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What a pain in the neck

Updated: Mar 21, 2023

Neck pain is no joke – many studies report an annual incidence rate of at least 10% among adults (and many reports appear to approach the high-teens and 20% range). Among these, it has been reported that up to 2 in 3 people will report some persistence of their neck pain up to and greater than a year in duration (1). The good news is that your neighborhood physical therapist can offer some intervention options to help with pain relief and to keep that neck pain from interfering with your normal day.

There are a few key things to understand if neck pain has been getting you down. In our opinion, there are three primary things to keep in mind as based in the literature and based on clinical practice. One, not all neck pain comes from the same thing or cause. Thus, treatment should not be the same for all neck pain; a thorough history and physical exam should help to identify what may be going on and, perhaps more importantly, what treatment strategies may be most beneficial for you (3). Third, it is relatively uncommon for there to be a significant, sinister cause for your neck pain – but seeing a provider that knows what to ask and what to look for will go a long way in making sure of that.

How do we know what is wrong? Coming up with a diagnosis.

One of the first questions we usually hear from people is "so what's wrong with me?" Research on spine pain tends to point to this approach – attempt to reduce suspicion or concern of something more serious or sinister being the cause of symptoms, and then manage the symptoms. Some healthcare providers are quick to point to a single tissue or joint as a cause of pain, but the reality is that we have a preponderance of evidence at this point that have shown "abnormal" findings on imaging do not simply correlate to having symptoms (neck pain abnormality reference), as well as a substantial amount of evidence that shows that people can get better without having a specific diagnostic label as to what's going on. A recent study (2) examining spinal pain offers this as one of the opening statements of their paper:

"The multifactorial nature of and the lack of association between structural damage and pain are examples of issues that healthcare professionals need to face and manage." (2)

Seeing a provider that has the background, education, and training to thoroughly screen – through a comprehensive history and thorough physical exam – is critical. If you've had a healthcare experience with different groups, you likely have realized that not all healthcare experiences are created equal. Some places may order every test and measure available (while some may do very little in the way of interview and examination) and may utilize several office visits – but is it all necessary?

For example, people routinely ask if they need an X-ray before seeing us (and if told that an X-ray isn't needed, people want to know why). Being able to utilize research-based guidelines (4) helps with being able to determine the relative risk of something more severe going on (and can reduce your total costs, if unnecessary); once those suspicions are quelled, we can then proceed with using our clinical research to determine what may best help with your symptoms.

So what can we do for your neck pain?

Classifying (the "what")

The easiest answer is that we can offer many things – mobilization and manipulation of the neck and the thoracic spine, soft tissue mobilization, traction, specific exercise, and more. More important, perhaps, than the what is the knowing of how, when, and why. Some treatments have a fair amount of support in the research – for example, thoracic manipulation has some support for different things, from acute mechanical neck pain to neck pain with symptoms that radiate down the arm. This is why a good history and exam is important. The most recent research-based guidelines we have aim to classify you based on your symptoms and history. From here, we can then determine what treatments may be best in helping you (3).

Treating (the "how")

Having neck pain with occasional headaches that are influenced by your neck pain or neck movement? With appropriate medical screening, you might be a good candidate for manipulation of the upper cervical spine (5), and you'll likely benefit from a specific mobilization you can perform yourself to improve your mobility and to reduce the frequency and severity of your headaches (6,7). Woke up with a stiff and painful neck a couple of days ago? Manipulation of your thoracic spine (8,9) and mobilization and manipulation of the neck (10,11), coupled with specific mobility exercise, likely will help get you back on track. Symptoms radiating down your arm that are worse with turning your head or lying down on that side? Manual mobilization to include traction with movement (12-14), exercise intended to improve the mobility and tolerance to mechanical stress of the nerves in your arm (14), and some activity and positional modification may do a lot to provide relief quickly. By applying the best available research we have with strong clinical reasoning (e.g., assessing you as an individual and constantly reassessing your response to treatment), we have helped countless people manage their neck pain.


1) Hoy DG, et al. The epidemiology of neck pain. Best Practice & Research Clinical Rheumatology. 2010;24:783-792.

2) Bonfim IS, et al. "Your spine is so worn out" – The influence of clinical diagnosis on beliefs in patients with non-specific chronic low back pain – A qualitative study. Brazilian Journal of Physical Therapy. 2021;25:811-818.

3) Blanpied PR, et al. Neck pain: Revision 2017. Clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2017;47(7):A1-A83.

4) Bandiera G, et al. The Canadian C-spine rule performs better than unstructured physician judgment. Annals Emerg Med. 2003;42(3):395-402.

5) Haas M, et al. Dose-response and efficacy of spinal manipulation for chronic cervicogenic headache: A pilot randomized controlled trial. Spine J. 2010;10(2):117.doi:10.1016/j.spinee.2009.09.002.

6) Hall T, et al. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. J Orthop Sports Phys Ther. 2007;37(3):100-107.

7) Paquin JP, et al. Effects of SNAG mobilization combined with a self-SNAG home-exercise for the treatment of cervicogenic headache: A pilot study. J Manual Manipulative Ther. 2021;29(4):244-254.

8) Cross KM, et al. Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: A systematic review. J Orthop Sports Phys Ther. 2011;41(9):633-642.

9) Cleland JA, et al. Immediate effects of thoracic manipulation in patients with neck pain: A randomized clinical trial. Man Ther. 2005;10:127-135.

10) Puentedura EJ, et al. Thoracic spine thrust manipulation versus cervical spine thrust manipulation in patients with acute neck pain: A randomized clinical trial. J Orthop Sports Phys Ther. 2011;41(4):208-220.

11) Puentedura EJ, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. J Orthop Sports Phys Ther. 2012;42(7):577-592.

12) Thoomes EJ. Effectiveness of manual therapy for cervical radiculopathy, a review. Chiropractic & Manual Therapies. 2016;24(45):doi:10.1186/s12998-016-0126-7

13) Borrella-Andrés S, et al. Manual therapy as a management of cervical radiculopathy: A systematic review. BioMed Research International. 2021;doi:10.1155/2021/9936981.

14) Savva C, et al. Effectiveness of neural mobilization with intermittent cervical traction in the management of cervical radiculopathy: A randomized controlled trial. Int J Osteopathic Med. 2016;21:19-28.

P.S. Ever wonder why we tend to list so many references? We believe heavily in evidence-informed, substantiated clinical practice. Ultimately, our goal is to help address your symptoms and to help you reach your functional goals, but this happens best when we look to and incorporate clinical evidence.



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