is unlikely to help and may actually aggravate the real problem. The danger isn’t great, but it’s not a harmless myth.

Of course, muscles can get torn. But this is rarely the direct cause of neck pain outside of obvious trauma. Muscle strain is usually the result of an obvious trauma, such as car accidents and snowboarding collisions … or dancing to heavy metal music by “head banging” (violently flinging your head up and down). Not that this is a likely cause of neck pain for readers here, but it’s an instructive example. In 2008, the British Medical Journal established in their annual Christmas parody edition — semi-serious science about silly topics — that head banging can cause real neck injury and brain injury.109 No kidding! And yet for all the violence of that motion, it takes a lot of head-banging intensity to do any injury, and head bangers in general do not have serious chronic neck pain.

And repeat …

Unsurprisingly, head-banging can cause both neck injuries & brain injuries, which might be why heavy metal music fans seem dazed & confused. And yet the neck tolerates it surprisingly well & injuries are more rare & minor than you might expect, even with much more violent neck movement than most people ever do. Good perspective!

It’s hard to get a true muscle strain and not know exactly when and how you got it. If you don’t know how you might have strained your neck, then you probably didn’t. Indeed, even if you think you did strain your neck muscles, you may still not have — because even “obvious” traumas often do less injury than people think.110 Most minor traumas to the neck will cause pain like a stubbed toe: briefly painful, but there’s no damage. And a typical neck crick can cause far worse discomfort than head-bangers generally suffer from — even with a “definite risk of mild traumatic brain injury”!

There might be such a thing as a muscle strain that is just bad enough to be a problem, but mild enough that it’s not quite clear how it happened. Sometimes, neck cricks start with a sudden sharp pain during ordinary movement or perhaps somewhat vigorous movement. In some of these cases, there may be a mild (grade 1) muscle strain. The irritation might lead to chronic pain by other mechanisms (which you’re about to read about below). But even in cases like this, only the sharpness of the original pain, and the first 2 to 3 days of discomfort, can really be attributed to the muscle strain itself — any pain that persists after that cannot really be said to be a “muscle strain,” but rather the consequences of one — and it certainly cannot be treated like a muscle strain.

It’s also possible that a person could accumulate a series of minor muscle strains, which would, in a sense be a muscle strain problem. Skiing and snowboarding are an excellent example of how this might happen.

Lessons from skiers and snowboarders wearing helmets

When people wear helmets for those sports, they definitely protect themselves from serious head injuries — no doubt about it. Research has shown that clearly.111 But could the weight of helmets cause neck injuries? In 2005, Hagel et al found some indication of “an increased risk of neck injuries with helmet use” and “could not rule it out,” and the editors of the British Medical Journal introduced that article by asking, “Do you value your head more than your neck?” Now there’s a dilemma! A few years later, it has been confirmed that helmets probably do not increase the risk of major neck injuries,112 so you don’t have to choose between breaking one or the other, and you should definitely wear a helmet! Head injury is obviously the greater evil here.

What about minor injuries? The risk of these is probably high, and will almost certainly remain unstudied: countless cases of low-grade whiplash, the kind of thing that you would never take to the first aid station, but which make you quite sore the next day, a common story. As a massage therapist, I saw many snow boarders with necks so sore that they could barely lift their heads, and it seems likely that a helmet makes that worse. A series of such incidents probably correlates with more chronic pain, much as we know to be the case with more extreme whiplash accidents (see the Atherton et al study). Although it’s clear that minor neck pain is much less dire than head injuries, it’s not nothing.

Generally speaking, snowboarders know it when they hurt their necks. What they may not know is that the repeated minor injuries are creating vulnerabilities in their neck tissues that can become chronic pain problems down the road.

But, once again, it’s not the muscle strain per se that is the problem here, but the long term consequences. This concept will come up again below.

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There are only so many tissues that can be a source of pain,113 and even fewer that are likely.

While there are many possible “insults” to many possible anatomical structures, there are just a few tissue types that can get insulted and produce nerve impulses that the brain may interpret as pain:

• Nerve tissue itself can be hurt — neuropathic pain — but this can also be ruled out relatively easily in most cases. It’s not common, as discussed above.
• Connective tissue is a large category, including both bone and all the soft connective tissues:
  • Bone is rarely the tissue with the issue: it usually only hurts if it has been fractured.114 Bone growth (like a callus) can be a problem in this area, but that’s because of whatever it’s pressing on, not the bone itself.
  • Ligaments and tendons and the fascial wrappings around muscles and muscle groups are all tough as leather and rarely get hurt without obvious trauma. Tendons certainly can get irritated in a bad way — tendinitis — but that particular misery rarely occurs in the neck.
  • Cartilage, intervertebral discs, and joint capsules are not quite as tough, and these are the tissues that tend to degenerate arthritically, but that probably doesn’t explain many neck cricks (which afflict people of all ages).

Muscle tissue is the elephant in this room. We know that muscle fatigue115 and tension116 are both among the only clearly identified risk factors for neck pain. By weight, there’s more muscle tissue than anything else in the neck, and it’s complex, active, sensitive tissue. It’s a suspect even when it’s not actually injured (strained) or misbehaving (spasm). Muscle pain probably accounts for the majority of stubborn moderate neck pain, especially the kind of neck pain associated with cricks. This unproven theory is probably the most useful idea that this tutorial has to offer: an important alternative to the more common ideas of spinal fragility, degeneration, and misalignment.

Many readers already suspected this, because neck pain often feels muscle-y. It may seem like an underwhelming or obvious idea to you at first, but bear with me: its implications can take time to work out and sink in, especially because most of us are (or were at one time) amazingly hung up on more mechanical explanations of spinal pain, involving any of the other tissues. This potent bias is more obvious when it comes to the low back, where nearly all patients are married to the idea that they are injured and/or degenerated or otherwise fragile and “broken” (misaligned, subluxed), and will cling to such beliefs quite fiercely. It’s not quite so bad with neck pain,117 but it’s still a hard idea to get past.

Understanding that muscle tissue can be a potent source of discomfort presents a good opportunity. Unfortunately, it’s commonly misunderstood and underestimated. The next several sections look more closely at the various ways that muscle might be making your neck miserable.

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Here’s a bizarre neck “spasm” experience, vividly described by reader A. Hawryluk:

Once in a while I get a really horrendous muscle spasm in the neck, accompanied by a loud “ping” noise and a lot of weird, sickly pain. I’ve had them since I was a kid. Get about one a year. Feels like I’ve been hit in the back of the head with something heavy and leaves me dizzy for a few minutes. Not nice. One would assume they’re somehow related to more mundane, less agonizing muscle twitches. They feel like a muscle twitch right up until they cave in the back of your skull and crush your medulla oblongata while pulling your ears and scalp around to the back of your head.

Sounds a bit crazy, right? And yet I know exactly what he’s talking about: I used to get the same thing! About once every several months. It’s just hell for a few seconds, disorienting for a few minutes, then it rapidly fades away to nothing — completely fine until the next time. The sensation is something like a funny bone hit, but in the head.

This bizarro phenomenon is completely unexplained (and likely to stay that way). However, I hypothesize that there is probably a nerve that, once in a while, gets yanked on by a poorly timed contraction or minor cramp — a dramatic sensation, but probably harmless. Maybe!

It’s rather shocking how little is known about the role of “spasm” in neck pain, or any kind of pain. I’ll devote the rest of the section to introducing those mysteries, and then in the next chapter I’ll move on to a more specific idea about how muscle might “spasm.”

What kind of a thing is a “spasm” anyway?

Sometimes muscles contract when they shouldn’t. This can be merely weird and annoying, or painful or even crippling. There are a bunch of specific types: exercise-induced cramps, night cramps, dystonia, spasticity, fasciculations (twitches), tremors, myokemia, clonus, tetany … phew!

And so what are the “spasms” that everyone seems to think they have? If you listen to people talk, their backs and necks are forever “spasming.”

All known kinds of pathological contractions fit into one of the types I just listed. And yet a “neck spasm” probably isn’t any of those things. It’s probably just a way of describing what neck pain often feels like … not what it actually is.

Unexplained musculoskeletal pain — especially spinal pain — is carelessly attributed to “spasms” by practically everyone. It’s a vague non-diagnosis with strong emotional appeal, which has been cynically exploited by pharmaceutical companies to sell muscle relaxants (which don’t work all that well, and we’ll get to that later in the book). It’s appealing because it’s simple and a lot of body pain just feels like a spasm, possibly because strong contractions may occur in the presence of pain with other causes.

Three major assumptions about “spasm” are often blended:

1. spasms hurt — they are a major mechanism of pain, especially in the back and neck
2. spasm is often “protective” — muscle guarding or splinting
3. painful spasms cause themselves — a pain-spasm-pain vicious cycle

All of these are repeated ad nauseam by both clinicians and amateurs.118 Among the academics and experts, there’s a long, erratic history of debate over almost zero data, fighting over scraps. No one actually knows if they are true, and there’s a good chance they are not.

For many years I denounced them as myths, or misleading half truths at best. My contrarianism was overconfident, and based mainly on my deep distrust of vague claims. They smell like myths … but I can’t actually refute them with good evidence, because there is no such evidence. At best I can point to some red flags. Here are some basic concerns:

• Cramps are obviously painful, but so is the visible contraction of the muscle and its effect on joints. If back and neck pain are caused by contracting muscle, why can’t we see it contracting? And why aren’t we actively fighting to keep the muscle elongated, as we must with cramps?
• If pain and spasm cause each other, why wouldn’t the vicious cycle escalate at least to the point of being an obviously contractile phenomenon like a cramp? It seems like it must either be so limited that it’s not very “vicious,” or it simply doesn’t happen.
• “Protective” muscle spasm clearly does not make biological sense with many injuries. For instance, it would be dangerous to strongly contract the muscles around a fracture: it would tear it apart!

Although those warning signs exist, there are also clinical clues that there are kernels of truth to these ideas about “spasm,” and it’s generally unwise to underestimate the complexity of muscle physiology and motor neurology. As with so much else in medicine, the truth is simply unknown.

Why does neck pain feel so “spasm-y”?

The idea of a “neck spasm” mostly seems to be a poetic, informal way of labelling a sudden onset of sharp pain. People tend to think that the sharp pain suggests injury or some specific mechanism — especially spasm — but pain sharpness is less informative than you might think. The sharper the pain, the more it seems like “spasm” to a lot of people, up to a point. But abrupt neck pain has many possible causes.

Back and neck pain may often seem spasm-y because of our strong, muscular reaction to the pain: clenching and bracing! Those aren’t spasms, though: they are just fast, muscular reactions to the back pain, not the cause of it.

The sensation of acute stiffness — which is complex, but basically boils down to uncomfortable movement — can also seem like muscle spasm.

The tricky idea of painful spasms

Can muscle contraction hurt? Is a lot of neck pain caused by contracting neck muscles? Cramps are certainly painful and thoroughly unsubtle. You can usually see cramping muscles bulging and flexing. They literally bend people out of shape and have to be fought with urgent stretching. Bad ones can be too strong to fight, and the worst can literally rip your muscles off the bone. The pain of a cramp is a warning of imminent trauma.

If there is such a thing as a painful spasm that is not a cramp, it must be an odd beast: strong enough to hurt a lot, but otherwise undetectable. How can a contraction be strong enough to hurt without the obvious bulging, flexing, and bending of a cramp? It’s not clear.

One simple explanation is that “spasm” is often just a way of saying “it hurts” while casually implying an incorrect explanation for why it hurts. And there are some obvious reasons why we might suspect contraction — stiffness and impaired movement around pain and injury. Three evidence-based points:

1. Digging into the archives, a 1989 editorial decries the “preposterous” spasm diagnosis, describing “overwhelming evidence that skeletal muscle spasm is nonexistent.”119 Unfortunately, the author only mentions one 1950 study (which I can’t find), and a replication of it that he was involved in (which I also cannot find). But giving him some benefit of the doubt, he describes a study of 50 people with neck and/or shoulder discomfort, none of whom “had EMG evidence of muscle activity in the area of pain or in the proximal paraspinal muscle.”
2. During my massage therapy career, I massaged hundreds of people who believed they had “spasms” that I couldn’t detect with my experienced hands — hands that could easily detect many other subtle things. In a more formal test, two doctors trained in manual medicine could not even identify the side of the body that neck pain was on by feel.120121 A neck muscle spasm so subtle that it defies detection even with direct, hands-on inspection cannot possibly involve much contraction.

   And one more thing about massage: if they’re caused by spasms, shouldn’t massage help a lot more than it does? I’m just asking!122

3. Anticonvulsant drugs (like Lyrica) appear to be at least partially effective for spasticity/dystonia, but definitely do not work for neck/back pain,123 suggesting that back pain is not normally caused by gross spasticity/dystonia.

But the truth is probably in the middle here. High muscle tone and a hardened, ropy texture are common in humans.124 In some cases, muscle tone may get high enough to be uncomfortable and “spasm” might be a reasonable way of describing it, albeit a little dramatic.

It’s a short hop from higher muscle tone to the more extreme and instructive example of spasticity — the name given to chronic contractions caused by some diseases. Not all of these are obvious, as with the “multiple sclerosis hug”: suffocating pain caused by complex dystonia of the muscles of the chest. The contractions aren’t obvious, but they cause great suffering. It’s clear from this example that rogue muscle behaviour can be painful without the nature of the problem being clear. “Spasms” seems like a fair way to describe that situation.

And could there be analogous discomfort in the neck or back? Maybe. Unfortunately, and rather incredibly, no one knows.

But there is one theory that could help lead us out of these woods: a poorly understood but well-described form of “spasm” known as the “trigger point.” A micro-cramp.

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Myofascial trigger points certainly don’t explain everything about neck pain, but they may explain a lot of it. Even if they aren’t the original cause of the problem, they are probably responsible for some of its severity and stubbornness. Their tendency to complicate other neck problems is the secret to their clinical significance.

Trigger points are the acne of your muscular system, a nearly universal soft tissue dysfunction in humans. Muscle aches! And yet trigger points are also routinely overlooked as a factor by most health care professionals, who tend instead to diagnose structural problems like arthritis or nerve impingements:

Currently, consideration of the possibility of a [trigger point] component of the pain complaint is commonly not … included in the differential diagnosis and therefore is missed cold turkey, which can be very expensive for the health care system (expensive examinations looking for a phantom diagnosis) and disastrous to the patient (wrong diagnosis, wrong treatment).

Dr. David Simons, medical expert on muscle pain125

Despite this medical blind spot, the existence of unusually sensitive spots in soft tissue is not scientifically controversial. Therapy for them is experimental but is safe and can be cheap.

Although the existence of trigger points is not controversial, the nature of the beast is definitely controversial. The dominant hypothesis is that a trigger point is basically a small cramp affecting a small patch of muscle tissue. But the science supporting that hypothesis is still a bit half-baked. It’s not even completely clear that it’s a “muscle” problem, per se.

See Trigger Point Doubts for a thorough discussion of all this. My doubts are more academic than practical, but it is tricky to reliably treat a pain that cannot be explained. Which brings us to the next problem …

Unfortunately and predictably, there is no good evidence that neck pain is primarily caused by trigger points, or that it can be treated that way. This is an almost unstudied niche of musculoskeletal medicine. In 2007, muscle pain researchers Dr. David Simons (quoted above) and Tiffany Fields wrote a review of the scientific literature, but found little scientific literature to review: as is so often the case in musculoskeletal health care, they concluded that “additional studies are needed,” acknowledging that the available evidence is weak, but expressing the opinion that “it seems that the pain profile of neck and head syndromes may be provoked referred pain from TrPs in the posterior cervical, head, and shoulder muscles.”126 This situation has not yet improved.

The lack of direct evidence is not a deal-breaker. There is indirect evidence to consider, and there are several reasons to take it seriously:

• The overall clinical importance of the phenomenon of trigger points is well-established — sore spots are strongly associated with chronic pain — even though we don’t know how they work. Virtually anywhere there is stubborn pain, there are probably some trigger points too. Just because it hasn’t been studied specifically for the neck doesn’t mean much in itself.
• It’s very likely that trigger points are a standard complication of any trauma. There are many possible reasons why injury sometimes leads to chronic pain, but trigger points are probably an important piece of that puzzle. I’ll discuss this in detail in the next section.
• The relationship between muscle tension and neck pain has been studied,127128and the relationship is straightforward: although we don’t know if muscle tension causes neck pain, or if it’s a reaction to it, they definitely go together. Although there is no such thing as a “pain-spasm-pain” vicious cycle, there probably is such a thing as a pain-tension-pain cycle.129 And overall muscle tension and trigger points are strongly correlated.
• Trigger points are closely linked to headache and migraine,130 and of course neck pain is often involved as well. While it isn’t clear from the evidence that trigger points actually cause headaches — they could be a symptom — in my opinion it’s likely that they do.131 And if that’s true, it’s likely that they cause neck pain as well.
• There is some better-than-nothing evidence that treatments aimed at trigger points help patients with neck pain. It’s not good or complete evidence, not by a long shot, but nearly every flawed little trial has a positive conclusion (I’ll review the evidence later in the treatment sections). Presumably, these treatments would not have shown any promise at all if trigger points weren’t part of the problem.
• How about the evidence for general massage for neck pain? (As opposed to trigger point therapy specifically.) The paltry evidence available is mostly discouraging: alas, massage is clearly not saving the world from neck pain. But there are hints of good news: for instance, a 2014 study showed that more massage therapy helped neck pain much more than less did. The authors suggested that perhaps other studies showing lackluster effects on neck pain “may have not administered adequate doses.”132 Interesting. This sure doesn’t prove that massage works for neck pain, but it is encouraging (see the footnote for more). Evidence about massage for back pain is more plentiful, but no more helpful — mostly just inconclusive.133
• Finally, I have no vested interest in pushing trigger points as the main explanation for neck pain.

For all these reasons, I suspect that muscle knots are a major factor in most stubborn neck pain, for most people, most of the time. Having supported that hypothesis as well as I can, I’ll now run with it, and expand on how I think it works.

What makes muscle knots so clinically important and fascinating is their unholy triple threat, their ability to:

1. cause pain problems,
2. complicate pain problems, and
3. mimic other pain problems.

Trigger points may be the entire cause of a neck crick. Provoked by relatively ordinary or pervasive risk factors in life, such as postural stress or emotional stress, they can seem to come “out of nowhere” and cause — on their own, with no other problem present — a great deal of pain and stiffness and cricky misery.

Or they may exist as a major complication of some other problem. For instance, joint dysfunction can provoke muscle discomfort, and vice versa. The pain-spasm-pain vicious cycle discussed above does not actually exist, but the joint-muscle-joint vicious cycle probably does. The formation of trigger points in response to other stresses and traumas is not only routine, but muscle pain then feeds more trouble back into the equation. A joint surrounded by cranky, misbehaving muscle tissue is virtually doomed to suffer more joint dysfunction, to be more vulnerable to additional irritation and trauma.

Yet trigger points are relatively easy to treat.

