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Part III of our series on neck pain will discuss beliefs about the causes of neck pain, before we move on to practical management strategies in part IV (Parts I and II available here and here). The traditional medical approach involves searching for structural issues that are thought to cause neck pain. This often involves using imaging tests like X-rays and MRI scans to find abnormalities that are then labeled as the source of pain. Interventions are then offered to address these structural abnormalities.

The usual reader of our material likely already understands that pain is a more complex experience that is influenced by numerous factors, not just structure. With this in mind we will discuss neck pain from this multifactorial perspective, including evidence regarding common beliefs about the causes of neck pain, imaging findings, and their relevance to management.

Framing the issue

 When an individual is experiencing neck pain their usual first question is: “What is causing this?” In some situations, there are identifiable factors that relate to the individual’s neck pain, whereas in other situations these can be harder to pin down. The good news is that scenarios requiring further investigation and specific medical interventions are rare. See Figure 1 for findings that warrant further investigation.

It is worth reiterating that these are rare instances in which other symptoms (e.g., fever, headache, dizziness, vision changes, difficulty with walking or balance) are present in addition to neck pain. In these scenarios it is recommended to seek consultation with a healthcare professional as soon as possible to ensure appropriate management. Popescu 2019

The good news is that most folks do not fall into this category of needing urgent medical evaluation and treatment. The majority of neck pain episodes tend to improve on their own over time, almost regardless of what we do. This expected trajectory without any treatment or intervention is known as the “natural history” of a condition.

A recent study demonstrated a natural regression in neck pain over time, with individuals reporting 30%, 35%, and 40% reductions in pain intensity at 3, 6, and 12 months respectively (see figure 2). In this study, complete resolution of pain occurred in 43% of participants by the 12-month follow-up. The subjects observed natural improvements that were similar to those attributed to many medical interventions. Vasseljen 2013

This means that when we healthcare professionals offer many of our interventions du jour, we may simply be entertaining ourselves and our patients while they get better on their own over time. However, as is illustrated in the above figure, a significant number of individuals still report pain and disability up to one year later. One study found that approximately 50% of individuals from general, working, and trauma-related (“whiplash”) populations still reported neck pain months to years later. Bier 2018 These data demonstrate that although many may experience an initial improvement in neck pain without any intervention, others may go on to have persistent and recurrent neck pain and disability.

This raises the question: why does neck pain recur or persist for some individuals?

Beliefs about neck pain

This isn’t an easy question to answer directly, but we can start by examining some of the common beliefs people hold about the cause of their neck pain. A recent study asked participants dealing with persistent neck pain to list the 3 most important factors they believed were causing their neck pain (see figure 3). Walton 2012

We will review two of the major themes here.

Theme 1: Posture and Movement

The most prevalent theme for common neck pain triggers was posture and movement. In particular, positions that were sustained or static (e.g., office work, driving, reading, sleeping, and computer usage) and movements including heavy lifting, repetitive, rotation or sudden, and reaching forward/overhead were the most commonly referenced.

Recall from part 2 of our article series that there is no general “optimal” posture or movement that can mitigate the development of neck pain for all people. Instead, sustained postures and movements may relate to an individual’s experience of neck pain. Instead of demonizing postures or movements in general, we can simply use these experiences as cues to add variety into our daily routine. Having opportunities to change positions or vary movement and the amount, type, or intensity of activity can help when coping with neck pain.

Theme 2: Mechanism, Structures, and Tissues

Theme 2 is the set of beliefs most rooted in traditional medical thinking, and relates to issues with general structures (e.g., “stiffness in the neck”), specific tissues (e.g., “bad discs”), and mechanisms of injury causing neck pain (e.g., car accident). Neck pain is commonly attributed to structural concerns such as neck muscle damage, strain, and tightness, joint stiffness, disc issues, nerve damage, ligament damage, and inflammation.

Although we can often find many “abnormalities” on X-rays or MRIs that raise concern, we have good reasons to question the meaningfulness of these imaging findings in usual neck pain situations. Although such findings tend to be the primary focus in healthcare settings, many of these can be more accurately understood as age- and experience-related adaptations, rather than as problems or evidence of disease. Let’s briefly examine a few of these ideas.