This is a vital point: neck cricks may be originally caused by joint dysfunction or sensitivity, but if any (or all) of the ongoing discomfort is caused by trigger points, that will be easier to treat. Regardless of whether a crick is more about the joint or the muscle around it, it is more likely to yield to trigger point therapy than manipulation of the joint. Trying to help muscle tissue offers better potential bang for buck.

If cranky muscle tissue tends to aggravate and perpetuate and complicate all other problems, then trying to help it calm down may be the quickest route to reducing the severity of the problem — even if it’s not treating the “root cause,” which may well be history anyway.

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Earlier I explained that the muscle strain myth (neck cricks are rarely caused by strains), and the muscle spasm myths (muscles do not go into “protective spasm” in response to an injury, and there’s no such thing as a vicious cycle of pain-spasm-pain). I’ve claimed that muscle probably does cause pain by forming trigger points, and this section is specifically about post-traumatic trigger points, which seem to be more of an issue in the neck than most other regions. If you have injured your neck, there’s a good chance that the healing process will be complicated by the formation of trigger points that may last much longer than the injury. Indeed, they may be the more serious long term problem.

There isn’t a great deal of good, direct evidence that trigger points complicate injury. But there is some.

The relationship between trauma and chronic neck pain is well established — people with chronic neck pain are 2-4 times likelier to have had a car accident than people with chronic back pain134 — and one study clearly showed that patients who suffer long after whiplash have more trigger points than other people … and that they reproduce their on-going pain.135 Trigger points have also been experimentally induced in rats by injuring them136 (unpleasant for the rats, but there are far worse fates for lab rats).

I have a good personal example of the phenomenon of trauma leading to a trigger point problem. It’s not a neck pain story — at least, not at first. But it became one eventually!

In the summer of 2008 I tore up my acromioclavicular joint, a shoulder sprain, a difficult injury to recover from — but it became the eye of a storm of muscle pain in the area that lasted for months longer than the injury itself should have caused pain directly. I had serious difficulties for many (sleepless) months with my body’s reaction to the sprain — all much worse than the original injury. To this day, 15 years later, I have flare ups of trouble in that area. Fortunately, I can always put out the fire with basic trigger point therapy tactics, especially self-massage.

I got hurt when I tried to stop someone else from catching a Frisbee while playing ultimate, an intense Frisbee sport. I leapt high in the air, tumbled over the other player who was catching the disc, and fell a couple of feet onto the tip of my shoulder. It should have been a collarbone cracker. My ligaments tore instead.137

Recovery was rough. I couldn’t lift my arm more than a few degrees. I couldn’t sleep on that side for months. But injury pain was gradually replaced by muscle pain — creating the illusion that I wasn’t healing. I went from the frying pan of the injury, to the fire of the trigger points that sprang up around it.

Two kinds of hurt

First the pain of an injury (the frying pan) & then the pain of seriously irritated muscle tissue (the fire).

The crazy thing about muscle pain is that it often gets worse than the original injury, and it lasts much longer. It is more than an occasional complication of injury — it’s probably a common, serious, and chronic consequence of physical traumas. Some injuries seem to be very difficult to recover from, and trigger points may be one of the main reasons why: it’s not the injury itself, per se, but how the body reacts to it. Damaged tissue heals remarkably well, but trigger points are stubborn by nature.

There is a stage in every healing process when the patient begins to think, This is never going to end. I am going to hurt forever. A lot of that persistence of symptoms is probably due to trigger points.

It is mainly the pain of the injury that provokes the formation of trigger points. Muscular exhaustion may also play a role. Although initially inhibited by the injury, muscle soon starts working hard to “work around” the injury — contracting a lot and in unfamiliar new patterns as you try to achieve functional goals without pulling on any broken tissue. It’s awkward, basically. All of those contortions we learn when we are injured, all the limping and squirming and fidgeting, requires unfamiliar and often intense muscle activity. The exhaustion that causes probably drives trigger point formation, or aggravates any trigger points that were already there (a common scenario).

How a shoulder injury became a neck pain problem with the help of trigger points

In my case, the trigger points spread from my shoulder to my neck over the course of several months. The discomfort and awkwardness in my shoulder seemed to irritate my neck muscles, and I started to get vivid “cricks” at the base of the neck, right where the shoulder meets the neck (the “sheck”). Initially they were simply part of a halo of symptoms around the shoulder, but as time went on the cricks started to overshadow the shoulder.

Just as shoulder muscle pain superceded the discomfort of the original injury, so too did the neck cricks supercede the shoulder pain. After a year or two, I rarely had shoulder pain, but I was having semi-regular flare-ups of neck pain that were actually worse than the shoulder had ever been! After losing several battles, my neck problem appeared to resolve fully and completely and forever … after a single particularly good (accurate) massage. I have not had that kind of neck pain ever again since (several years).

My own shoulder/neck rehab story is of potential value to anyone with any kind of injury. If you have hurt your neck, I recommend that you read the whole story. It goes into more detail about this relationship between trigger points and injury.

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People are amazed by the sensitivity of muscle tissue. In many cases, even mild pressure on some muscle tissue can cause strong discomfort. Massage clients often ask in amazement: “What is that?” They can hardly believe that it’s “just muscle” — that it’s not the result of bothering some vulnerable spinal structure. Muscle should not hurt when you poke it, and most of it doesn’t. We can make a reasonably safe assumption that sensitive muscle tissue is probably unhealthy in some sense.

In necks with cricks, it seems to be particularly sensitive.

Muscle tissue is never “just” muscle tissue — it’s a complicated, massive, volatile organ. It’s biologically intricate, metabolically hot, sensitive, highly responsive to our mental state, and it’s got a tough job. Sometimes muscles seem to get “sick,” and the pain can be agonizing.

The standard diagnostic label for widespread muscle sensitivity is “myofascial pain syndrome” (MPS), clinically characterised by a lot of sensitive patches of muscle tissue, also known as “trigger points.” Sometimes, neck pain is isolated in a small region of discomfort in the neck — too limited a range to be considered myofascial pain “syndrome.” But often it’s part of a pattern of widespread muscular sensitivity throughout the upper back, shoulders, neck and head. In such cases, acute episodes of neck cricks could be considered part of a case of MPS.

MPS was originally studied and roughly described by Dr. Janet Travell and Dr. David Simons, and has been written about most authoritatively since by Dr. Siegfried Mense in the seminal text, Muscle Pain, and by Dommerholt et al in Myofascial Trigger Points: Pathophysiology and evidence-informed diagnosis and management. In their explanations of MPS, trigger points are basically a tiny cramp: a localized metabolic crisis in which a variety of stressful factors can trigger a vicious cycle of clenching, causing a muscle to choke off its own blood supply, resulting in oxygen and nutrient deprivation and then stagnant tissue fluids which irritate sensory nerves and renew the cycle. This is hypothetical, unproven, and somewhat controversial, but there is a fair amount of moderate quality indirect evidence that something is going wrong with muscle tissue at these locations. I’ve written a great deal about the controversy elsewhere, but it’s beyond the scope of this book.138

Some muscles seem to be more vulnerable to this phenomenon than others — the neck and back muscles most of all.139

These muscle “knots” are not just painful at the spot in your tissues where they live. They also tend to generate pain that spreads to nearby regions. This spreading is an under-explained but well-documented phenomenon. For example, it’s routine for people with neck pain to also have:

• upper back pain
• headaches and/or migraine
• sinus pain
• jaw pain
• eye pain
• shoulder, elbow and wrist pain

These radiating sensations can be tough to distinguish from the pain of a pinched nerve, resulting in a common misdiagnosis. In most people with neck pain, the trigger points causing these radiating sensations can be located fairly easily in areas where nerve compression is impossible or unlikely. The spot is sensitive and radiates in a familiar way — clients say things like “it shoots down my arms” and “that’s exactly what my pain is like.”

Unsurprisingly, sometimes when these trigger points are stimulated, the “pinched nerve” pain goes away immediately! In a decade of treating neck pain routinely, I saw few cases of true nerve irritation.140 On the contrary I saw a great many cases that I believed were muscle pain that was causing shooting pains that seemed like a nerve problem. When I treated those cases like a muscle problem, I often saw good results.

To sum up, muscle knots are an important part of the story of neck pain because:

• almost everybody has them to some degree
• they can be the entire problem
• they make you vulnerable to other problems like joint dysfunction and MIDs
• they confuse diagnosis with referred pain, which may seem like a pinched nerve
• they can be caused by other problems
• they can be more painful and (much) longer-lasting than other neck problems

The good news: muscle knots are relatively easily to treat, compared to many other problems. Although there is no proven therapy for them, and they are occasionally extremely stubborn, they do often seem to respond well to the stimulation of massage therapy and self-massage. Even when there are other things wrong in the neck, you may be able to “use” the trigger points to break a vicious cycle of various factors reinforcing each other. For instance, a really stubborn MID may simply be the invincible part of a vicious cycle, but you can actually do something about the trigger points that form in reaction to it, safely and cheaply.

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In this chapter we’ll rifle through a grab bag of things that do not directly “cause” neck pain in the traditional sense — not a tidy B-follows-A cause and effect relationship — but the conditions in which it seems to flourish, the soils and fertilizers it likes. If a minor problem with the spine can cause major trouble in some people, and nothing at all in others, then the spine problem is not the real problem: the real story is one of vulnerability, both biological and psychological, that increases the risk of a minor glitch blooming into a chronic pain problem.

Many of these are not the kinds of things we’re used to thinking of as the causes of a specific body pain.

For instance, chronic neck pain is certainly stressful and depressing.141 But are stress and depression a pain in the neck? That is, do stress and depression cause neck trouble? I’ll go with a cautious “probably.” There are many clues and you’d certainly think it was an established fact if you read some scientific papers,142 but, bizarrely, the kind of research needed to actually answer the question has never been done.143 There are definitely clues, though! Let’s explore the “circumstantial” evidence that stress does indeed cause neck pain.

Before we dig into that mess, though, let’s start with some basics. What else is in a recipe for neck pain? What’s not?

Basic risk factors for neck pain

It’s 2018, and there’s still only two things we know for sure are risk factors for neck trouble:

1. being a woman
2. a history of neck pain

So, if you’re a woman who has had neck pain before, watch out! You are definitely at risk for more. No one knows why. And every woman reading this is now thinking, “Fantastic: as if being a woman in this world wasn’t challenging enough, now this?” I wish it wasn’t true, but it is literally one of the only two things we know for sure.

A few other fairly likely risk factors have been identified by other reviews (which I don’t trust as much as Paksaichol et al):144145146

• older age up to a point (increasing through middle age and then levelling off)
• smoking (no surprise there: smoking is a risk factor for almost everything)
• a history of back pain as well as neck pain
• subjective tension147
• repetitive work, unsatisfying work, and/or a demanding job with low “support”
• being out of shape (metabolic syndrome)148

So if you’re a woman smoker “of a certain age” with a stiff neck, a history of neck and back pain, in a crappy job with a bad boss, and generally unfit, you are totally screwed.

There are many other possibilities (almost four dozen different risk factors were considered in the seven studies Paksaichol et al reviewed). There isn’t enough evidence for most of them. But here are some of the most common suspects that remain unconfirmed but plausible:

• sportiness, weekend warriorism, risking your neck by playing hard in your free time
• general stress, anxiety, depression, pessimism
• social stress in particular: threats to social status or acceptance in a group
• office and computer work in general, but computer usage specifically is addressed next

Despite decades of studying in circles around these topics, there’s still an absence of adequate evidence for any of this, mostly just because the right type of research is difficult, slow, and expensive.

Things that probably are not neck pain risk factors

Paksaichol et al noted an absence of evidence for most suspected risk factors. But they did find “strong evidence for … not having predictive value” of …

• social isolation, being a loner, lack of involvement in community
• two major ergonomic bogeymen:
  • lots of keyboard time
  • the perception that a computer display is poorly placed

Humans are social animals, and we do suffer all kinds of consequences when isolated. But not, apparently, neck pain. This is quite firm.

Those ergonomic factors are a bit of a bombshell. Whatever goes into a recipe for a neck pain, it’s probably not your total keyboard time, unless you have an unusually awful workstation.

And computer display position? Not a risk factor? Really? I believed for about 20 years that computer positioning had to be a factor in neck pain and headache, and I have taken that position on this website for more than half that. But, as of 2012, quite good data says no, not for neck pain — and so I will respect the evidence. (Headaches may well be another matter, but it’s unclear.)

Depression causes neck pain: the direct evidence

The first and only direct, hard evidence that depression actually causes neck pain was published in 2015 in the Journal of Pain.149 It was not perfect — not a very powerful study — but at least it was the right type of study, looking at the right things. 171 healthy office workers were quizzed for a year, identifying the following risk factors:

• depression
• poor neck muscle endurance
• low pain tolerance150

There’s a lot more evidence, but that’s the only recent, direct, reasonably high quality evidence we’ve got.

Stress and pain (in general)

The path from psychological distress to pain is probably twisty and slow, but it almost certainly exists. For a full general discussion of this sub-topic, see my anxiety article, section “Does stress wreck us?”

It’s a common assumption that stress and anxiety have biological consequences that drive up the risk of pain later in life, but this has been a surprisingly difficult thing to nail down,151 and the classic idea of “adrenal fatigue/burnout” has largely been debunked.152 Stress hormones don’t get “depleted.”

But they surely do have effects. Psychologist Dr. Robert Sapolsky explores this in extreme detail in his famous book, Why Zebras Don’t Get Ulcers, and concludes that chronic episodic stress — the kind of stress most of us suffer from, the onslaught of hassles both major and minor that plague modern lives — probably does ramp up immune function to the point of dysfunction. Too much inflammation, in other words.153

And having generally ramped up inflammation sounds like just the sort of thing that might, over time, make someone more vulnerable to neck pain (and more). It is one of the possible pathways from stress to pain.

“A schematic representation of how repeated stress increases the risk of autoimmune disease,” adapted from Sapolsky’s Why Zebras Don’t Get Ulcers. Click to embiggen.

It’s also the only reasonably well-understood pathway, but there are probably others. For instance, sensitization (which has come up a couple times so far): stress may make our pain system more touchy and paranoid.154 And I’m not talking about “all in your head” pain here, mind you, but a genuinely messed up nervous system that combines with real problems like arthritis or a nerve impingement, making them more likely to actually hurt.

Circumstantial evidence: the power of optimism (and pessimism)

One of the strangest things about neck pain, and one of the best clues that it might actually be driven by psychological factors, is how much it seems to be affected by our confidence that we will recover. This is probably true for all healing challenges.155

I’ll start with an example of low back pain research which has clearly shown this effect, which likely applies to neck pain as well. Jonathan Berkowitz is a statistician at the University of British Columbia, here in Vancouver. He contributed to one of the largest studies available on the factors that predict how quickly people with back pain will return to work.156 He was the chief number cruncher for the study, and what he found was quite remarkable: patient expectations were the single most significant factor in the duration of their recovery! All other factors were significantly less significant.

“Basically, what the numbers clearly showed is that, if you think you’re going to get better and go back to work,” Dr. Berkowitz explained, “you’ll probably get better and go back to work!”

In other words, pessimism is a major risk factor for the persistence of low back pain! This is such an important part of low back pain management that, in my low back pain tutorial, I make quite a big deal of “the confidence cure” — I argue that having rational confidence is one of the most important back pain treatments. I will not make as much of a deal of that here in the neck crick tutorial, because the evidence is less direct, and because cricks have certain characteristics that make them less susceptible to psychological factors.

But it’s interesting, isn’t it? And although neck pain is much less studied, there is some similar evidence specifically about neck pain. A 2015 Norwegian study of hundreds of workers with neck pain is the most similar; it showed that fear of pain and avoidance of work-related activities “seems to be an important predictor for return to work” in neck pain patients who were otherwise similar.157

Neck pain patients recover more slowly when they sleep badly

Now for some sleep science from Spain, home of the siesta: a 2015 study of the relationship between neck pain and sleeping badly,158 in more than 400 neck pain patients, mostly “subacute and mildly impaired” and therefore — this is an important detail — unlikely to be sleeping poorly because of the neck pain. They were compared before and after a three month period to see if changes in their neck pain were linked with changes in sleep quality.

They were, of course: people who were sleeping better to begin with, or started to sleep better during the study, were much more likely to feel better.

This was true regardless of major confounding factors like age, sex, catastrophizing, depression, or other treatments. It was probably the sleep, and the sleep was probably actually complicating the neck pain (as opposed to the other way around).

This isn’t surprising, of course — crappy sleep can make anything in life worse — but it’s an easy way to start building the case that our general health is surprisingly relevant to recovery from neck pain.

Persistence of pain after injury: accident severity not the biggest risk factor (or even second biggest)

To understand the importance of vulnerability to chronic neck pain, consider the difference between having an accident with and without it.

In 2006, a UK research group at University College London studied people in the aftermath of whiplashing accidents.159 The researchers surveyed almost 500 people after they had car crashes, asking them about their neck pain. It was no surprise that the worst injuries led to more persistent pain. People with badly damaged neck muscles and ligaments were more likely to have chronic pain than people with less serious injuries, of course.

But the role of injury severity was actually outweighed by much less obvious ones. The researchers concluded:

“The greatest predictors of persistent neck pain following a motor vehicle collision relate to psychological distress and aspects of pre-collision health rather than to various attributes of the collision itself.”

That’s fascinating. Worth writing about! (And it has been supported by other science.160)

It’s easy enough to see how your physical health going into an accident would have something to do with how well you recover, but the “psychological distress” part is weirder, and strangest of all is that both of these factors are actually greater risk factors for chronic pain than the severity of the accident. All other things being equal, a severe accident is going to hurt worse than a lesser accident … but your mental and physical health going into it is an even more potent predictor of long term neck pain. Wow.

So a person who has a severe accident with awful whiplash may actually recover quickly and have no chronic neck pain … if they have no history of body pain and minimal emotional stress. By contrast, someone who has a relatively minor accident may be worse off in a year … if they went into the accident with those psychological and physical risk factors.

Risk factors for chronic pain after whiplash have a cumulative effect

There’s another layer of newsworthiness here: Atherton et al found that a combination of pre-injury risk factors results in a disproportionate stubborn-ness of post-injury pain. Patients who had all of the measured risk factors were five times as likely to have persistent neck pain.

Misfortune begets misfortune!

For anyone who has been under stress and already has a history of widespread body pain, advice to avoid driving seems justified. The stakes are too high! It’s bad enough to have whiplash, but it’s devastating for whiplash to turn into severe chronic pain.

Driving is dangerous, and it kills more people than any other common human activity by far. It often surprises me how readily we accept those risks. And the risks are clearly higher for some people than others.

•

Now, let’s bring this home to non-accident cases again. If a combination of stress and a history of aches and pains makes your reaction to an accident much worse … how do you suppose it affects your vulnerability to “out of nowhere” neck pain? How about the effects on recovery from a crick?

The point is that neck pain and crick severity and chronicity are probably at least as much about risk factors as they are anything specifically wrong with the spine. They are the tips of icebergs of stress and being run down. (Indeed, I am starting to think this is true of all persistent pain problems to some extent.) They are probably just one of many other aches and pains around the body, a continuation of a story about increasing body pain. To have a persistent neck crick is, most likely, to have these risk factors as well.

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I’d like to take a detour to compare and contrast neck and back pain. Obviously there is a lot of common ground between these topics, and therefore a lot of similar content in this tutorial and my low back pain tutorial, which has been a nightmarish organizational challenge for me for many years now — because so much of the information is so basically the same but not quite.

Some of the differences are informative and interesting. They are much more similar than they are different. Scanning the diagnosis chapters in both books, I’d say there’s about 80% nearly perfect overlap. But we have a couple chapters here that are virtually irrelevant to back pain, like digital motion x-ray (a rather exotic and unwise type of super x-ray that is barely ever used in the back), and upper cervical instability (quite a serious problem that involves anatomy you’ll only find in the neck).

Shared roots: backs and necks hurt together

In addition to many ordinary similarities, there are some more surprising ones, shared qualities that go well beyond the obvious. For example…

A 2010 study of 800 car accident victims showed that about 40% of neck injuries are accompanied by a back injury regardless of accident severity, bracing, and angle of impact: “We were surprised that patients with next to no car damage had the same incidence of back pain as those involved in more violent crashes.”161 So what is relevant? Previous back pain. If you’re a back pain veteran (as so many people are) you’re much more likely to hurt your back along with your neck in a car accident, regardless of any other factor.

This strongly suggests that experience with pain outranks the mechanics of injury, and that a history of any spinal pain probably predisposes us to other spinal pain. Neck and back pain are more than just similar: they make each other worse. Almost no one in that study (just 5%) had back pain without neck pain.

Broadly speaking, this strange relationship probably points to a basic truth about chronic pain: that it has at least as much to do with how chronic pain works than what’s wrong with tissues. In other words: both neck and back pain are just different locations for the same basic chronic pain problem.

The research difference: neck pain is a second class citizen

Unfortunately, although neck pain is just as common as back pain, it is studied much less than back pain. Since 2010, 9000 studies of back pain were published, compared to only about 1600 for neck pain.162 Much of what we can “know” about neck pain, and much of what I’ve written in this article, has been extrapolated from back pain research.

It’s hard to know how safe that extrapolation is. Backs and necks are similar, but they are definitely not the same.

The fear factor difference: neck pain is as scary (on average)

Back pain is usually more emotionally intimidating than neck pain, and not just because problems tend to be more painful and debilitating: there is much more harmful misinformation about back pain, myths that cause real panic, perpetuating the widely held belief that the low back is a dangerously fragile piece of anatomy, which is not supported by the evidence.163

Therapy for back pain is particularly prone to backfiring — which is probably caused by all the nervousness about back pain.164 Back pain patients seem to need more “de-programming” — to reduce their fearful expectations. Although anxiety about neck pain can also run pretty high, of course, the topic isn’t as rife with fear, uncertainty, and doubt.

The crick difference: necks get them, backs not so much

Neck cricks are such a significant clinical phenomenon that they are a major focus of this book. But low back cricks? It’s not really a thing. The low back does not seem to get nearly as many cricks, and no one knows why. That type of discomfort seems to be most common in the lower cervical spine, and then gets more rare with each joint below that.

The difference is likely to have something to do with joint mobility — the neck joints are much looser than the rest of the spine. However, the lumbar joints are more mobile than the thoracic spine, but crick sensations are much more common in the thoracic spine — so it can’t just be about joint mobility.

One possibility is that the brain is even more hypervigilant about the state of the cervical spine than it is about the state of the lumbar spine. The brain might more aggressively inhibit movement of joints that are worrying it, leading to stronger sensations of “stuckness.”

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I argued above that nerve pinches are actually not a common cause of neck pain: they are hard to pinch in the first place (especially in the neck compared to the low back), and often not bothered by it when they are.

But “you’re not paranoid if they’re really after you.” Sometimes, when it feels like you really have nerve pain, it’s because you really have nerve pain (neuropathy, one of the basic types of pain).

For instance, here’s an unusual example of a rare but all-too-real nerve pinching problem: nerve root impingement by an artery, of all things. The vertebral artery in the neck is notoriously tortuous. It can spiral and twist its way up the neck in configurations completely unnecessary for the delivery of blood. And it’s not soft and malleable. An artery is a high pressure tube, which can sometimes press firmly and relentlessly on nerve roots, eventually causing symptoms.165 Weird neck pain science!

So if you suspect that your neck pain is the tip of a neuropathic iceberg, it’s important to be able to work towards confirmation of that suspicion.

The three main kinds of neck-related neuropathy

The Big Three types of neuropathy are all about location, location, location. There are three locations where nerve tissue can be bothered, each of them associated with its own “pathy”:

• spinal cord → myelopathy
• nerve roots → radiculopathy
• nerve “branches”166 (peripheral nerves) → peripheral neuropathy

Radiculopathy is the disease of a troubled spinal nerve root. A pair of nerve roots splits off from the spinal cord at each vertebra, and exits through big holes on each side of the spine. They are about a centimetre or two long. The nerve roots quickly split into major nerve trunks, which rapidly split into smaller nerves branching out into the body. Bothering nerve roots usually causes pain, tingling, numbness, and weakness throughout the tissue those nerves penetrate, in a roughly “dermatomal” pattern (see below). “Radicular” pain (the pain of radiculopathy) is often like an electric shock.

Myelopathy is a more dramatic kind of nerve pinch: it refers to the more complex symptoms (including pain) that are caused by the pinching of the entire spinal cord, which is just a giant bundle of nerves of course. The cervical spinal cord is a neurological bottleneck through which every nerve impulse from or to the body must pass, so symptoms caused by trouble at this level of the spinal cord are notoriously variable and can cause trouble essentially anywhere, even — and this is not widely appreciated — shooting pains in the backs of the legs (sciatica).167 It’s even possible that spinal cord pinching may cause chronic widespread pain.168 Symptoms mostly only occur when the spinal canal is narrowed quite a bit by significant degeneration or injury. Narrowing of the spinal canal is spinal stenosis, and fairly common in older people. Interestingly, impingement does not lead inevitably to symptoms: as with any other nerve, the cord is not necessarily vulnerable to a bit of squeezing. “It depends.” So that’s nice to know.

Peripheral neuropathy is trouble with nerves out in the body, away from the spine. The nerve roots of the cervical spine rapidly divide into a complex web of nerve trunks on the side of the neck, reaching out towards the shoulder, called the “brachial plexus.” If the brachial plexus gets into trouble, that’s a “peripheral” neuropathy (even though it’s happening very close to the spine). Despite that proximity, these injuries almost never have anything to do with chronic neck pain: they cause symptoms almost exclusively in the shoulders and arms, sometimes the side of the face. I’m describing it for completeness and perspective, not because brachial plexus injury has much to do with neck pain. Unless you hurt your neck at the same time, of course!

Neuropathic symptoms

Both radiculopathy and myelopathy can cause chronic neck pain! Neither problem is common, and they definitely don’t always cause neck pain, but it is one of the standard symptoms. Exactly how often they cause neck pain is unknown. And then they also usually cause symptoms “downstream” in the tissues affected by those nerves (practically anywhere in the case of myelopathy). Really the only way to know whether your neck pain is related to myelopathy or radiculopathy is if you have both neck pain and other classic neuropathic symptoms. And so here’s an overview …

Classic symptoms of cervical radiculopathy:

• pain spreading into the arm, neck, chest, upper back and/or shoulders
• especially “radicular” (zappy, shooting) pain (more on this below)
• muscle weakness and/or numbness or tingling in fingers or hands
• clumsiness with the hands

Classic symptoms of cervical myelopathy:

• widespread weakness and “heaviness,” and muscle atrophy (advanced cases)
• clumsy hands (just like radiculopathy)
• diffuse numbness in the limbs
• shooting pains in the limbs (especially when bending the head forward)
• an awkward gait

And all of that can be surprisingly subtle. These symptoms are not a diagnostic slam dunk, not even close. It is possible to have radiculopathy and myelopathy with no classic symptoms at all for long periods. And most of the symptoms also have other causes! For instance, with sciatica, “pain below the knee” is the closest thing to a signature symptom, but not every patient with sciatica has that symptom, and some with that symptom do not have sciatica.169 The symptoms just don’t tell the whole story, and that’s almost certainly true for the cervical nerve roots as well.

And so ultimately this review is intended only to inspire further medical investigation. If you have chronic neck pain and you have some other neurological symptoms … then it’s worth asking a doctor about it.

Radicular pain: what nerve root pinching feels like

Radiculopathy can cause very boring pain — just standard aches and pains — but it also often causes a very distinctive type of pain called radicular pain. (That’s basically just Latin for “root pain,” where radix = root.) Radicular pain makes a strong impression on people. It’s not boring.

• It usually goes well into the legs, often past the knee and even as far down as the feet.
• The quality is “electrical” pain that feels like it “zaps” or “shoots.” Sometimes the pain may have a somewhat more “hot piano wire” feeling than electrical. In any case, the pain comes in dramatic blasts along the thin line of a specific nerve — nothing like the more typical nagging aches and throbs of most neck pain.
• Radicular pain is often associated with altered sensation as well:
• True tactile numbness, in which you have reasonably well-defined patches of skin that cannot feel the prick of a pin.
• Pins and needles — or “parasthesia,” which is Latin for altered sensation.
• Radicular pain mostly occurs in patterns, following one of the dermatomes. Sort of — it’s less predictable than I was taught to expect. Most nerve root pinching in the neck occurs at the bottom of the neck, in the C6 or (mostly) C7 dermatome: a stripe down the back and/or thumb side of the forearm into the back of the hand and thumb and first and second fingers. More about these patterns below.

None of that nonsense is normal for non-radicular neck pain, of course. Most neck pain has only minor effects on the arms, if any at all. Trigger points (muscle knots) in the neck and shoulders often do spread aching and burning pains down the arms, and can definitely cause some confusion — but probably not vivid pain and tingling and numbness along a clearly defined path. And muscle pain can also make the arms feel heavy and dead, which is kind of like numbness — but not at all like the true lack of skin sensation that nerve impingement causes. The pins and needles and crawling prickles of neuropathy are especially distinctive.

More about radiculopathy symptoms: Nerve root trouble is felt in interesting patterns … kinda

Lots of data and instructions pass through a nerve root, coming to and from the tissues it supplies. Trouble with the root (radiculopathy) causes trouble throughout the distribution of the root’s downstream nerves, which spreads out in curious patterns: the dermatomes, the stripes of skin associated with each nerve root. Dermatomes spiral around the body like ribbons, down and away from the spine. Pain in a roughly “dermatomal” pattern is one of the most distinctive features of radiculopathy.

Only certain muscles are powered by each nerve root, too — myotomes — so trouble with a nerve root results in weakness of specific muscles.

So every nerve root is responsible for a couple of “tomes”: a skin-tome and a muscle-tome. A dermatome and a myotome.

A standard dermatome diagram showing the curious spiralling stripes of sensory innervation around the arms & legs. The reality is much less tidy, with lots of fuzziness & overlap. A truthful dermatome diagram would look more like a child’s colouring book! Click to embiggen.

Pain, weakness, numbness, and tingling within a tome-zone are strong indicators that a particular nerve root is being squeezed or irritated. But pain and weird sensations usually don’t fill in the area of a dermatome precisely. Instead, they are filled in more like a child’s colouring book: lots of colouring outside the lines! A detailed dermatome mapping study back in 1998, in which brave subjects were subjected to deliberate provocation of their nerve roots — ouch! — finding strong trends but many exceptions: “symptoms were frequently provoked outside of the distribution of classic dermatomal maps.”170 In another study, less than half of patients with L5 nerve root compression identified symptoms in the L5 dermatome.171 In yet another,only about a third was non-dermatomal; in the back, about two thirds.172 It’s all much less predictable than I was trained to expect.173

But why? Probably mainly because anatomy is messy. “Although there is a regular and orderly progression of innervation within each individual, it is likely that innervation patterns differ considerably between individuals.”174 That variability was confirmed in a cadaver study in 2000: no two corpses’ nerves were quite alike. Although nerve roots themselves were quite consistent, they had a rat’s nest of random small branches connecting them, like the tangled roots of a tree.175

Another wrinkle: even when the pain is in a dermatomal pattern, it may not “fill” the pattern, and pain is often experienced mainly in one section of the dermatome, often the most remote part. For instance, burning pain in the middle fingers, which lives completely within the dermatome for the C7 nerve root. Most of the dermatome feels fine, but oh, that finger!

Despite all that, I want to emphasize that the patterns are still mostly reliable: for instance, you don’t have to worry about finding the symptoms of a C6 radiculopathy way over in the C4 dermatome. But adjacent dermatomes likely do overlap more than most professionals think. And this stuff is why neurologists get paid the big bucks. Even the simplified concepts are difficult.

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One possible source of neck pain is the knuckle-like facet joints, as discussed above. In a sense it doesn’t even matter what, exactly, might be going wrong with a facet joint — not if you can numb the whole thing, turning off all sensation like flicking a light switch. Facet joints are a specific anatomical structures with clear “edges,” much clearer than other tissues like muscle,176 so they have become the target of several minimally invasive diagnostic and treatment procedures that aim to temporarily or permanently silence any pain noise coming from them:

• injections of various pain-relieving substances into the joint itself
• nerve blocks which temporarily cut off sensation in the whole structure
• destroying those same nerves

These procedures are all provided by medical specialists, most likely either a physiatrist or an orthopedic surgeon. Do they work? Are they safe?

Nerve blocks as a diagnostic tool

Here’s an interesting (if somewhat drastic) way to find out if a facet joint is the wellspring of spinal pain: cut off the nerve supply to the facet joint! If your pain stops, voila: presumably that’s where the pain was coming from.

This is called a “medial branch block” (MBB), or just “nerve block.” The medial branch nerves are the wee nerves that send information to the brain about tissue condition in the facet joints.177 Without those nerves, the facet joint reports nothing to the brain, and so the brain assumes all is well — a nearly perfect numbing. It’s the same as getting part of your mouth “frozen” at the dentist.

Thus, if an MBB relieves pain, “well there’s your problem.” That provides some diagnostic confidence that the facet joint is the cause of the pain.

But it’s not exactly foolproof. This practice is supported as a diagnostic tool only by scanty, conflicting scientific evidence. Some authors call it “fair” evidence, but probably shouldn’t have.178 The evidence is similar for the thoracic179 and lumbar180 spine.

Nerve blocks as a flawed diagnostic tool

Many other factors tend to confuse this method of diagnosis, which is probably why it hasn’t been validated by research. For example:

• What if 60% of your pain is coming from one facet joint, 20% from another, and 10% from a third? And only one of them gets blocked? What if something else entirely is also causing pain?
• What if the injection just misses? It can be difficult to be accurate with these injections. It takes skill!
• What if the anaesthetic “leaks” into surrounding tissues and numbs the wrong thing?

It gets murkier: the amount of relief low back pain patients get from facet joint injections can be predicted by psychological factors.181 Why would that be? Numbing might provide strong enough temporary relief to create an overconfident “eureka!” And that confidence might itself deliver some pain relief, further clouding the issue, and adding up to a false positive: a misleading result that puts a spotlight on the facet joint that is actually innocent, or only part of the problem. Fortunately, the evidence suggests that this kind of confusion is probably rare, and clear relief probably means what it seems to mean.

All this complexity is also why “the effectiveness of a specific treatment cannot simply be reverse engineered to conclude what caused the pain.”182 So MBB results should be considered as a diagnostic tool for stubborn neck or back pain, but nothing is ever as simple as it seems.

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Provocation discography is the diagnostic evil twin of nerve blocks: while nerve blocks aim to identify the source of pain by eliminating it, discography is intended to identify the source by aggravating it, deliberately injecting an irritant into intervertebral discs. Although this sounds like a clear violation of “do no harm,” it’s surprisingly safe and mostly just a simple and useful idea that has the potential to get badly needed answers about exactly which part of your neck is giving you so much grief. For whatever that’s worth (because even if you identify a discogenic source of pain, that doesn’t mean you can do much about it, or that there aren’t other sources of pain).

Provocative discography

The irritant injected into the disc has high contrast for visibility on X-ray, to confirm the placement of the injection. The pain of the irritant can be quickly relieved with a little anaesthetic.

It’s basically the same as prodding with fingertips to see exactly which bit of anatomy hurts … only the prodding is with a needle deep in the neck. And it’s not as painful as it sounds. It’s only a mild provocation. If the injection causes the same kind of pain that the patient normally suffers from — “is that it?” — that disc is likely a factor in your neck pain. On the other hand, if the poked disc does not produce all-too-familiar discomfort, then it is probably not to blame.

Despite the simple principle and the potential to clarify the situation, provocation discography is far from foolproof; it’s probably more error prone than nerve blocks. The intention to provoke is problematic, especially if it combines with a hatred of needles. The sensory reaction may be clouded by anxiety. The nervous system may interpret the discomfort of the needle as feeling “like” the problem even when it isn’t (false positive). Some results may be ambiguous or just dead wrong, while other results may be crystal clear. Surgeons have expressed concerns about false positives183, lack of standard methods,184 and numerous potential confounding factors, such as a neck with multiple partially involved joints.185 And so discography does not have the clear scientific support that nerve blocks do, at least where low back pain is concerned: The American Pain Society gave a thumbs down to provocative discography in their 2009 guidelines for low back pain.186

The news is oddly much better for neck discography, which received strong scientific endorsement in 2009 with the publication of a paper in Pain Physician.187 Manchikanti et al make a strong case for it, concluding that “cervical discography plays a significant role in selecting surgical candidates and improving outcomes,” despite the controversies, and despite nearly the opposite conclusions about the low back.

There’s enough good sense in this method, and some supporting evidence for it as well, that I think it’s in the “worth a shot” category when the need is great. It’s obviously a terrible idea for new cases of neck pain, or probably even after several months, but for patients struggling with really stubborn pain there’s not much to lose and a genuine hope of a clarified diagnosis. Discuss the possibility with your physician.

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As I’ve argued above, trigger points are probably involved to some degree in almost every case of neck pain. But to what degree? Are they the whole problem? Or “only” a complicating factor? Are they the meal or the sauce?

There are several characteristic signs and symptoms of neck pain that is caused mainly by muscle, or neck pain with another origin that has come to be dominated by trigger points over time. This section provides a quick checklist to give you a rough idea, and a slow checklist that goes into more detail.

For most people, most of the time, confirming a trigger point diagnosis is simple enough. Check all that apply — if you have more than half of these, and no other apparent explanation for your pain, you probably have a trigger point or two.

• You have sore spots in muscles.
• Your pain usually occurs in specific areas of your body.
• The problem feels more like muscles than joints.
• Your pain is primarily dull, aching, and nagging.
• You feel a lot of stiffness as well as pain.
• Affected areas feel weak and heavy.
• Stretching is appealing (but not very effective).
• Hot showers and baths are usually helpful.
• Anti-inflammatory medications don’t really work.

And now for the slow checklist. This list is very similar to the slow checklist for myofascial pain syndrome in the trigger points tutorial, but it is customized for neck pain. Muscle pain in the neck has some distinctive features that are not relevant with muscle pain in other areas — many distinctions are made throughout this section.