Spinal Alignment

Alignment of the cervical spine is a commonly provided explanation for why someone might experience neck pain, and it seems to make intuitive sense to many patients. The cervical spine typically has an inward curve (known as a “lordosis”), however, as we age and have life experiences, this curvature may begin to straighten and transition in the opposite direction. The reversal of this lordotic curvature is known as “kyphosis”. Although kyphosis of the cervical spine is often viewed as a problem, this same type of curvature can be found in 26% of pain-free people in the general population. Kim 2018

When comparing those with and without neck pain, a study by Grob et al found no association between cervical spine alignment and neck pain. The authors state, “we suggest that when so-called ‘abnormalities’ of the sagittal profile are observed in the older patient with neck pain they must be considered coincidental, i.e. not necessarily indicative of the cause of pain.” Grob 2007

Although this “alignment” theory seems plausible to many individuals, there are many variations in alignment that can naturally develop over time, and we can adapt to these changes. Generally speaking, these kinds of changes in cervical spinal alignment shouldn’t be labeled as problems requiring specific treatment.

Spinal Degeneration

Cervical spine “degeneration” is a broad term for various findings on imaging tests such as disc herniations, decreased disc space height, bony outgrowths known as “osteophytes”, changes in spinal alignment, and narrowing known as “stenosis”.

Although these findings are often viewed as definitive causes of neck pain, we have evidence of the very same findings in many individuals without neck pain. One study performed MRI scans on 497 volunteers who had no neck pain and found disc degeneration in 17% of males and 12% of females in their 20s, with rates increasing to 86% and 89% among individuals over 60 years of age. To reiterate: none of these individuals had neck pain. Matsumoto 1998

Ten years later, 223 of the original study subjects underwent repeat MRI scan. While 85% (189) of participants demonstrated progression of at least one degenerative finding on the MRI, only 34% had experienced symptoms in the interim (neck pain, stiff shoulders, and numbness in upper extremities). Age was the factor most related to the progression of imaging findings. Okada 2009 20 years later the authors followed up again with 193 participants. Unsurprisingly, the authors found 95% of the participants demonstrated evidence of disc degeneration. At this time — 30 years after the initial study — the only imaging finding that appeared to correlate with symptoms was progression of stenosis. Otherwise, none of the symptoms including stiff shoulders, headache, neck pain, ringing in the ears, or numbness in the arms were correlated with progression of MRI abnormalities. The authors concluded:

“.…the degenerative findings on cervical MRI do not appear to be generally associated with the development of clinical symptoms. Thus, we propose that these changes be referred to as ‘age-related changes’ rather than ‘degenerative,’ which implies pathology to patients and families.” [emphasis ours] Daimon 2018

Another study of 1211 healthy, pain-free subjects demonstrated similar MRI findings. Despite having no symptoms, 87.6% of participants were found to have disc bulging that increased in frequency and severity by age. Nakashima 2015 Disc bulging, spinal cord compression, and abnormalities in the appearance of the spinal cord all increased throughout the lifespan, with some findings becoming apparent as early as age 20.

Aside from these two examples, similar findings have been replicated elsewhere, with a recent review of 31 studies found no meaningful MRI differences between individuals with neck pain versus without. Farrell 2019

Whiplash

The mechanism of how neck pain starts (e.g., after a motor vehicle accident) is another common belief for why neck pain persists. This scenario has been called “Whiplash-Associated Disorder” (WAD) and includes various symptoms such as neck pain, shoulder stiffness, dizziness, and other symptoms occurring after a car crash or other high-velocity injury. Watanabe 2020 It is thought that neck structures stressed by an accident will have increased degeneration, leading to more neck pain and disability throughout life.

Daimon et al did a 20 year follow-up with 81 study participants dealing with whiplash injury. Daimon 2019 Fujimura 1997 The authors found 95% of participants had evidence of disc degeneration — but this shouldn’t be surprising given our discussion above and the expected rates of these changes occurring throughout life. More pertinent to this discussion is that these changes on imaging did NOT lead to more reporting of symptoms. These study findings suggest that the usual concern about an increased risk of degeneration causing more neck pain throughout life remains largely unfounded. The authors state:

“These results suggest that the degenerative changes observed in the intervertebral discs of the cervical spine on MRI at the long-term follow-up represent the physiological aging process rather than pathological changes occurring a long time after a traffic accident. [emphasis ours] Daimon 2019

To drive this point home further, the authors contacted and recruited participants from the pain-free imaging studies and from the whiplash-associated disorder (WAD) studies to compare the two groups 20 years later. The authors compared 75 individuals with WAD and 181 originally pain-free individuals using new MRI scans and symptom questionnaires.

Figure 5 demonstrates the reported symptoms between the two groups. The prevalence of shoulder stiffness, headache, and arm pain were higher in patients dealing with whiplash-associated disorder compared to controls, although reports of neck pain and arm numbness were not statistically different.