• Sensitive under pressure. By definition, trigger points are sensitive patches of soft tissue. If you have a trigger point problem in the neck, your neck muscles will be more sensitive to pressure. That is, it will hurt to poke your neck muscles, compared to muscles in problem-free areas of your body. (These are fairly small muscles in an area that tends to be more sensitive even when it’s healthy, so don’t assume that any sensitivity means trigger points. Use only moderate pressure to check.)
• Headaches! Headaches are a common problem with many possible causes, of course, and could occur even if you don’t have trigger points in your neck. However, their presence is a good indicator of trigger points. And the more headaches feel like an extension of your neck pain, the more likely it is that trigger points are involved.
• Feels like muscle! Pain is a difficult sensation to interpret, but trigger points do often feel like a muscle problem. Many small clues can contribute to this subjective impression: a sense of moderate depth (deeper than skin, shallower than bone), for instance, or sensitivity to flexing and stretching. Muscle pain might be much sharper than you expect, but usually it’s dull. If your pain is mostly aching, and nagging, with a strong “stiffness” component — and there are no obvious signs of other kinds of pain, like stabbing or burning or electrical sensations — then muscle may be the source of your troubles.
• No other obvious cause for pain! And by “obvious” I mostly mean “injury.” One of the simplest ways to diagnose trigger points is simply by elimination: if there is no obvious trauma, then trigger points are more likely. There is much more detail about this in the section about trigger points and injury.
• You have neck trauma, but it’s old. Perhaps you really did injure your neck … once upon a time. However, necks heal like any other part of your body. If your injury happened more than twelve weeks ago, you have probably more-or-less healed, and any continuing pain that you have is much more likely to be caused by trigger points. (There are other reasons pain might persist after healing, but trigger points are a strong possibility.) This is the “out of the frying pan, into the fire” phenomenon, discussed in another section, and in a separate article, Muscle Pain as an Injury Complication: The story of how I finally “miraculously” recovered from the pain of a serious shoulder injury, long after the injury itself had healed.
• Aching, not sharp. Your pain is primarily dull, aching, nagging pain, as opposed to sharp, stabbing, burning. Although nearly any quality of pain is possible, and particularly flared up triggers can get more focal and intense and toothachy, most trigger point pain most of the time is a dull ache. There aren’t many other unclear causes of pain that ache. For instance, arthritis usually has an aching quality, but it’s obviously joint pain.
• Similar pain in areas of the body. Trigger point pain is “patchy,” afflicting some predictable areas of the body, especially the meatier tissues of the trunk (neck, shoulders, upper back, low back, and hips). Other kinds of problems would cause different kinds of pain, or more widespread and uniform pain (like the diffuse all-over sensitivity of the flu, or muscle soreness after unfamiliar exertion, which always affects an entire muscle group uniformly). Trigger points usually afflict just one or two regions of the body at a time (but sometimes more, of course).
• Abnormal texture. You might be able to feel a lump in your muscle and a hard and ropy texture around it, but then again you might not. This is an unreliable way to diagnose trigger points, but it’s particularly tricky in the neck, because there are many normal anatomical structures that feel like bumps and ropy structures. However, in some muscles in this area bumps stand out quite nicely: the long smooth slope of the trapezius muscle on the top of the shoulder,188 or the long and lanky sternocleidomastoid on the side of the throat (the ones that make a V-shape).
• Anti-inflammatories don’t help much. Since there is little or no inflammation per se involved in MPS, anti-inflammatories like Aspirin or ibuprofen (Motrin, Advil, etc) often have little or no effect. If they do help, that suggests the pain has a more “traditional” inflammatory nature (associated with tissue damage, such as a wounded facet joint or a ruptured intervertebral disc). Some other conditions, notably fibromyalgia, also cause pain that doesn’t respond well to anti-inflammatories, so this sign is hardly a slam dunk on its own. Note that benefits from other drugs are not very informative.189
• Wandering pain. One of the clearest signs of muscle-dominated pain is symptoms that change location, either moving to another area of the body altogether, or erratically shifting around and spreading out from a predictable epicentre. In addition to moving, trigger point pain also often changes quality, and comes and goes without much rhyme or reason (the “outta nowhere” phenomenon). Not all trigger point pain is so erratic, but it often is. On the other hand, injury pain is much more predictable, and particularly tends to stay put. If your neck pain keeps moving on you, this is a good indication that muscle pain is the main problem, and it’s especially common for the muscle pain in the neck to drift higher or lower, or to switch sides (see next checklist item).
• Mirror image pain. Pain arising from damaged anatomy is rarely neatly symmetrical. Trigger points, however, quite often have “evil twins” in the same location on the opposite side of the spine. Although the pain dominates one side, it may occasionally flip over to the other, and even a single instance of this is a strong indicator that injured tissue is not to blame (because injured tissues can’t change sides). It’s more likely to be caused by muscular trigger points than by injury. Also, it’s an extremely common pattern with neck pain patients that their pain flips to the other side following some kind (any kind) of treatment.190
• There are signs of chronic or severe stress in your life. If the connection between neck pain and stress is not obvious in your case — flare ups of neck pain during crises — there may be many other signs of it. People who suffer from excessive muscle pain often have a medical history that includes other consequences of stress and stress-sensitive conditions (e.g. ulcers, panic attacks, insomnia, irritable bowel syndrome, etc).
• Heat helps. Hot showers and baths and other forms of heating, even just warm weather, are almost always helpful. Many kinds of chronic pain are helped by heat,191 but not all, and fibromyalgia pain is the most interesting exception: it is usually worsened by hot weather,192 but MPS patients almost always prefer it. This is one of the clearest differences between these otherwise extremely similar conditions. Score a point for a trigger point diagnosis if you like to be toasty.
• Symptoms are aggravated by muscular effort and overexertion. Assuming that trigger points are some kind of muscle dysfunction, it follows that they will flare up when we demand more function from the muscle, and this is commonly reported. Muscles can be exhausted either by an obviously intense exercise like shoveling, or by less obvious postural stress — holding awkward postures. If you predictably have flare-ups of pain in situations where muscles are working, then muscle is probably the problem. In the case of the neck, “muscular effort” almost always means postural stress. For instance, you will tend to notice symptoms most when sitting at a computer. Reading tutorials like this, perhaps! If you predictably have flare-ups of pain in situations where muscles are working, then muscle is probably the problem.
• The pain of stuckness. The discomfort of trigger points may be experienced as stiffness following periods of immobilization (e.g. hours in an airplane seat, or even a movie). This is a weak signal because there are several other possible causes of stiffness, particularly in older people (arthritis and the progression of many subtle sources of inflammation that accumulate over the years, known as “inflammaging”). But relatively widespread stiffness in a younger person with no other known health issues, trigger points are a more plausible suspect.

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“I just can’t figure out what sets it off!” Seemingly random flare-ups of pain that come and go relatively quickly are one of the signature symptoms of pain problems dominated by muscle; by contrast, pain originating with any spinal tissue insults tends to be more obviously associated with trauma followed by a traditional recovery period. Consider how long it takes for a bad bruise to fade, and compare and contrast that with your neck pain. Did you fairly obviously piss off your neck one day playing hockey, and it took about 3 weeks to calm down, and another 3 to fully resolve? That’s a typical injury progression: tissues were insulted and needed some time to get over it.

Or did you get a weird spike in pain one day, and it drove you nuts for 5 days and then eased up? And then you were mostly fine for a week and it happened again, but higher up? That kind of erratic pain pattern is much more likely to be the work of muscles.

The difference is hardly clear cut. Injuries can be erratically re-aggravated, resembling the mercurial behaviour of muscle pain. And muscle pain can be shockingly consistent and cause 6-week batches of pain that are nearly impossible to distinguish from injuries. But as a general rule of thumb, muscle pain is more “all over the place” than other kinds of pain, and in particular it’s much more prone to “time bomb effect”: bursting onto the scene with no obvious provocation.

That time-bomb effect is probably due to pre-existing painless vulnerability which can be pushed over into a more serious pain problem by relatively minor stresses.

Trigger points appear to exist in two states (really just halves of a spectrum of severity): latent and active. Latent trigger points are present but they don’t hurt unless poked. An active trigger point hurts no matter what. Latent trigger points can lurk unsuspected for weeks, months or years, finally becoming active and painful with minor provocation — the straw that broke the camel’s back. This creates the illusion that the symptoms have come “outta nowhere,” when in fact the problem was simply developing for a long time before you felt it.

Again, there are other possible explanations. For instance, low-grade irritation from a spinal structure could also constitute a vulnerability that suddenly blossoms into full-blown pain with relatively little provocation. Brains may ignore a slow-developing problem for a long time and then sound the alarm quite loudly and suddenly when a certain threshold of severity if reached. So there’s no way to be sure.

But the “outta nowhere” phenomenon is a strong feature of chronic pain problems dominated by muscle, and even more so with neck and back pain. Neck pain routinely occurs in prominent spikes of intensity.

There is one particularly obvious situation in which neck pain comes out of nowhere: people wake up with neck pain …

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Sleeping is hazardous! An amazing amount of both neck and back pain — but particularly neck pain — seems to start when we are sleeping. This is probably because spines are often in awkward positions at night, and because we may move suddenly and groggily in response to dreams and nightmares, or because the cat jumps on us.

The neck (much more than the back) is also often exposed to cold drafts at night, which is an another risk factor for the formation and activation of trigger points. Chilling an over-stretched muscle seems to be one of the most reliable methods of creating a trigger point in a previously healthy muscle (or for aggravating a mild one into something much more obvious). I suspect that this is a common cause of woke-up-with-it neck cricks. But I also haven’t got a shred of proof of that, and I will probably die not actually knowing.193

Although it’s also possible that we might experience mild trauma (MIDs) during the night, I doubt that is the cause of morning-onset neck pain. Patients rarely report being woken by a sudden stab of neck pain. Rather, they report that they wake up at the normal time only to discover that their necks feel rather worse than when they went to bed. In many cases, it’s not actually even all that bad upon waking — just a stiffness, really — but then escalates steadily into a major problem well before lunch. This is definitely how trigger points can behave: once irritated, they can rapidly get worse.

I have experienced being woken up by a sudden onset of my own neck pain, once or twice in my life I think. Being jarred awake by sudden neck pain is definitely not the same thing as waking up with neck pain, and it seems to be the much less common experience.

The phenomenon of waking up with neck pain suggests that there might be an opportunity for treatment and prevention. For instance, protecting the neck from drafts with a light scarf might be useful. Could sleeping position or pillows help? I’ll look at those possibilities later on, especially pillowing, but there is only so much we can do to protect ourselves while we sleep. It is interesting though, isn’t it? Perhaps understanding it helps to reduce some of the mystery and uncertainty of morning-onset neck cricks.

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Neck cricks/pain and headaches often go together. If you’re having “all of the above,” it’s important to understand how they might be working together to make you miserable. Your headache might simply be an extension of your neck pain, and it might be possible — or even necessary — to solve them together.

A headache caused by neck trouble is a “cervicogenic” headache.194 The International Headache Society recognises this type of headache as a distinct and common disorder.195 A survey of 1400 patients with chronic neck pain found 10% had severe chronic headaches as well, mainly migraines (90%) but cervicogenic headache was in second place.196 Three quarters had at least one sensitive spot in their neck musculature.197 We also know that a lot of headaches can be shut down by numbing the neck (diagnostic nerve block),198 which kinda sorta proves that at least some headaches have neck roots.

Here are some diagnostic clues that your headaches are more of a neck problem (derived from the IHS diagnostic criteria):

1. pain on one side of the head
2. discomfort in the arm/shoulder on the same side
3. limited neck movement — a crick, in other words!
4. poking muscles in the neck, or pushing against movement limits, aggravates the headache

And I’ll add one more, which comes from a survey of Norwegians: about 4% had headaches with seemingly cervicogenic characteristics, and in nearly all of those cases (97%) their headaches typically started in the neck.199 So here’s another clue:

5. headache pain starts in the neck

The other side of the story

So all that sounds almost official, like cervicogenic headache is a Totally Real Thing. But nothing is ever as simple as it seems in this business. Although the IHS criteria for cervicogenic headache seem impressively technical, the savvy reader will notice that’s just a heavily jargonized way of saying this:

“If a headache seems like it’s related to neck pain … well, it sure might be!”

•slow clap•

A close look at the criteria does not inspire confidence. For instance, the formal diagnostic criteria declare the need for “clinical, laboratory and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache.” Let’s break that down. “Clinical evidence” is just “professional opinion,” and “known to be able to cause headache” is a reference to … non-existent knowledge. Know to whom? Known how? What disorders or lesions are those? Wouldn’t that be rather relevant to include in the criteria? Yes, it would! They aren’t included because no one knows that. So really what that statement means is this: “To diagnose cervicogenic headache, you need to suspect it’s a cervicogenic headache, and/or have test results that show a problem in the neck that could definitely maybe cause a headache.”

So no one has a damn clue if some headaches start in the neck, not really. But it sure does seem like it! It really, really does!

Migraine and neck pain

Migraine is a neurological brain ache, typically much weirder than a tension headache. “A migraine is not just a bad headache,” writes James Cottrill, a migraineur (migraine sufferer) and prolific writer on the subject. “In fact, some people get migraine without any headache at all!” Just hallucinations and stuff. Fun.

There is no reason to believe that neck pain, or trigger points in the head or neck, actually cause migraines. However, the discomfort might trigger migraine attacks in some patients.200 Migraine attacks are set off by a variety of odd triggers, things as different as chocolate, menstruation, and getting too much sleep. Trigger points probably trigger migraines too, simply because they are uncomfortable. And therefore any neck crick, regardless of cause, might also occasionally be a migraine trigger.

But this is just speculation. It’s also possible that trigger points are just a sideshow and have little impact on the biology of migraine.

Although trigger points don’t explain migraines, migraines can certainly directly cause trigger points — anything painful can cause trigger points, and very few things are as painful as a painful migraine. So migraine sufferers tend to have trigger points throughout their heads and necks — and are therefore almost certainly at a higher risk for getting neck cricks!

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For more information about ordinary headaches, see my own tutorial, The Complete Guide to Chronic Tension Headaches. For more about migraine, see Jim Cottrill’s websites, Headache and Migraine News Blog and Relieve Migraine Headache. An informative and surprisingly hilarious book about migraine is Paula Kamen’s All in My Head: An epic quest to cure an unrelenting, totally unreasonable, and only slightly enlightening headache.

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Know your enemy!

This section presents quite a comprehensive list of somewhat common medical problems that can cause neck pain (and might, conceivably, be confused with an “ordinary” case of neck pain), and gives you a quick idea of what they are and what distinguishes them. If you find anything on this list that seems related to your case, present the idea to your doctor, and get a referral to a specialist if necessary. (Note: truly serious causes of neck pain were discussed above. This list focuses on less severe possible causes of neck pain … though some are still nasty!)

Some skin problems on the neck can cause neck pain, but are usually obvious — most people will identify them as “skin problems on the neck” and not “a neck problem affecting the skin.” Herpes zoster (shingles) causes a painful rash, cellulitis is extremely painful but superficial, and a carbuncle … well, it’s just a super zit, basically. If you can’t diagnose that one on your own, I can’t help you!

Bornholm disease (or epidemic pleurodynia or epidemic myalgia or any of several other interesting and colorful names such as Bamble disease, the Devil’s Grip, and The Grasp of the Phantom! I swear I’m not making those up!) Bornholm disease is a crazy viral disease that feels like a vice-grip on the chest and lungs, is strongly painful, and sometimes also causes neck pain. If you feel like you can’t breathe, you should look into this. The infection is temporary. I bet this tutorial can be on the market for the next thirty years and not one reader will discover that his or her neck pain is caused by Bornholm disease. Still, it’s good to be thorough!

Trichinosis (or trichinellosis, or trichiniasis) is a parasitic disease caused by eating raw or undercooked pork and wild game. It can be mild or severe or fatal, and digestive disturbance is likely. It can also cause spasming and widespread muscle pain, including the neck. There’s a laundry list of other symptoms, so if you think this could possibly be your problem, read more about it.

Arteries in the temple can become inflamed, causing many symptoms: severe headache, fever, scalp tenderness, jaw pain, vision trouble, and ringing in the ears are all possible symptoms, along with neck pain. It’s almost unheard of in people younger than 50, and it usually occurs in people with other diseases or infections.

Lymphadenopathy. The lymph nodes of the neck may bulge and swell in response to disease or infection. Once in a blue moon, someone might mistake these bulgings for muscle knots. More likely, it will be obvious that something else is going on: a variety of other symptoms.

Parsonage-Turner syndrome (inflammation of the brachial plexus). For no known reason, sometimes the web of nerves that exit the cervical spine, the brachial plexus, becomes rapidly inflamed. This condition may sometimes occur along with neck pain. Strong pain in the shoulder and arm develops quickly, weakens the limb, and even atrophies the muscles over several months. There is no cure, but most people make a complete recovery.

Thyroiditis, inflammation of the thyroid gland in the throat, can be difficult to diagnose, causing a bewildering array of vague symptoms. If your neck pain is accompanied by symptoms like fatigue, weight gain, feeling “fuzzy headed,” depression and constipation, consider checking with your doctor.

Eagle’s syndrome is a rare abnormal elongation of a bizarre little bit of bone at the back of the throat called the styloid process. Even a normal styloid process looks jarring when you first see one: it is so skinny and sharp that it makes one wonder how it can possibly not be stabbing something. Well, it turns out that in some cases it does “stab” you in the neck. This will cause a feeling of a lump in the throat and/or moderate intensity pains throughout the region, possibly including the side of the neck, although pain is more likely to dominate the jaw and throat.201

Orthostatic hypotension, poor blood pressure on standing, can cause coat hanger pain in the neck and upper shoulders. This is a fairly common symptom of a troubled autonomic nervous system, which in turn has many possible causes. There’s a short chapter about this below… but you can skip it if your neck pain isn’t part of an obvious coat hanger pattern and obviously eased by lying down.

Once again: tumours, rheumatoid arthritis, serious infections like meningitis, spinal cord impingement, and other ominous causes of neck pain are covered in another section.

And then there’s atlantoaxial instability …

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Atlantoaxial instability (AAI) is wobbliness of the top joint in the neck, the last one before the spine connection to the underside of the cranium. When this joint is unstable, the spinal cord can get pinched. The precarious situation often causes years of discomfort in the area without any other dramatic symptoms. It’s rare enough that few people need to worry about it, but common enough that I need to bring it up. It is ominous enough to be serious, but not so impossible to live with that a diagnosis needs to scare anyone. It is a truly mechanical problem with the spine, and yet has nothing to do with the spine being “out” in the sense that a chiropractor could “adjust” — indeed, adjustment of this condition could be lethal or, at the least, extremely unpleasant.

I had a barber that once got so dizzy after a massage that he couldn’t stand or drive properly. He vomited several times when he arrived home. His therapist told him that the massage had “released lots of toxins into your bloodstream.”

Please repeat after me: severe dizziness and repeated vomiting is not a normal reaction to massage therapy!202 Nor is it a normal reaction to any other kind of physical therapy.

This case is described in more detail in a separate article, What Happened To My Barber?

These are the first & second cervical vertebrae — the “atlas” & “axis” — with the peculiar finger-like projection of the axis (the “dens”). It sticks upwards into the ring of the atlas above it … & it shares that small space with the brain stem (red). It is normally strapped to the side of the ring by a tough ligament. But if that ligament loosens or breaks … 😬

My barber was probably poked in the brainstem. Most likely he had AAI. (It might also have been a mini-stroke, a possibility I cover in the full article about his case.) AAI might be caused by an old injury to the neck, sometimes by disease, or by a birth defect. If you’ve got it, neck flexion can cause a finger-like projection of bone — the “dens” — to poke you in the brain stem, with consequences ranging from extremely unpleasant to dangerous in some cases.

Severe chronic neck pain and headaches — the reason my barber went for a massage in the first place — are probably the result of neck muscles working tirelessly to keep everything stable, and probably developing a good crop of trigger points. Thus a bad case of chronic neck pain could be directly due to this underlying problem.

Or not. AAI is one of the most fascinating examples in all of musculoskeletal health care of something that seems like it should always cause severe problems, but it actually doesn’t, and no one really has a clue why. It illustrates perfectly how difficult it is to understand the role of joint dysfunction in neck pain. Even patients with severe AAI may have no symptoms at all, while others with relatively minor instability experience significant problems.203 It is also impossible for professionals to reliably diagnose AAI “by feel,”204 as I was trained to do.

Despite the seeming seriousness of a cervical joint dislocation, it is obviously possible for patients with AAI to lead normal lives. If they suffer from chronic neck pain or headaches they can probably be treated cautiously with massage therapy — but it is crucial that they understand the nature of their problem. Careless massage therapy and virtually any chiropractic adjustment are obviously potentially hazardous for patients with AAI, and athletic activities like skiing need to be reconsidered.

If you have a history of unexplained nausea and vomiting, particularly if you can associate these symptoms with neck movement, do read the full article about my barber, and please discuss your concerns with your physician. Many family doctors may not be familiar with AAI, but most will be sympathetic to your desire to investigate such a serious concern. Just express it in terms of “better safe than sorry.”

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“Coat hanger” pain is a triangular pattern of headache, neck, and upper shoulder pain. This pattern of pain can occur for relatively trivial reasons, many of which are discussed in this tutorial in detail, but if it’s strong and clearly linked to standing up, then more serious causes should be suspected — nothing that’s an emergency, but more exotic and, with more general medical implications than most neck pain involves. I am devoting a small chapter to it because it’s relatively common.

The coat-hanger pattern is linked to an inability to sustain blood pressure when standing up (orthostatic or postural hypotension ❐), which in turn has many possible causes. Blood pressure is regulated by the autonomic nervous system, and many things can throw the ANS off kilter to varying degrees (dysautonomia), but it’s a common complication of spinal injuries.205

If your neck pain is caused by this phenomenon, you will probably also have headaches, general malaise and fragility (dysautonomia is linked to fibromyalgia). Most distinctively, you’ll have surges of symptoms when you stand up after lying down, especially lightheadedness. If you can get some relief by lying down, that’s even more diagnostically certain.

Since the mechanism of pain is probably “just” a lack of blood flow to the muscles, anything that increases blood volume (and therefore pressure) is likely to be helpful: salt, fluids, compression stockings, exercise, and drugs. DysautonomiaInternational.org ❐ is a good source of more information about orthostatic hypertension.

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Digital motion X-ray (DMX) is an X-ray video: many hundreds or even thousands of X-ray images strung together. This technology seems amazing, and maybe it offers some diagnostic hope to people with serious, mysterious chronic pain — especially in the highly mobile neck, where there seems to be the greatest potential for a moving X-ray to expose something too hard to see with conventional X-ray, CT scan, or MRI. For instance, these two videos (part 1, part 2) show several cervical spine injuries that somehow (!) escaped previous diagnosis. Some DMX videos are really eyebrow raising, like this cringe-inducer:

In this video, the patient’s head is almost literally falling off. The 1st cervical vertebra is not fully attached to the 2nd! Click to embiggen.

I’m bringing up DMX in this book because neck pain patients are the largest target market for DMX, and I have major concerns about it. This is a quick summary of the topic. For a more detailed review, see:

Despite the diagnostic power of DMX, this is not a common or mainstream medical technology, and there are good reasons for that. It is used almost exclusively by chiropractors, and has a dark side: radiation exposure.

With great power comes great responsibility. Radiation is dangerous! Radiologists and technicians carefully tune X-ray equipment to minimize exposure to both patients and medical staff. If a regular series of five well-calibrated X-rays involves some risk from radiation exposure, preferably avoided, how much for hundreds of pictures at least? Video X-ray requires a series of X-rays, enough of them for animation, so by definition it involves more radiation exposure. How much more? Unknown — and that’s the problem. There are many variables, but even the best case scenario is a concern. Health Canada banned this technology because of the unknowns: unknown energy output, and unknown calibration status particularly.

So, how badly do you need that “high-tech” diagnosis? (It’s not really high tech. It’s just an X-ray movie.) Is it worth an increased risk of cancer? Possibly even a greatly increased risk? To diagnose conditions that, mostly, can and should be diagnosed any other way?

Yes, it is true that scary problems can be missed by doctors. But that doesn’t mean it’s a good idea to soak yourself in X-rays to chase them down. Any radiologist who actually missed something as serious as a complete fracture in the upper neck would probably get sued. It is possible that an X-ray movie could occasionally identify something difficult to diagnose by other means — but you could say that about exploratory surgery and autopsy, too. Not all diagnostic procedures are worth the risks, and radiation exposure is one of the worst down-sides in all of medical technology.

I’m not actually telling you categorically not to do it. I’m telling you to be super cautious about it. For desperate patients with little to lose, and a trusted provider who is being candid about the potential risks as well as benefits, it could be appropriate. But I suspect that most patients who are thinking about paying for this diagnostic service probably shouldn’t.

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Earlier I introduced the concept of sensitization: the over-reaction of the nervous system to stimuli that usually sets in and takes over and puts the “chronic” in chronic pain. The fully sensitized neck pain patient often has more of a sensitization problem than a neck problem.

This begs the question:206 how can you tell the difference? It’s kind of like asking someone hard-of-hearing if their TV is turned up too loud: it sounds right to them. How are you supposed to know if your brain has turned neck pain up too loud?

There truly is no way to be sure, but the more of these items you check off, the more likely you are to be sensitized. (These items are taken from many sources, but particularly Smart et al.207)

• Starting with the obvious: you have no obvious cause for your pain, no recent injury, no known source for the pain. You are medically unexplained.
• Your pain is chronic. Sensitization usually requires months to establish itself.
• Your pain is out of proportion to any known, recent injury.
• It’s hard to tell what’s going to make you feel better or worse. While some things may help or hurt consistently, others do not. You have good days and bad days and can’t figure out why.
• You are seriously pessimistic, and you have a lot of worries about it being a sign of something worse (e.g. catastrophizing).
• You have too much pain and tenderness elsewhere: sore anatomy that “shouldn’t” be sore because it’s unlikely to be related to your pain.
• A history of troubles in the areas that are strongly associated with sensitization: neck and shoulders, low back, abdomen, jaw.
• High overall stress load: exhaustion, poor sleep, chronic stress, anxiety, depression, and/or anything else that drains or menaces you (like another significant medical problem). Obviously almost any adult without a perfect life could check this one off, but it’s a matter of degree.
• You’re female. Unfortunately, this really is a risk factor!
• Overuse of stimulants like nicotine, caffeine, or more potent ones. Or withdrawal from sedatives like benzos (Valium), which can jangle your nerves for a surprisingly long time (months).
• Your pain is erratic and more likely to fade into the background when you’re happily preoccupied. This is a whole category of tricky, subtle possibilities.

That last one deserves some extra attention. Sensitization makes pain worse because the CNS is convinced that there’s more of a threat than there actually is. If pain backs off at times when the brain is “reassured” and/or distracted, that tends to indicate that sensitization is involved.

Failure to respond to “reassuring” situations doesn’t mean that there’s no sensitization — because it may just be too strong, which is absolutely possible. Likewise, a strong improvement doesn’t guarantee that there’s no pathology, or an injury still slowly healing — because the brain is capable of dampening any pain.

But a pattern of signs that your pain backs off when your brain is either reassured or preoccupied with higher priorities … that is a valuable clue, and well worth bearing in mind throughout any and all treatment experiments.

For example, “positional_release” is deliberate, meditative resting in a position of comfort: an exceptionally subtle and minimalistic treatment concept. It’s doomed to failure unless sensitization is a big factor… but if it succeeds, it tends to confirm that sensitization is a big factor.

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A placebo is relief from belief: people often feel better simply because they believe they have been treated. More precisely, it is the appearance or illusion of a treatment effect that is not actually attributable to a biological treatment mechanism. It’s a fascinating phenomenon, but its “power” is over-hyped.

This is a standard section in most of my books, covering several key points about placebo that are important context for any thorough discussion of evidence-based treatment options. I do not substantiate any of these points here — all the references are in a more detailed article about placebo.

• Placebo is not just one phenomenon — “the” placebo effect — but miscellaneous illusions that can collectively create the appearance of an effective treatment. Placebo is complicated!
• Placebo has a special relationship with pain. Reassurance (placebo) has more potential to relieve pain than most symptoms, because pain is strongly modulated by perception. But that only goes so far.
• Placebo is not a magical mind-over-pain superpower and its effects tend to be minor and/or brief. It can’t affect injury and organic pathology; it can only tinker with our experience of them.
• Placebo can also backfire. When a placebo effect wears off — as it usually does — people often fear that they must be really screwed, and then placebo turns to nocebo, placebo’s evil twin: feeling worse because of belief.
• Placebo potency is driven by whatever impresses the patient with the seriousness and legitimacy of treatment: risks, costs, size, intensity, technology and even odd minutiae like the colour of pills. This is why we have the concept of “therapy theatre” — because so much therapy is all about putting on a show.
• One of the best ways to impress people is with novel and intense sensations, because the patient can feel the “power” of the treatment. This is the basis of most manual (hands-on) therapies: they are sensation-enhanced placebos (“interactive therapy theatre”).
• Placebo has been hijacked and re-branded for its public relations value to alternative medicine. If your treatment isn’t evidence-based, no worries: you can still sell the power of placebo! “The power of placebo” is widely, weirdly used as a justification for therapy that can’t beat a placebo.
• Placebo does not work when you know it’s a placebo, contrary to what many people have heard (based on a couple bad scientific papers). The popular idea of “placebo without deception” is just bullshit, based on an experiment that created a strong expectation effect by inflating the participants’ expectations of placebo. So it was just an odd way of getting to the same phenomenon.
• Many snake oils supposedly work on animals, and if animals are immune to placebo then the treatment must be legit. But animals (and their biased human observers and caregivers) are definitely not immune to placebo. In fact, with animals there is even more opportunity for an illusion of a treatment effect.

We have a word for medical treatments that only work if you believe that they will, and it rhymes with “gazebo.”

Book Review, Unlearn Your Pain [Schubiner], by Scott Alexander

Is it okay to pay for a placebo?

Many people claim to be happy to pay for a placebo. As long as it works, who cares how? And placebo can work! So why not? This is an extremely common sentiment, raised in most discussions about a treatment that failed to beat a placebo in a fair test (invariably overlooking the fact that neither the treatment nor the placebo actually work very well).

I have no problem with people paying for a placebo as long as their eyes are wide open, but the wider your eyes get the less likely you are to get even a minor benefit.

And paying for things is never completely harmless.

Treatments with unknown efficacy but some plausibility and low risks are the least objectionable placebos to pay for. I’ve tried many such treatments, knowing full well that any effect I enjoy is probably just placebo (or regression to the mean, or natural recovery)… but it might be an actual effect, and I’m willing to pay a little for that chance. I’m gambling on getting a genuine benefit, with a bit of placebo as a consolation prize. So, for me, the plausibility has to be there.

Comic by Loren Fishman, HumoresqueCartoons.com.

What I want readers to take away from this is that placebo is not therapy. It’s mostly just an over-rated curve ball that accounts for an awful lot of temporary “success” stories.

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One of the most important developments in medicine is the string of recent discoveries that many popular musculoskeletal surgeries simply don’t work. Surgeries have always been surprisingly based on tradition, authority, and educated guessing rather than good scientific trials; as they are (finally) tested properly, compared to a placebo (a sham surgery), many are failing those tests.

This all started with a famous study in 2002 that showed that “polishing” the surfaces of arthritic knee joints worked no better than a placebo surgery where only an incision was made.215 Since then, many similar studies have been done, with many similar results, especially for orthopedic surgeries,216 or any problem dominated by chronic pain.217

Pain-dominated conditions are much more susceptible to placebo, and tend to make surgery seem a lot more effective than it is. This recent discovery that the repair of “obvious” defects often doesn’t do much is completely consistent with a major theme in this book: that chronic pain is multifactorial and rarely attributable to anything anatomical that can be trimmed, fused, or excised.

All the disappointing results have become a crisis for orthopedic surgery, with many experts starting to wonder if any procedure actually works. For these reasons, when I write about surgery in my tutorials, it is mostly to discuss whether or not it might be possible to avoid surgery, and at what point to start considering surgery. Beyond that point, it’s all between you and your surgeon. Just beware of surgeons who don’t seem to be aware of the evidence that it’s difficult to “correct” musculoskeletal problems. The standard answer to the question “should I have surgery” is that there’s always a chance it’s worth it for a given case … even if it’s not for 20 others. But you need a good surgeon to talk that through with.

No good (or terrible) surgical options

Despite the orthopedic surgery crisis, few common neck pain surgeries have yet been compared to placebo. As usual, the best we have to go on is the back pain research.

Sometimes I write about specific surgeries that are strongly supported or undermined by the evidence. However, there are no such procedures for the neck: no common surgery for neck pain is either clearly useless or an obvious win. The science is a complicated, inconclusive mess — which is to be expected, since we don’t really understand what causes most chronic neck pain in the first place. Results depend on a lot of unknown and unknowable variables. The right surgery for the right patient can be effective. It can also fail completely, or even go terribly wrong, causing worse pain and dysfunction. The risks are not high for most procedures, but all surgery is well worth avoiding if at all possible.

Surgery for neck pain is most worth considering when conservative therapy isn’t working, and/or when your symptoms are severe or include neurological problems, like severe and persistent tingling and numbness in the arms. However, since extremely few patients have truly “tried everything” — indeed, since most have spent months or years paying through the nose for therapies of dubious value — it’s a rare patient who should be thinking about surgery yet. Most have simply not yet given non-surgical options a fair shot, and really need to do that before considering surgery … guided by a better understanding of the issues.

But some cases really do defy all accessible treatments. And if you are experiencing progressive neurological symptoms involving your arms and legs and/or difficulty with balance or walking, it’s time to talk to a surgeon.

The major surgical options

• Disc removal or “trimming” (discectomy) is the removal of a little bit of the disk (and possibly bone) that seems to be causing trouble by pressing on a nerve root. The approach can be quite cautious, or much more aggressive, depending on the specific problem and the surgeon,219 but the spirit of it is always “let’s just clean this up a bit.” Of all the common procedures, this is the most cautious, and also the least likely to either help or harm. Even for back pain, discectomy is poorly studied: not much evidence, and none of the right kind.220
• Fusion is based on the dubious logic that there will be less pain in an intervertebral joint if it’s immobilized. While undoubtedly true in a few cases, it’s probably wrong in most. The lockdown is usually achieved by building a bone bridge across the gap between vertebrae, and then fresh bone grows across the bridge. But there are many different ways of fusing intervertebral joints. Sometimes the intervertebral disc is removed to let the vertebra grow into each other. And “heavily marketed” artificial implants are now often being used for the same purpose… but these are disturbingly unstudied at least as late as 2018.221 There have been other major scandals with untested implants causing widespread harm, most notably the fascinating/creepy disaster of metal-on-metal hip implants.222
• Disc replacement is a fancy modern alternative to fusion which involves installing an artificial intervertebral disc, which is intended to allow for continued function rather than just completely eliminating the utility of the joint. This fairly radical procedure is supported mainly by the “common sense” of surgeons and a few promising preliminary trials. Many surgeons are super excited about it: “the most significant advancement since the modern treatment of spinal disorders began 70 years ago … the lives of millions of patients will change for the better.” That’s hyperbole for sure. Like so many surgeries, it has not yet been properly tested, and probably won’t perform as well as hoped when it finally is. What little evidence there is so far clearly indicates only that it works roughly as well as conventional fusion,223 a procedure that itself is widely regarded as ineffective. And, as with fusion, it involves another implant with an unknown safety profile.

Making space — There are several ways to surgically remove physical pressure from the cervical nerve roots, the spinal cord, or both. There are so many different options here that it’s difficult to summarize meaningfully, but they are definitely all variations on the same theme: making space! Probably the most common version is posterior cervical laminoforaminotomy, which is basically hole widening surgery — the hole that the nerve root passes through. This isn’t as drastic as it sounds, and is even considered a “minimally invasive” procedure. Used with the right patients, the space-making surgeries might be the most promising of the neck surgeries: relatively lower risks, and more directly relevant to a well-established mechanism of pain. That said, this category is just as inadequately studied as the others. The others are performed because they “make sense,” not because they’ve been proven effective, and the only difference here is that the sense and safety are clearer.

Discouraging footnote: NICE is a UK organization that publishes high quality medical practice guidelines … and both fusion and lumbar disc replacement are on NICE’s naughty list of ineffective back pain treatments, along with the likes of antidepressants, TENS, support belts, and traction.224 Not good!

Muscle pain in recovery from surgery

Muscle pain is an important factor to consider in recovery from surgery, just as it is in every other aspect of neck pain, for several reasons: muscle is usually responsible for some significant portion of symptoms and continues to produce pain despite alleged repair of any defect. Muscle pain may emerge as a significant complication of surgery. Surgery is a trauma, after all, and muscle pain is a common and often underestimated complication of trauma. Continuing muscle pain may even explain why surgery sometimes “fails.”

Consider a hypothetical patient whose pain was originally caused by a serious disc herniation, which caused a complex mix of radiculopathy (nerve pain) and muscle pain. Discectomy finally relieved the symptoms of nerve root compression, but pain increased because the muscle tissue was even more irritated in the aftermath of the surgery. The patient knows next to nothing about muscle pain, and neither did the surgeon or any other health professional involved. The surgery is eventually, tragically regarded as a failure, when in fact it did all that could have been hoped, and simply needed more appropriate therapy follow-up.

This is why this tutorial is still helpful, I hope, for cases that clearly require a surgical solution: because understanding the role of muscle in neck pain may really increase the chances of a surgical success.

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If you smoke … quit before surgery, if you possibly can. The effects of smoking go far beyond lungs. Smoking damages the architecture of the spine,225 slows down recovery, and is strongly associated with chronic pain.226 Both smoking and obesity have been shown to have a negative impact on spinal fusion surgery outcome.