The reader may be thinking these data demonstrate something relevant, and indeed they do — but interestingly, the symptoms do not align with imaging findings. The prevalence of all analyzed MRI findings were similar between both groups. In other words, at 20 year follow-up, MRI findings did not differ whether individuals originally experienced whiplash or not. In fact, neck pain appeared to be more prevalent in those without significant progression of disc degeneration versus with, and headache was more prevalent in those without progression of posterior disc protrusions than those with. So although a prior history of a whiplash injury was a significant risk factor for certain symptoms (shoulder stiffness, headache, and arm pain), this risk doesn’t seem to line up as we’d expect with findings on MRI scans. The authors conclude, “The [cause of] long-lasting symptoms after [whiplash-associated disorder] is still unknown.” Watanabe 2020

When a recent study asked participants about their healthcare journey and experience with acute to persistent whiplash associated disorder, several common themes emerged. Many reported the need to “shop around” for healthcare professionals, searching for someone who believed what they were reporting, provided insight into their situation, and had an acceptable treatment plan.

When participants reported lacking such a healthcare professional, confusion arose. One participant stated, “My doctor said to me it’s about time I faced up to the fact that there’s nothing wrong with me, there’s nothing physically wrong. He suggested that I go to a psychiatrist or a psychologist for treatment of the mental side of things and that once that was treated then I would be right. The sooner I’ve faced up to that then the better off I’d be.Ritchie 2017

Others were not keen on the recommendations of more imaging, tests, or medications. Participants reported having to figure out what worked for them over time via trial and error, with some feeling unable to trust the advice of their healthcare professional. We’ve previously discussed the stigmatization that can occur with people experiencing persistent pain. The authors state, “The importance of being believed and validated aligns with previous literature about patient experiences with chronic pain. There is no diagnostic test for WAD so patients may feel a need to prove the existence of their pain resulting in feelings of being judged about the legitimacy of their injury.” Ritchie 2017 When these scenarios also involve dealing with insurance companies, financial compensation, and other incentives, folks likely have increased pressure to demonstrate that they are, in fact, injured and deserving of compensation.

Reframing “Degeneration”

Ultimately, the reasons for why neck pain persists over time don’t have a clear explanation. The data we’ve covered so far lead us at Barbell Medicine to change our language from that of “spinal degeneration” to describing such findings as age- and experience-based adaptations. The hope for shifting our language is to avoid unnecessarily turning such findings into ominous “diseases” that need specific treatment.

A recent study demonstrated just how damaging certain language can be for both patients and healthcare professionals. Rajasekaran 2021 The authors recruited two groups of individuals experiencing low back pain who also had undergone an MRI scan. Group A received their imaging results with usual medical terminology, while group B received re-worded reports that were consistent with current evidence regarding normal age- and experience-based adaptations. Participants were assessed for 1) pain severity, 2) perception of “disease” status, and 3) functional abilities at baseline, after MRI reading, and after 6 weeks of conservative management.

Individuals in group A — who received the usual medical jargon-filled reports — demonstrated a worsening of pain severity, disease perception, and functional status after six weeks of conservative treatment. Group B — who received reports with modified language to reflect the current best evidence —  experienced improvements in these outcomes. In other words, the language provided in the MRI report and how the results were framed had a profound impact on patients’ self-perception and response to treatment.

The authors then compiled the usual MRI terminology and substituted out fear- or anxiety-provoking words, and then disseminated two reports with old and new language to spine surgeons, orthopedic surgeons, and physiotherapists. They wanted to see how the language would affect the clinician’s perceptions of disease status and their recommended treatments. The new language report significantly reduced disease severity assessments, and the choice of treatment was downgraded to less aggressive recommendations. This was observed for all professional titles except spine surgeons.

The study demonstrates how the language used on MRI reports affects both patients & healthcare professionals, and influences expectations of treatment. MRI scanning continues to increase for back pain despite practice guidelines and evidence showing significant negative effects from inappropriate overuse. Spinal surgery rates are similarly on the rise; these are not unrelated events. Although this particular study involves patients with low back pain, we see the exact same events unfold in scenarios in which folks are dealing with neck pain.

Given that these imaging findings are readily identified in those without symptoms, we can think of them as incidentalomas. Chojniak 2015 An incidentaloma is something found on an imaging test by happenstance, that does not necessarily relate to a patient’s symptoms. The difficulty is that once these are identified, the clinician and/or patient may become worried and seek further investigation or treatments that, by definition, cannot offer benefit – since the finding is not causing any problems in the first place. These downstream consequences happen often enough that we have an acronym for the negative effects: V.O.M.I.T., or “Victims of Modern Imaging Technology”. Hayward 2003

Many of these issues can be prevented by minimizing inappropriate imaging tests, while also framing neck pain as a multifactorial experience. Since numerous variables can influence the experience of pain, we have numerous variables that we can act upon to mitigate symptoms, rather than being confined to a myopic focus on tissue structure alone – which we may not be able to modify.