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Earlier in the tutorial, I explained the diagnostic power of nerve blocks (specifically medial branch blocks, or MBBs). If cutting off the nerve supply to a facet joint significantly improves your symptoms, then maybe the facet joint is the source of the pain — it’s not as sure a thing as we’d like, but it’s a good clue.

The same idea can also be used to treat facet joint pain. Three common treatments all try to stop facet joints from hurting: injecting various pain-relieving substances into the joint itself, the chemical nerve block, and actual destruction of the nerve (using a clever, no-needle method). None of these treatments should be considered until a facet joint pain source has been suggested by the results of a diagnostic MBB.

Why the focus on facet joints? They are a well-defined anatomical structure, which makes it easy to target — a case of “looking where the light is” (streelight effect) or treating where it’s easy to treat.

The evidence for treatment efficacy is mixed — of course! Results are far from guaranteed, about two kilometres from it. Benefits may be temporary and/or partial, and it’s not risk-free. The value of injections right into the joint is particularly questionable. A treatment does not have to be perfect to be worthwhile, and there is probably some good being done with these procedures, but not a lot, or the evidence wouldn’t be so thin.

The journal Pain Physician has published a few studies of facet joint injection treatments for the cervical and lumbar spine,227228 and the thoracic spine.229 The only major review was published by Spine,230 which was the most discouraging: “There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain,” although the benefits of some types of injection therapy for certain patients “cannot be ruled out.” The others were more positive, but also not based on much actual data. So what do the more specific reviews in Pain Physician have to say?

Much of what’s positive in them comes from a 2008 experiment (done by some of the same researchers), in which they gave medial branch nerve blocks to 120 chronic neck pain patients, and found that they produced “significant relief and functional improvement” in “over 83% of patients.”231

This study has been widely cited as near proof that nerve blocks work, and it is the main source of enthusiasm about needles for neck pain in recent history. I think it is pretty decent evidence, and so MBB is an option chronic neck or back pain patients could consider. However, as always, you have to read the fine print. A more detailed look at this paper is quite educational …

6 reasons to curb your enthusiasm for medial branch blocks as a treatment option

I can see at least 6 reasons why the Manchikanti et al paper is not exactly a slam dunk, and MBBs are no miracle cure:

1. “Over 83%” of patients sounds awfully good — and it is, for a neck or back pain treatment — but it’s hardly everyone. More than 1 in 10 people were not helped, even after a facet joint was “confirmed” as the source of pain by an earlier nerve block.
2. In science, the words “significant improvement” do not mean “cured”: they mean statistically significant, which is highly problematic. Statistical significance just doesn’t mean much. Those who were helped were not necessarily helped a lot — just enough that we can say, “Yep, that treatment was better than nothing.” So many of those people almost undoubtedly had results that were somewhat less than miraculous.

3. These patients didn’t just get one needle in the neck and then walk out the door with their “significant improvement.” They walked out the door … and then came back again a few weeks later for another dose. And another. The average number of treatments over the course of the year they were studied was, wait for it … three and a half, plus or minus one. That’s off to the pain clinic with you three, maybe even four or five times per year to get your “significant results.” That’s a fair amount of getting stabbed in the neck, I have to say. Is this procedure starting to sound a little less awesome than it did at first?
4. As implied by the need for repeat treatments, the benefits were not exactly long term. The average duration of average pain relief was 14–16 weeks, give or take a lot. Some patients were getting their statistically significant but probably minor symptom relief for only half that time — about a couple of months. No wonder they needed repeat treatments.
5. And, of course, it’s a minimally invasive procedure, and all invasive procedures have higher costs and risks, and should be avoided unless absolutely necessary.
6. Last and definitely not least, these patients were not compared to patients receiving any other kind of treatment or no-treatment or a placebo, which I find really strange. It leaves us wondering how well they would have done with no treatment at all. Spinal pain is notoriously unpredictable. People who receive no treatment routinely experience “significant relief” for no apparent reason. Thus, this study just doesn’t fully answer the question it asks — it can’t.

Epidural injections

Epidural injections are a similar-but-different needling treatment, and “one of the commonly performed interventions in the United States.” Unlike MBBs, they are not directed at a facet joint. Instead, you just squirt a dose of anaesthetic into the space alongside the spine that is inhabited by the spinal nerve roots.232

The higher you go on the spine, the smaller the epidural space gets, and the more difficult and risky it is to stick a needle into it. Because of this, epidural injection techniques have long been more common and more suitable in locations from the upper back down, and their reliability and safety for neck pain has been considered dubious. However, it is becoming more accurate, practical and safe with new techniques. Fluoroscopic guidance! Ask your surgeon if he’s using it (and, if not, why not).

So, here’s a shocker: “The underlying mechanism of action of epidurally administered steroid and local anesthetic injection is still not well understood.”233 And yet, despite the predictable mysteriousness of it, there is evidence that it’s helpful. In early 2009, Benyamin et al concluded that studies of epidural injections show “that they have a significant effect in relieving chronic intractable pain of cervical origin and also provide long-term relief.”234

And there’s that damn word again: “significant”!

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One way to treat pain is to destroy the nerves that detect possible tissue threats (nociceptors). They are usually destroyed with heat: “kill it with fire!” Specifically, this is known as electrocoagulation or radiofrequency ablation (and other names and similar methods). A tiny probe delivers high frequency radio waves to the tissues, a cousin of what your microwave does to food. It’s a precise way of burninating things.

This treatment approach might seem simplistic and destructive and maybe even a Very Bad Idea … and you could be right. Certainly it’s understudied, but it has produced some promising results for wrist pain, back pain, and tennis elbow.235 This “circumstantial evidence” is better than nothing. On the other hand …

So what could possibly go wrong with denervation?

It doesn’t always work, of course. Which is a little surprising. Why wouldn’t destruction of nerve fibres completely, definitely solve the problem?

1. Most importantly, it might not be complete destruction: the surgery might not destroy enough of the right nerves.
2. Pain doesn’t actually come from nerves: they merely deliver information about tissue condition to the brain for consideration. The brain has other ways of deciding whether or not a neck hurts, and it can simply ignore the eerie silence of destroyed neck nerves. If the brain thinks your neck hurts … then your neck hurts. (Remember the phenomenon of phantom limb pain: if people can feel missing limbs, they can certainly feel partially denervated joints.)
3. The procedure might seem to work at first due to the powerful placebo effects that surgery can generate, only to reassert itself later.
4. Neck pain has many possible mechanisms. Depending on exactly what’s going on, denervating a facet joint could be a clean miss.

So should you ablate? It might be worth a try for desperate patients only after plenty of other options have been exhausted. It’s most likely to work at least a bit if there is a strong clinical suspicion of facet joint pain specifically, as opposed to other sources (that are difficult or impossible to treat in this way). But the evidence is too limited and mixed for any real confidence.

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Anti-inflammatory medications are widely seen as a first line of defense against neck pain. They are somewhat effective for the tension headaches that so often accompany neck pain,236 and there might be some overlap. That is, treating a headache might help with neck pain.

But using anti-inflammatories assumes there is inflammation to extinguish. The assumption that inflammation is a key factor in neck pain is mostly based on common misconceptions about neck pain. It plays nicely with fears of arthritic degeneration, muscle strain and spasm, ligament sprain, and other common but poor explanations for neck pain.

Regardless, inflammation is not one “thing” that can be shot with one magic bullet. It isn’t a simple fire that can always be hosed down with ibuprofen: it is a broad category of physiological phenomena mainly (but not exclusively) associated with trauma.237 The less trauma-like a painful problem is, the less classic the inflammatory signature, and the less likely the benefit of ibuprofen and similar drugs. Many cases of neck pain involve little or nothing of the biology that characterizes inflammation, and anti-inflammatories are imperfect medications even when inflammation is prominent. So taking these kinds of meds is mostly doomed to unremarkable results, and particularly in the case of tough cases.

There’s little harm in trying temporarily, given that side effects are minimal for most people with cautious usage and limited dosing. However, as virtually anyone with a real neck problem will be quick to confirm, you should keep your expectations low. And that’s what the scanty science says, too.238 A 2016 review was ever-so-slightly encouraging, but so tentatively that it hardly counts.239 In a 2017 review of 35 studies, both placebos and common anti-inflammatories for back pain had a “smallest worthwhile effect” of about 10%.240 The authors think that “there are no simple analgesics that provide clinically important effects for spinal pain over placebo.”

Also, bear in mind that, when anti-inflammatory medications don’t work, this is consistent with the presence of muscle pain, which does not usually respond to them. If there is inflammation involved in trigger point pain, it is minimal, or of the wrong type to respond well to anti-inflammatories.

A guide to experimenting with ordinary painkillers

It’s possible that they just don’t work at all, complete duds, and the only reason they have any effect is placebo — same as the sugar pill, as suggested by Machado et al. Or maybe their effects are just weak and unpredictable. Everyone’s different, every case is different. These meds may do more for some cases than others. Our reactions to drugs are surprisingly variable, from person to person, and day to day.

Most drugs work on only about a third of the population, they do no damage to another third, and the final third can have negative consequences.

Craig Venter, extremely famous and spooky smart geneticist (public lecture, Vancouver, May 3, 2011)

And so: try them, briefly, once in a while. Experiment, but experiment safely.

Over-the-counter (OTC) pain medications are fairly safe in moderation and work in different ways, so do experiment with the different types …cautiously. There are four kinds: acetaminophen/paracetamol (Tylenol, Panadol), plus three non-steroidal anti-inflammatories (NSAIDs): aspirin (Bayer, Bufferin), ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn).

Do not take any of them chronically — risks generally go up with repeated exposure.

Do not exceed recommended doses.

Acetaminophen is good for fever and pain, and is one of the safest of all drugs at recommended dosages, but overdose can badly hurt livers241 and unfortunately it doesn’t seem to work well (at all?) for musculoskeletal pain.242

The NSAIDs reduce inflammation as well as pain and fever, but at any dose they can cause heart attacks and strokes243 and they are “gut burners” — they can badly irritate the GI tract (even taken with food, and especially with booze). Aspirin is usually best for joint and muscle pain — and therefore probably neck pain — but it’s the most gut-burning of them all.

Voltaren is an ointment NSAID, safer for treating superficial pain, and probably a little more effective.244 It’s by far the safest option to try out, but it is only going to have an effect on your neck pain if the source isn’t too deep — and the neck joints are probably too deep. Still, it’s worth a shot, because the dose is much more “targeted” than NSAIDs.

The standard of care has definitely moved on from routine prescription of medication for neck and back pain, but “many patients with persisting symptoms also continue to take medicines long-term despite the low likelihood of ongoing benefits.”245 Don’t be one of those people. I think the main point to take away from this is that it’s just fine to do some cautious experimenting, but there’s definitely no point (and plenty of risk) in continuing to take them if they aren’t obviously helping.

Hell, they could even be the actual problem …

Is medication overuse a factor?

It might be. There is good evidence that overuse of pain medications may actually cause and worsen neck and headache pain.246 I cover this topic in somewhat more detail in my headache guide, because it’s especially relevant to those patients, but all the basics are here.

When you take a lot of pain-killers, it’s possible to pre-empt the production of your body’s own pain-fighting molecules. The body stops making so much of its own, because something similar is being supplied. Endorphin production, for instance, may drop. This can have serious consequences when you stop taking the drugs, resulting in worse pain than ever.

This is part of the phenomenon of the well-known serious withdrawal symptoms from some drugs; it is a much less well-known problem with over-the-counter pain-killers. It’s not clear how much of a problem it is. Most sources report it as an underestimated plague; others have pointed out that we just don’t really know.247

Although this phenomenon isn’t necessarily hard to spot, there are scenarios where analgesic rebound may be difficult to detect. Given how extremely common analgesic usage is, it’s possible that people with recurrent headaches and/or neck pain may be suffering primarily from bouts of rebound pain, which occur in the occasional gaps between erratic episodes of pain killers. This can create a particularly confusing situation, because it may seem like the pain is continuous and simply “revealed” when medication usage drops — but in fact it may be appearing at those times.

Particularly if you suffer from chronically recurring headaches as a part or extension of your neck pain, do ask yourself: do your symptoms correspond in any way to your usage of medications? Does your pain surge when you take a break from regular usage?

Contrast with the nuclear option: opioids

photo by Paul Ingraham

Ripening seed head of an opium poppy.

The infamous opioids are drugs like codeine (found in small doses in Tylenol IIs and IIIs) and the more heroin derivatives and imitators like Oxycontin, Percocet, and Vicodin. They induce deep relaxation and euphoria and have the potential to make you not care about pain. Unfortunately, not caring is not a cure and their efficacy is surprisingly dubious. Some people are even genetically immune to them. They do not work well at all for chronic musculoskeletal pain (non-cancer pain), and may even backfire and cause pain. They aren’t even as effective for acute pain as they are supposed to be.

And, of course, they also have grim risks like life-altering addiction and death by overdose, which is shockingly common. The danger can’t be overstated: more ordinary Americans have started to die from opioid overdose than car accidents. The CDC declared in early 2016 that opioids should not be an option for chronic musculoskeletal pain: there’s too much danger, and too little evidence of benefit.

On the other hand, not everyone gets addicted and some people get real relief, so despite “the opioid crisis” — which is all-too real — there’s plenty of grey area here. If you have a good relationship with a cautious doctor who respects the risks, it can be reasonable to consider a short term opioid experiment: it could provide some much needed relief, and maybe even break a vicious cycle. But the need for caution and medical supervision is as high as it gets.

For more information, see Opioids for Chronic Aches & Pains: The nuclear option: Oxycontin, codeine and other opioids for musculoskeletal problems like neck and back pain.

Note that there is no research specifically about opioids for neck pain. As usual, there is some probably-relevant evidence about opioids for back pain: a 2016 review conclude that opioids are “not likely to be clinically important within guideline recommended doses.”248

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Photo by Jose Luis Sanchez Pereyra on Unsplash

Perhaps the most interesting & controversial plant in the world.

Cannabis is a plant, most notably marijuana (bred for its narcotic effects) and the major strain of hemp (bred for other purposes). It’s one of the most interesting plants in the world because it produces chemicals with interesting effects, the cannabinoids. The most interesting and famous of those are THC (tetrahydrocannabinol) and CBD (cannabidiol). All cannabis contains THC, CBD, and hundreds of other related compounds, but there’s a lot more THC in marijuana plants, and a lot more CBD in hemp.

THC gets you high (psychoactive effects), and CBD does not. Both are alleged to be pain killers: it’s their most popular medicinal use (either that or as a sleep aid), but CBD is much less studied.

The evidence for pain-killing

So, are cannabinoids effective pain killers? “It’s complicated”!

As a science journalist, I am honour bound to emphasize that cannabinoids are not proven pain-killers. “Proof” is a high bar that has not yet been cleared. A huge 2017 review of the scientific literature on cannabis concluded that there is “substantial evidence that cannabis is an effective treatment for chronic pain in adults.”249 But the review also explains that the evidence shows only modest benefits so far, there is uncertainty about every detail, and significant practical problems abound for both researchers and consumers.

And that was hardly the last or only word. Other reviews of largely the same evidence have been much less optimistic. In 2017, Nugent et al looked at 27 scientific trials of cannabis for chronic pain trials, and it was disappointing: weakly positive for neuropathic pain, and just inconclusive otherwise.250 In 2019, Häuser et al wrote “Cannabis medicines can be regarded to be third-line therapy for chronic neuropathic pain. There are signals of a lack of efficacy for all other chronic pain syndromes.”251

So that’s not great.

THC might have some bonus effects for some neck pain patients because it can function as a muscle relaxant. More about that in the muscle relaxant chapter. But it is one way that THC might be relieving pain indirectly.

A noteworthy new trial of CBD for acute back pain (and, as always, let’s assume back pain research is mostly applicable to neck pain)

Studies of pure CBD for pain remain rare, which makes a good 2021 Australian trial noteworthy.252 Researchers tested CBD in the same situation where doctors might normally prescribe powerful anti-inflammatories or opioids: in people who have gone to the emergency room with severe back pain. A hundred patients were given an ibuprofen and paracetamol plus either 400mg of CBD or a bogus pill that looked just like it.

This a fair test in several ways. If CBD actually has anti-inflammatory properties, the people who got a CBD booster should certainly have gotten some extra relief. Severe acute back pain is a tough pain-killing challenge, but we should expect anything touted as “good for pain” to help out at least a little in this situation.

Unfortunately, CBD made no difference at all: it was like it wasn’t even there. •sad trombone• The groups were identical on all outcomes: pain levels, how long the patient stayed, the need for “rescue analgesia” (the Oxycodone), and adverse events.

It is conceivable that CBD alone, or repeated doses, would have performed at least as well as standard meds, and maybe more safely — safer than NSAIDs anyway253 — but it’s a long shot. This was quite a fair test, and CBD just bombed.

Usage guidelines for beginners

If you’re new to marijuana, there’s a bit of a learning curve. Here are some tips:

• Pure topical CBD creams and oils are overall the safest and most convenient, so they should probably be your first priority to try. THC may be where it’s at, but it’s harder to use…
• Use caution with THC edibles! Dosing and duration of effect are huge wildcards. You can get way, way too high for comfort — not very dangerous, but scary.
• Avoid vaporizers that use oil infused with cannabinoids, due to scandalous, tragic safety issues because asshole manufacturers have added other dangerous, un-tested substances254. Dozens of people died in 2019. Died!
• Infused oils aside, vaping raw cannabis in moderation is quite safe.255 Just take it easy for at least your first three times — just one or two modest inhalations of vapour is just fine to start.

For more detailed information, see Marijuana for Pain.

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“Muscle relaxant” is an odd category of drug. There are several drugs that are relaxing, but are not exactly “muscle relaxants” because they are not specifically interfering with the biology of muscle contraction. A true muscle relaxant is essentially a poison that messes directly with muscle physiology.

You really don’t want too much of a true muscle relaxant. It can cross into paralysis. Amazonians used a muscle relaxant … on their poison arrows. Curare poison relaxes you to death. European explorers encountered the stuff early in their visits to North America, and it led to some of the earliest scientific studies in pharmacology.

And yet, on the other hand, it’s not clear that the muscle relaxant drugs are actually interfering with muscle contraction! So it’s a tricky topic.

Muscle relaxants and neck pain

I have already thoroughly discussed the idea of spasm as a major cause of neck pain. Refresher: it’s a hopelessly vague description of a sensation that probably doesn’t have much to do with actual cramping of neck muscles. Or it’s something more specific, like trigger points — micro-cramps that do involve unhealthy contraction, but aren’t really anything like the popular mental picture of a whole-muscle clenching painfully.

If some kind of spasm is not a cause of neck pain, then surely muscle relaxants are largely pointless, even if they actually relax muscles. Some experts are very cynical about this, describing muscle spasm as a simplistic non-diagnosis with strong emotional appeal to both doctors and patients, and therefore cynically exploited by pharmaceutical companies to sell a treatment (muscle relaxants).256 Some muscle relaxants certainly are marketed specifically as remedies for “muscle pain.” For instance, King Pharmaceuticals claims that Skelaxin produces “fast relief for muscle spasms.” There are definitely plenty of pros who think that’s just a scam.

Maybe. I’m sympathetic to that point of view, but I’m also not so sure it’s settled.

If muscle spasm is a major factor in spinal pain, or even a significant complication, then muscle relaxants are obviously useful in principle — and in fact we do know that muscle relaxants are somewhat helpful for acute low back pain (evidence discussion below). But there are also reasons other than actually relaxing muscles why those drugs might work a bit.

And then of course there’s the unavoidable truth that there are many causes of neck pain that really have nothing to do with tight muscles. Even an extremely potent muscle relaxant is not going to make any difference if tense muscles aren’t the problem in the first place.

But, if they help you, it’s actually diagnostic. Effective treatment isolates uncomfortable muscular contraction (of some kind) as a cause or clinically significant complication.

Muscle relaxant primer

Muscle relaxants come in many related varieties,257 but only one that is widely available without a prescription: methocarbamol, as found in Robaxin, Robaxacet, and similar brand names.

There are also several prescription muscle relaxants, obscure to most patients, but most notably carisoprodol (Soma), cyclobenzaprine (Flexeril), metaxalone (Skelaxin).

All muscle relaxants are tame cousins of the truly potent sedatives (also discussed below), and can cause significant drowsiness, dizziness, and a laundry list of other common side effects, but there’s also a surprisingly wide range of safe dosage (hard to overdose).

Methocarbamol and friends are not widely used because they are not super effective. It’s probably because they’ve been around forever, because the drowsiness they cause makes them feel more potent than they actually are, and because relaxing muscles just seems like such a good idea to literally everyone, both patients and pros. I think perhaps muscle relaxants have been grandfathered into modern, scientific medicine. Tradition-based medicine, rather than evidence-based medicine.

Muscle relaxants are surprisingly unstudied, like many other popular drugs.258 In particular, good luck finding any study of the effect of these drugs on muscle function. It’s not clear if muscle relaxants actually relax muscles, or if they just make us feel more relaxed.

What evidence we do have is not exactly high quality.259260261

An expert of my acquaintance thinks they are useless specifically at low dosages.262

Acute back pain is the only condition for which there is adequate data. Some muscle relaxants (including methocarbamol) do appear to be roughly as effective for acute back pain as common over-the-counter pain killers263264 — so they can help, but not all that much, and with great potential for side effects. It’s also damning that there doesn’t seem to be much difference between muscle relaxants: “Comparison studies have not shown one skeletal muscle relaxant to be superior to another.”265 So we have a class of drugs that shows little sign of effect, no matter which flavour you use. Whoop-de-do!

Even a prescription muscle relaxant like carisoprodol (Soma) is so impotent that patients will (this is bizarre) actually tense up if they are lied to and told that the drug is a stimulant.266 (The study was quite interesting — if you only read one footnote about a study in this book, this would be a good one to choose.) Clearly the brain is the boss of your muscle tone, and the drugs only nudge us towards relaxation. Bear this fun fact in mind for the discussion of alcohol and other psychoactive drugs coming up — it’s a ray of hope.

And here’s another fun fact: even anasthesia doesn’t truly “relax” muscle.267 It stops voluntary contraction, but it doesn’t eliminate muscle tone. Only death does that, and even in that extreme case the tenacity of the contractile proteins is demonstrated in the phenomenon of rigor mortis.268

Muscle relaxants clearly work at least a little for some people, some of the time, probably usually at higher doses. And they are relatively safe to experiment with, even at higher dosages. In fact, it’s so hard to overdose on them that I even feel comfortable endorsing cautious testing of a larger dosage than what’s recommended on the box. Just don’t go driving, don’t combine with alcohol, and be alert for significant side effects — they aren’t effective enough to bother with if they harass you with side effects.

Narcotic “muscle relaxants” (sedatives like Valium)

If our goal is to loosen up tense muscles that might be causing neck pain, is there any drug at all that will definitely do the job? Any drug that’s reasonably accessible?

Narcotic sedatives, mainly the benzodiazepenes, relax everything. Like the opioids, the benzos are another “nuclear option” — they do interfere with muscle contraction, while also interfering with everything else: like consciousness! Many drugs have highly unpredictable effects, but the benzos are as potent and predictable as cobra venom.

The most famous of all the sedatives is diazepam, AKA Valium, a benzodiazepene. But it is only the most infamous member of a family of rogues, like Klonopin, Ativan, and Xanax.

Just because they are potent — and they certainly are that — does not mean they actually work, or that they work by relaxing muscles. A 2017 study showed that “Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain” (they put the result right into the title).269 However, I suspect that the your-mileage-may-vary factor is huge with these drugs.

As with the milder muscle relaxants, it’s surprisingly unclear whether or not these drugs actually reduce muscle tone, or whether they achieve relaxation indirectly via their potent sedative and psychoactive effects. Those psychoactive effects are a huge wildcard that could account for a wide range of responses. They are primarily used to relieve anxiety and improve sleep, both of which could easily relieve pain on their own.

I don’t think there’s any question that benzos might be a useful tool for treating headache. It seems worth at least considering this treatment option, despite the hazards… which are a big deal.

Benzos really do involve dire risks of physical dependence and addiction, and withdrawal can be nightmarish, dangerous, and even lethal at the extremes. Although it is possible to take and stop taking benzos safely, many people do not get the information and help they need for that. Sadly, I have extensive personal experience with benzo withdrawal, and I’ve written about that in detail.270

However, benzos can be safe if used in moderation for short periods only. They are a dangerous tool, like a gun, which must be respected and used with great caution. If you’re interested in dancing with this devil, don’t just ask your doctor for a prescription: make a point of showing your prudence by asking for only a 2-week supply of a small dosage only (the exact amount varies with the specific drug).271

The curious case of alcohol as a pseudo-muscle-relaxant

Alcohol is hard on your system in many ways. It’s a myth that a drink every night is a tonic, and there really is no safe intake level272 — it is a poison, and it can make people more vulnerable to chronic pain. And yet…

There’s plenty to be said for a glass of wine or beer as a kind of medicine.273 Anecdotally, moderate usage seems useful for taking the edge off nearly any kind of pain. This may be because it’s functioning as a kind of muscle relaxant, or at least as a general sedative.

Let me be clear: alcohol is not a muscle relaxant per se,274 not in a biochemical sense (and warning: it also combines dangerously with actual muscle relaxants and sedatives). In a world full of alcoholism and drug addiction, obviously a “prescription” of alcohol has to be offered and taken rather cautiously. But it is highly accessible, cheap, relatively harmless in moderation, and it’s a psychoactive drug — and anything that bends your mind has the potential to be a mild, obliquely effective muscle relaxant.

Combined with the confidence cure, alcohol might be effective, after a fashion. It’s one thing to be anxious about your neck pain and to drink to take the edge off your nerves — only to get right back to it as the effect of the beer therapy wears off. It’s quite another to know that your spine is safe but grouchy, and to drink judiciously to help break the vicious cycle of tension and anxiety itself, instead of just temporarily escaping it.

All psychoactive drugs — anti-depressants, alcohol, marijuana, amphetamines, opioids, benzodiazepines — often seem to help almost any problem, but the emphasis is on seem, because they mainly affect mood: “It is my impression that ‘pain-killing’ drugs improve the patient’s mood rather than take away the pain.” (Sarno)

Mood isn’t nothing. If you are genuinely happy and relaxed… if that’s something alcohol can do for you…

THC as a pseudo-muscle-relaxant

Tetrahydrocannabinol (THC) is the most famous cannabinoid produced by cannabis (marijuana). It is another relatively safe and accessible psychoactive drug, probably the only other one that seems tame enough to take seriously for this purpose. (Sure, you could blow your mind with acid or ecstasy and hope for a muscle relaxant effect, but that seems like overkill.) Obviously its accessibility varies widely from place to place as the entire world grapples slowly and awkwardly with legalization.

Like alcohol, THC doesn’t zap muscle tone directly, but it probably can do it indirectly and erratically.

If you are happy and relaxed while stoned, it’s certainly possible that a tense neck will get … less tense! Whether it can meaningfully affect the kind of fierce contractions (or trigger points) that can make you miserable in the first place is anybody’s guess, but it seems worth trying.

For this purpose, virtually any strain of marijuana will do, but ideally a THC-rich one (not CBD) because you want the psychoactive effects. Whee!

With pot, there is also the added potential for direct pain relief (discussed above, along with usage guidelines).

And so I do tentatively recommend THC as another “muscle relaxant” worth experimenting with.

Botox?

Botox is the infamous face-paralyzing drug of the stars! It’s a special case, quite different from the other muscle relaxants. Like curare on poison arrows, Botox is outrageously toxic and doesn’t “relax” muscles but just outright paralyzes them, even in small doses. It’s obviously related to muscle relaxants, but it’s a separate topic.

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PainSci also has a very detailed guide to trigger points.

The two guides have a close relationship. The trigger points tutorial was last mentioned several sections back when I was introducing you to the role that trigger points play in back pain. I’m bringing it up again because we’re now going to be talking about treatment options for neck pain — most of which are directly concerned with trigger points, and are quite similar in both tutorials.

This duplication is unavoidable: the subjects are woven together like the snakes of the caduceus. And this is why I sell the two tutorials as a pair. I have made every effort to reduce the duplication, and to discuss trigger point therapy concepts here as they relate specifically to neck pain. For instance, rather than discussing only the general principles of mobilization exercises (as in the trigger point tutorial), I provide some specific examples of mobilization exercises for the neck specifically. But it’s impossible to eliminate the duplication altogether.

For detailed trigger point therapy information, please refer to that book-length tutorial, which is much bigger than this one. The next several sections of this tutorial are an executive summary of the same sections in the book-length trigger point tutorial. It may seem like there’s a lot here, but, trust me, there’s a lot more in the trigger points tutorial!

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Massage therapy for neck pain is not a scientifically proven treatment — not by a long shot. The best available evidence still all sucks. It’s not bad news, it’s just no news: the evidence is all shabby stuff that doesn’t prove or disprove much of anything.275 There are some promising signs, and even a bunch of mediocre little experiments did manage to convince Patel et al that massage provides “an immediate or short-term effectiveness or both in pain and tenderness,”276 which is at least competitive with an Aspirin. But the cruddy data can’t confirm that benefits last longer. For contrast, we do have good evidence of lasting benefits from strength training. But not for massage!

My confidence in massage for neck pain is based mostly on educated speculation, my own professional experiences, and impressive success stories like Alice’s (coming up below). It’s what we’ve got so far. And so, this is what I provisionally believe about massage for neck pain …

Trigger points are a major factor in most neck pain, either causing it or complicating it, and some of that discomfort can usually be relieved with a surprisingly small amount of simple self-massage with your own thumbs or cheap tools like a tennis ball. Although trigger points can get amazingly nasty, most are fairly easy to find and get rid of with a just little rubbing. Dr. Janet Travell wrote that “almost any intervention” can relieve a trigger point, and self-massage is usually the simplest, cheapest, safest, and most effective method. Which sounds too good to be true! How can such a trivial treatment work?

The pain may be more of a phantom pain than something wrong with the tissue.277 It may be relatively easy to change with massage because there’s not much to “fix,” mainly just a sensation to change, a sensory rut to get out of.

On the other hand, if we accept the conventional wisdom, then massage may work well because it’s surprisingly easy to “flush” the waste metabolites out of a minor trigger point,278 like popping a zit — and maybe that interrupts a vicious cycle, preventing the trigger point from coming back, at least for a while.

Also, isolated trigger points are easier to manage — neurologically simpler.279 If the problem is limited to just one part of the neck, or at least just the neck — and not also the shoulders, chest, etc — there’s a better chance of dealing with it.

The pillars of safe, easy, cheap self-treatment for neck pain trigger points are:

1. Self-massage — the creative, persistent stimulation of musculature in the neck with pressure, applied a little bit with thumbs and fingers and fists, but mostly with massage tools like tennis balls or a massage stick.
2. Mobilization, or “massage with movement” — gentle but precise rhythmic movements that stimulate the core musculature, preventing tissue stagnancy without overexertion.
3. Heat therapy — hot baths, showers, hot tubs, hot water bottles, heating pads.
4. Elimination of perpetuating factors — the things that might be causing trigger points to form in the first place. We’ve already discussed a major one (stress/anxiety), but there are several others.

Self-treatment of trigger points is the most useful idea that this tutorial has to offer. It’s important because, on the one hand, trigger point therapy is actually quite safe and easy to do yourself and yet, on the other hand, it can be surprisingly difficult to get good trigger point therapy from therapists.280 And when you can get good trigger point therapy, it’s usually too expensive to get enough of it. So even just a little skill with self-treatment can really make a difference, either supplementing professional therapy or entirely replacing it.

While far from a miracle cure, it’s plausible and harmless enough to be well worth trying and practicing. Time and again over the years, I have seen neck pain patients improve markedly with tweaks to their self-treatment methods, such as learning not to overdo it, learning to work on it right before sleep, or exploring until you discover the spots that matter most (which are not necessarily obvious at first).

If nothing else, simple pressure on trigger points in the neck is definitely relaxing! That effect was measured carefully in an odd little 2017 study,281 and it also showed modest pain relief. It’s a good example of the kind of weak trigger point science we can’t really trust … but the relaxation part is pretty solid. We are talking about massage, after all — as long as the pressure is reasonable, you really can’t go too far wrong!

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Self-massage offers the best potential bang for buck of all treatments for back pain.

It is not difficult to apply pressure yourself to a few key trigger points in the neck, shoulders, and upper back, especially with the assistance of some simple tools. For average cases of stubborn neck pain, a small investment in experimenting with applying pressure can be surprisingly effective. People who’ve had intractable neck pain for years may experience more relief than they ever have before. Some find that self-treatment of trigger points becomes the only thing they need over the long term to control their symptoms enough to feel “good enough,” if not actually completely symptom free.

Not every case goes quite that well, of course. Just like with medications, response to treatment varies widely, based on many variables, most of which we don’t really understand. Applying pressure to sore spots is an experimental treatment, complete with a (modest) risk of harm.

Some patients will need to experiment rather more. Some may find that self-treatment is never a complete solution in itself. There are some baked-in limitations to self-treatment for trigger points, particularly in the neck. It’s a physically awkward area to work on yourself. It can take a while to get the hang of it.

On the one hand, some of the basics are easy. For instance, it’s easy to knead the cervical paraspinal muscles with the tips of the fingers. Ideally, do this lying down — this minimizes contraction of the same muscles you are trying to relax. I have no idea if it’s actually important — for all I know, massaging slightly contracted muscles might work better — but it seems like a sensible approach. Try putting some hand lotion on your fingers as well, so that you can slide up or down the length of the muscles, slowly but firmly — and that’s just practical and efficient. It makes it easier to apply pressure smoothly in sequence up and down the length of the muscle group.

That’s the easy part. The upper back and the base of the neck are important areas — often the epicentre of crick-type discomfort, as well as crickless aching — and yet they present a major self-massage challenge. The spot where the shoulder and neck merge — I call it the “sheck” — is tricky to apply satisfying pressure to, even with the help of a tool. The thoracic spine below the first couple vertebrae is a hard place to reach even just to scratch, let alone massage, but many people crave extra pressure in this region of tough, thick muscle, often more pressure than can be applied without assistance. (And you shouldn’t start with too much pressure in any case.) In particular, it is almost impossible to self-massage the deeper muscles of the lower cervical spine without help. I have often tried to solve this problem, experimenting thoroughly in the quest for any suitable self-massage method for these key spots, and I simply cannot crack the code: it’s one of those places in the human body where massage simply has to be done by someone else.

Fortunately, it’s just one important spot of many in the area, and it’s not impossible to self-massage, just tough to do thoroughly and well. I’m emphasizing that self-massage stands little chance of being a complete solution. This potential of self-massage for neck pain is limited in a way that self-massage for low back pain patients is not (although not necessarily easy, there are viable self-massage techniques for every clinically important bit of muscle in the low back).

Despite the challenges, it is well worth trying. I encourage every chronic neck pain sufferer to become as comfortable as possible with this before giving up on self-treatment.

The following free articles, from my “Perfect Spots” series, explain in detail four of the classic, clinically important trigger points in the region of the neck. Although there is always more to learn, these are more than enough to occupy yourself with for a long time. Experienced massage therapists have been known to neglect some of these. Just please explore cautiously and keep your pressure tame at first, especially anywhere forward of the sides the neck.

• Perfect Spot No. 1 — The suboccipital group, under the base of the skull. Trigger points in this group are critical to both headache and neck pain. Despite this, they are given short shrift by too many massage therapists.
• Perfect Spot No. 4 — The scalene muscle group, on the front and sides of the throat. Although most people feel shy about exploring this area, there’s nothing to worry about if you move slowly and gently, especially at first. You won’t choke yourself accidentally, you’ll know instantly if you’re squishing an artery, and you won’t feel your nerves — and it really can be extremely helpful.

• Jaw muscles get used heavily. Sometimes they get very tired.

  Perfect Spot No. 7 — The masseter muscle. Although only indirectly related to neck pain, jaw tension should not be ignored, if for no other reason than as an important key to relaxing the whole region.
• Perfect Spot No. 11 — The thoracic paraspinal muscles. These muscles are the roots of the neck musculature. To the extent that your neck pain or crick feels like it extends into the upper back, more attention should be given to this hard-to-reach spot. Even if there’s no obvious connection, they are well worth exploring.

And then, of course, there are the long muscles along each side of the neck — which are critical to neck pain. But there is no perfect spot here, and they are straightforward. To self-massage this muscle group, just reach up and do it: press your fingertips into the back of your neck muscles.

How do you know it’s working? Getting a trigger point to “release”

The goal of self-massage for trigger points is to achieve a trigger point “release.” What is trigger point “release” and what does it feel like? How do you measure success? It is entirely subjective.

At its most basic, trigger point massage is just a gentle hunt for significant sore spots in your muscles and pressing or kneading them until the sensitivity eases (hopefully). The main thing to look for is sensitivity that feels like part of your problem… and the main things to avoid are hurting yourself by being too aggressive with lumps, bumps, and sore spots that may just be normal anatomy.282

How do you tell the difference? With many trigger points, successful release is usually associated with “good pain” — that clear, strong and satisfying sensation that is somehow both painful and yet also relieving.

Trigger point release is, in theory, relief from the micro-cramp that makes a trigger point what it is. It’s analogous to what happens when an athlete cramps up and then gets relief from stretching the muscle until it stops contracting … but just occurring on a much smaller scale.

Unfortunately, relief from the micro-cramp may not be obvious. One possible reason for this is that the tissue may still be polluted with waste metabolites even after a successful release. Or, release could actually involve or even require damage to the tissue of the muscle knots. This means that it will probably still be sensitive to pressure, even if you’ve succeeded. It’s a sore spot, and it may stay sore for a bit … just like a pimple that you’ve just “released.”

For beginners, the way to cope with all the uncertainty is to just not worry about it! Simply trust that you probably achieved a release, or a partial release, and then wait for the tissue to recover. Over the next several hours, if you were successful, you will notice a distinct reduction in symptoms — mission accomplished.

Technique tips

Here are several specific ideas about exactly how to self-massage trigger points. (This is still just an overview of the basics. Everything is spelled on in much greater detail in the main trigger points tutorial.)

Rub in what way? For simplicity, either simply press on the trigger point directly and hold the pressure still, or apply very small kneading strokes, either circular or back and forth across the muscle fibres.

Rub how hard? The intensity of the treatment should be strong, but easy to live with. On a scale of 10 — where 1 is painless and 10 is intolerable — please aim for the 5–7 range, and err on the side of gentler at first.

What should it feel like? Pressure on a muscle knot should usually be clear and strong and satisfying; it should have a relieving, welcome quality. This is “good pain.” If you are wincing or gritting your teeth, you may need to be more gentle. You need to be able to relax.

What if it backfires? It probably won’t. But if you experience any negative reaction in the hours after treatment, simply ease up. In basic therapy, you can always count on trigger points adapting to stronger pressures over the course of a few days of regular treatment. If they don’t, either the problem isn’t really trigger points, or they are worse trigger points than you thought!

Rub how much? Massage each suspected trigger point for about 30 seconds. This is actually enough for many trigger points — especially if you think that you have several that all need attention! Five minutes is roughly the maximum that any trigger point will need at one time, but there is not really any limit — if rubbing the trigger point continues to feel good, you should certainly feel free to keep going.

Rub how often? As long as you aren’t experiencing any negative reactions, you should massage a key trigger point at least once per day, and as often as a half dozen times per day.

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This is both another story of a worst-case scenario, and a massage success story. It starts poorly, but ends well.

A middle-aged female cashier, “Alice,” started to have episodes of severe neck pain over a period of a few years. Early episodes were minor, but her pain eventually reached frightening levels before finally being completely relieved, apparently, by a single self-massage: a transition from a chronic eight on the pain scale to almost no pain at all, in the span of about three minutes. She had no pain at all the following day and remained mostly symptom free as of several months later, but for a few minor flare ups, easily treated.

Unlike many of my readers, Alice happened to be local to me. She was also unusually articulate and precise in her recollections, so I met her in person and interviewed her thoroughly.

Her pain was consistently a right side pain spanning from the middle of the neck to the upper back. It had a classic “crick” quality: she complained (with great feeling) that something in her lower cervical spine felt stuck.283 She constantly squirmed and flexed her upper back and neck, to the point that it became a distinctive, tic-like behaviour.

“It’s not just that it hurt,” she said to me. “It was maddening, like an itch I couldn’t scratch. It was both. It was a painful itch.”

With such a clear impression of spinal derangement, chiropractic care seemed like an obvious option to her at the time, and at first that seemed like a great success: she enjoyed significant relief for several days after her first treatment. “I remember how blissed out I was.” But then the problem returned. Encouraged by the first success, she returned, but a cycle of diminishing returns rapidly developed. After spending over a thousand dollars, spinal “adjustment” seemed to stop working altogether except for a brief burst of relief. “I would be squirming again by the time I got back to my car.”284

She had also tried massage therapy, but “I never really gave it a good chance to work,” she said, because it was too expensive for her and because it didn’t seem to do much. That’s when she found this book and began experimenting with (much cheaper) self-treatment instead, but her results were still unsatisfying.

For a while there I didn’t like you, Mr. Ingraham. To be fair to you, there are plenty of warnings in your book that massage is obviously not going to work for everyone, but I was so hopeful! I felt betrayed when it didn’t work out. I was all over the place with massage tools and I was trying the scalenes and looking at anatomy pictures, and I’d find a little spot here or there that felt pretty great to rub and I’d think, “Maybe this is it!” But it never was. It was never even as good as those early chiropractic treatments. I was so disappointed I thought, “To hell with this guy’s methods! What a load of crap!” And I gave up.

Alice’s breakthrough: the magic spot

The breakthrough came several months after giving up on self-massage. In the final period of the story, Alice’s symptoms became “outrageous.” Gaps between episodes shortened until they blurred together. She could hardly move her right arm at times. She missed work regularly, became depressed and irritable, and started to drink heavily. She started to become afraid that she had a tumour, and went to the doctor, but medical assessment showed nothing. Her doctor prescribed pain meds and recommended a chiropractor. The pain meds helped a little, but not nearly enough.

In this period, Alice began to develop symptoms of frank muscle spasm, which is quite unusual. “When I stretched, I’d cramp up, like a charlie horse in my neck. Just like you have to flex your feet to keep a calf cramp at bay, I’d have to lean my head to the left.” These muscular sensations drove her to seek massage again. Her massage therapist stumbled on something important: a spot in her shoulder that felt like a revelation.

There is no way to describe how important that spot felt. It was like an orgasm of relief. The itch was getting scratched, after three years. It was like saving my life. It was incredible. I was yelling, “That’s it, that’s it, right there, don’t move, please don’t move, just push on that!” I felt crazy. I cried with relief.

The magic spot was somewhat lateral to the symptom and Alice says she “never would have looked there, and might have missed it even if I had.” It took a fair bit of pressure at just the right angle to do the trick. It was probably the levator scapula or posterior scalene muscle. The therapist admitted that he would not have known what he’d found without her reaction. Apparently he was just “working the area” and could not tell there was anything going on in that spot until Alice reacted.

Alice’s symptoms were greatly improved after the appointment, but this is not the end of the story quite yet.

Her symptoms returned in force two days later. Alice was crushed. She had gotten very hopeful over those two days! But not only was her pain back, it was pretty bad — a relapse reminiscent of her experiences with chiropractic therapy.

Alice went to the local pool because floating was painless. She did a series of experiments in the water and discovered that she had no pain at all as long as her right arm was supported by the water. She could turn her symptoms off and on by sinking into the water or standing up and letting gravity pull on her arm. Supporting her arm with the other arm also worked. But if she let her right arm dangle, it felt like the weight “pulled on my neck” and the pain was almost unbearable. In particular, “The slightest chin tilt forward was agony … if my arm was dangling unsupported, for some reason.” The point of all this is that she had found a nice clear provocation test for her pain. She knew she could reliably make it hurt in a very specific way.

She had a little ball with her that she had brought for the purpose of rubbing The Spot that the massage therapist had discovered. She rubbed The Spot with the ball for about three minutes. “I didn’t feel like such a big deal as it did when the massage therapist did it. It was nice. I knew exactly where to go.”

Her symptoms eased. She returned to the pool and repeated her experiments, rising out of the water with and without the arm supported. She could tilt her head forward, whether her arm was supported or not. Her pain was 90% gone. The rest of the day went by in peace. The next morning the symptoms were undetectable. “I felt completely normal. I felt like my old self.”

Alice’s upper back and neck are not perfect. Since then, she has had a few minor flare-ups. However, each time she has easily treated them with a little self-massage. For now at least, her problem is effectively cured — and one of the most interesting self-treatment success stories I have ever heard. Her experience with an initially heart-sinking relapse is familiar, though.

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Although there are a plethora of options, and I am all in favour of experimenting with massage tools, they have less of a role in self-treatment of the neck than other regions. Because it’s your neck. And necks have some vulnerabilities.

Many of the primary targets of neck massage are not especially pressure tolerant compared to many other targets. Tools make more sense in the low back, for instance, because the low back muscles are so much larger and durable, and there is no shallow delicate anatomy at all. For the most part, thumbs and fingers are able to deliver as much pressure as most people require in the neck — and they can do it more safely.

Many massage tools actually make massage more difficult in the neck. They can be awkward to position and control in the complex contours of the neck. This is not to say that they have no place, just that they are much less obviously advantageous. For instance, the tennis ball — by far the best known of all easy, useful massage tools — is too clumsy and imprecise for a lot of neck massage.

Here are some ideas about tools and tool-use that you might find more useful in self-massage of the neck …

Tennis balls are useful in two locations: the suboccipital muscle group under the back of the skull, and the upper back. For the suboccipitals, simply put it under the back of the skull like a tiny pillow and roll your head back and forth. The upper back is best treated by standing with the ball pinched between your back and a wall.

Lacrosse balls are less common and much firmer than tennis balls — probably too hard for many people — but they have a great rubbery texture that makes them easy to work with, and less prone to slipping.

The Jacknobber massage tool: basically just a handful of hard plastic thumbs.

Finger-replacers like the the Jacknobber. Tools like this make it easier to control and sustain focused pressure, especially in the nooks and crannies. Or consider a Knobble, which is just a single larger “thumb” of plastic with a wide, grippy handle — very easy to hold and aim.

The Zubo

Massage tools don’t get much simpler than this.

The Zubo is another kind of finger replacement: just a short, simple stick available from Allan Saltzman of yogatools.com. Yes, that’s $20 for a dowel with rounded ends!285

Mr. Saltzman also makes a sturdy massage roller, firmer than the firmest foam roller: a hard tube wrapped with a dense, rubbery foam. It’s the best way I have to apply long, firm strokes of pressure along the length of the spinal muscles. Although it’s useless for the neck, it is great for the upper back — which may be indirectly helpful for the neck. Allan’s spinal roller is by far the most reliable method I have of cracking my upper back, FWIW (I find it pleasant and relieving, but I doubt it matters much, and I am rarely willing to pay a chiropractor to do it for me).

A long massage stick (such as the well-known TheraCane, or the snakier Backnobber, which I prefer) is especially handy for reaching the lower neck and upper back musculature, and that spot where the neck and shoulder merge — I call it the “sheck” — where it is especially difficult to apply a satisfying pressure without help of a tool. On the downside, Theracanes and similar products can be a bit awkward and imprecise, and they are primarily ideal for spots that you really cannot reach comfortably with your hands and shorter tools — the neck mostly doesn’t need a long, reachy massage tool.

The Backnobber

A massage tool like this is handy for reaching the lower neck & upper back musculature. On the downside, it can be a bit awkward & imprecise.

Squash balls are an excellent choice for the neck, and particularly the long part of the neck. Only squash players have squash balls just lying around, but they aren’t hard to find — any sports store with a racquet sports section. They are ideal for the neck because they are quite small (for focused pressure) and yet also quite soft. Their rubbery tackiness makes them easy to manipulate. Just palm the ball, hold it against your neck, and roll it — less tiring and much more thorough than fingers.

Squash balls are softer & smaller than tennis balls, which makes them ideal for massaging some hard-to-reach spots.

Dog KONG® (classic). Another great massage tool that a lot of people have handy — or that they can get easily — is a KONG® dog toy, of all things! With its pyramidal shape and hardness that varies depending on how you use it, it’s quite versatile. The smallest one is the most likely to be useful in the neck.

The Classic KONG® dog toy is an amazingly good self-massage tool!

A very small, hard rubber ball — the hardness of a lacrosse ball, but the size of a golf or squash ball, can also be useful in the neck, but is surprisingly hard to find. Miscellaneous balls like this can often be had at dollar and toy stores. One approach to this area is to apply strong pressure to the muscles right beside the top 2-3 thoracic vertebrae — as close to the neck as you can get without actually being in the neck. This is a sturdy spot. Most people are significantly more pressure tolerant in this area than above (in the neck) or below (between the shoulder blades). Thus it’s a good place to apply stronger and more focused pressure with a smaller, harder ball. It is best done by trapping the ball between your back and the wall, and rolling up and down in short (2-inch) strokes. The muscles below may also appreciate this, but it’s that small area at the top of the upper back that is most likely to appreciate your special effort of finding just the right size and hardness of ball and using stronger pressures.

The Thumper Mini.

The Thumper is a sturdy vibrating massage tool. (Do not use this kind of tool on the front of the neck near big blood vessels — it can damage them!286 But it’s completely safe on the thick muscles of the back of the neck and shoulders.) There are many of these gadgets, but I am fond of the Thumper brand: a well-designed device built here in Canada. I’ve had my Thumper for about 15 years now, and it works as well today as it did the day I brought it home. I used it routinely in my clinic for many years (a favourite part of the treatment for many clients), and mainly as a self-massage tool ever since. Why thump? It feels good! The value of vibration is unclear, but it’s inherently relaxing, “because reasons.”287 Vibration isn’t reputed to be good for trigger point pain specifically, but it could be: vibration clearly has some effect on muscle tissue state, because even already flexible gymnasts can get a surprising boost in flexibility from it.288 All of this is covered in greater detail in the trigger points tutorial.

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ZAP!

The pain of a sensitive nerve has an extremely distinctive quality: it is electrical or zappy. Some people describe it as “a shower of sparks” or “a hot wire.” Officially, it’s called “lancinating” pain or “radicular” pain when it comes from a nerve root. But by any name, “electrical” is the best description & it can’t easily be mistaken for anything else.

You can damage nerves by massaging your neck, but it’s rare and the damage is usually not serious. This is a common question that I get, related to the common and excessive “nerve fear” in our society. Here’s an example:

One thing that helps sometimes when my neck pain gets excruciating is to really dig my fingers hard into a couple of knots in the back of the neck (not right on the spine but off to each side, below the occipitals), or to use a Thera Cane to do the same thing. Is there any chance of causing nerve damage from so much pressure?

reader Peter Spaeth, Boston

I’m going to answer this in detail so that you have good confidence about this issue. I’ll discuss the physical protection most nerves have, some of the potentially more vulnerable locations (endangerment sites), the toughness of nerves, and the extra caution needed with tools.

Why nerves are not very vulnerable to massage

Fortunately, if you are even slightly cautious, it is nearly impossible to damage your nerves with self-massage, because:

1. larger nerves are mostly padded well by other tissues
2. healthy nerves are not especially fragile or sensitive
3. if actually threatened by trauma, nerves produce plenty of warning sensations that will stop any sensible person before much harm is done

In my years of clinical experience, I have never known of anyone injuring a nerve by massaging except … er, well, I did it to a patient once. Only once. Yikes. See below for the story.

Larger nerves are mostly protected

The larger nerves and nerve roots — the only nerves of any concern — are mostly shielded by skin, fat, muscle, and bone. It’s particularly unlikely that you could harm yourself by massaging in the location Peter asked about, on the back of the neck (beside and behind the spine). The only prominent nerves in the back of the neck are the nerve roots, the bundles of nerve tissue that emerge from between each pair of vertebrae. But these are under at least a half inch of sturdy musculature, the meaty paraspinal muscles.

But not all nerves are well-protected, of course.

Endangerment, Will Robinson!

There are a few places in the body where nerves are more exposed and can be injured by stronger pressures. All of these sites are familiar to any well-trained massage therapist: we call them “endangerment sites,” but the danger is minimal. Perhaps a better thing to call them would be “unpleasant places to rub.”

Here are all of the commonly cited endangerment sites (nerves highlighted):

The endangerment sites are debatable and in some cases definitely misleading. Nerves are everywhere, and there are many locations where they are potentially just as vulnerable to pressure as some of the ones listed above … but no one has ever proposed them as an endangerment site.289 The idea that the sciatic nerve is “exposed” to any degree in the sciatic notch, for instance, is a bit ridiculous (compared to the ulnar nerve, say).

And you can easily massage the scalene muscle group (in the posterior triangle of the neck) without ever bothering a nerve fibre. Extra caution is justified in this area, but not because the brachial plexus is notoriously sensitive — it’s more because of the blood vessels.

If you massage these locations with reasonable caution, you might feel electrical, zappy, funny-bone-esque pains, but you will feel them before there is any actual danger. Healthy nerves aren’t particularly sensitive, but they will speak up if they are on the verge of being crushed or torn (like any tissue).

Nerves aren’t naturally very fragile or sensitive

Most nerves, most of the time, can be firmly squeezed without producing any symptoms whatsoever. The ulnar nerve — the “funny bone” — is tolerant of almost any fingertip pressure, and only produces that infamous zing with much greater force. However, there are almost certainly circumstances where nerves can be more sensitive. For instance, they may only be sensitive to pressure when oxygen-starved (or otherwise vulnerable).290 Which may be exactly what’s going on with some of the nerve tissue in your neck — muscles rotten with trigger points are measurably hypoxic, low-oxygen, as discussed above.

And so, one way or another, nerve roots in the posterior of the neck might sometimes be sensitive enough that you may get some stranger, nervier sensations when self-massaging in the neck. However, this sensation tells you nothing you didn’t already know: your soft tissues are cranky. There is no cause for concern if the sensations are easily tolerable.

In my experience, however, blatant nerve sensitivity in the neck is rare in association with neck cricks, even quite severe ones.

Or maybe they are naturally sensitive? But not in a “zappy” way

Another intriguing possibility is that the sensitivity of nerves and trigger points are actually the same thing — trigger points might be the sensitivity of vulnerable nerves. This is in contrast to the much more widely believed “tiny cramp” model of a trigger point.291 This idea is highly speculative; I’m including it just because it’s quite an interesting notion in this context.

If so, then pressing on them isn’t likely to injure them, or even cause clasically zappy nerve pain: just the familiar aching and burning of common muscle pain. The nerves are clearly vulnerable in some sense, but probably not to injury.

What happens if you push your luck and push too hard on nerves?

Push hard enough, and you can injure a nerve, of course. In a 2017 incident, a woman’s radial nerve was crushed by an aggressive massage in her upper, inner arm. It’s rare, but it happens.292 Deliberately ramping up pressure on a sensitive nerve is hard to do, like sticking your hand into a jar of scorpions. And yet, surprisingly, sometimes people still do it! It’s amazing what we can put up with if think it’s necessary, and the no-pain-no-gain attitude inspires a lot of foolishness.

Nerves can recover from a lot of abuse, up to and including being mangled in nasty accidents, or being pinched hard for years. For instance, many people who have severe carpal tunnel syndrome — years of disabling median nerve impingement — often recover just fine once pressure on the nerve is finally relieved by surgery.

In the unlikely event that you cause yourself a nerve injury, it would probably only result in annoying but trivial symptoms that would take a few days to resolve, or perhaps a few weeks at the worst. But I have rarely heard of this happening by self-massage — it’s just too unpleasant as you approach the point of injury to actually get there.

Please beware of tools

I’m sure that there are people, somewhere out there, who have hurt their nerves with self-massage. And I bet most of them were using a massage tool. When you use massage tools, it may be easier to apply too much pressure too quickly … before you have that “I’ve made a huge mistake” moment.

It’s harder to control tools, and hard to tell what’s going on when your sensitive fingers and thumbs aren’t involved. For example: you can easily feel the pulse of an artery when you are massaging with your fingers, but you can’t feel it at all when you use a tool.

So if you use a tool, use it with extra caution.

That one time I injured a client’s nerves

Once upon a time I pushed my luck, and injured a patient’s cervical plexus — this area where most people will probably never self-massage strongly. I injured him by applying strong pressures in a vulnerable area too quickly. It was one of my more reckless moments in a decade of mostly quite gentle massage.

He was alarmed and unhappy with me, of course, but his symptoms were minor: he had annoying flashes of moderate pain that slowly faded over about three weeks, and probably the worst thing about it was simply that he was less sure of his prognosis than I was. I knew he’d get better steadily, but he didn’t know if he could trust my opinion! Fair enough.

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