To be clear, this doesn’t mean imaging findings are irrelevant or don’t matter. The increase in frequency/severity of findings does appear coupled to reporting of neck symptoms, but these relationships are highly variable between individuals, making useful generalizations quite difficult. One study goes as far to say, “… it is dangerous to make interventional decisions only by judging degenerative changes using [MRI] images alone”. Nakashima 2015

The larger question is: do these imaging findings matter sufficiently to influence or change what we should recommendations for the individual? Most often, the answer here is “no”, but we will explore management of neck pain in part 4 of our series with a broader and more inclusive approach to helping those dealing with neck pain.

As always, if you are struggling with pain or injury, we’d be happy to try and help guide your path back to activity. You can check out our coaching page to get signed up for a remote consultation with one of our pain and rehab clinicians.

References:

  1. Popescu A, Lee H. Neck Pain and Lower Back Pain. Med Clin North Am. 2020; 104(2):279-292.
  2. Vasseljen O, Woodhouse A, Bjørngaard JH, Leivseth L. Natural course of acute neck and low back pain in the general population: the HUNT study. Pain. 2013; 154(8):1237-44.
  3. Bier JD, Scholten-Peeters WGM, Staal JB, et al. Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain. Phys Ther. 2018; 98(3):162-171.
  4. Walton DM, Balsor B, Etruw E. Exploring the Causes of Neck Pain and Disability as Perceived by Those Who Experience the Condition: A Mixed-Methods Study ISRN Rehabilitation. 2012; 2012:1-7.
  5. Kim SW, Kim TH, Bok DH, et al. Analysis of cervical spine alignment in currently asymptomatic individuals: prevalence of kyphotic posture and its relationship with other spinopelvic parameters. Spine J. 2018; 18(5):797-810.
  6. Grob D, Frauenfelder H, Mannion AF. The association between cervical spine curvature and neck pain. Eur Spine J. 2007; 16(5):669-78. [PDF]
  7. Matsumoto M, Fujimura Y, Suzuki N, et al. MRI of cervical intervertebral discs in asymptomatic subjects. J Bone Joint Surg Br. 1998; 80(1):19-24.
  8. Okada E, Matsumoto M, Ichihara D, et al. Aging of the cervical spine in healthy volunteers: a 10-year longitudinal magnetic resonance imaging study. Spine (Phila Pa 1976). 2009; 34(7):706-12.
  9. Daimon K, Fujiwara H, Nishiwaki Y, et al. A 20-Year Prospective Longitudinal Study of Degeneration of the Cervical Spine in a Volunteer Cohort Assessed Using MRI: Follow-up of a Cross-Sectional Study. J Bone Joint Surg Am. 2018; 100(10):843-849.
  10. Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015; 40(6):392-8.
  11. Farrell SF, Smith AD, Hancock MJ, Webb AL, Sterling M. Cervical spine findings on MRI in people with neck pain compared with pain‐free controls: A systematic review and meta‐analysis J. Magn. Reson. Imaging. 2019; 49(6):1638-1654.
  12. Watanabe K, Daimon K, Fujiwara H, et al. The Long-term Impact of Whiplash Injuries on Patient Symptoms and the Associated Degenerative Changes Detected Using MRI: A Prospective 20-year Follow-up Study Comparing Patients with Whiplash-associated Disorders with Asymptomatic Subjects. Spine (Phila Pa 1976). 2021; 46(11):710-716.
  13. Fujimura, Y., & Matsumoto, M. (1997). Diagnostic value of magnetic resonance imaging in whiplash injury. International Medical Journal, 4(3), 177-180.
  14. Daimon K, Fujiwara H, Nishiwaki Y, et al. A 20-year prospective longitudinal MRI study on cervical spine after whiplash injury: Follow-up of a cross-sectional study. J Orthop Sci. 2019; 24(4):579-583.
  15. Ritchie C, Ehrlich C, Sterling M. Living with ongoing whiplash associated disorders: a qualitative study of individual perceptions and experiences BMC Musculoskelet Disord. 2017; 18(1).
  16. Rajasekaran S, Dilip Chand Raja S, Pushpa BT, Ananda KB, Ajoy Prasad S, Rishi MK. The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials. Eur Spine J. 2021.
  17. Chojniak R. Incidentalomas: managing risks Radiol Bras. 2015; 48(4):IX-X.
  18. Hayward R. VOMIT (victims of modern imaging technology)–an acronym for our times BMJ. 2003; 326(7401):1273-1273.

About Michael Ray

Dr. Ray is the founder of Shenandoah Valley Performance Clinic in Harrisonburg, VA. He obtained a M.S. in Exercise Science from the University of South Carolina and graduated Magna Cum Laude with his Doctorate of Chiropractic (D.C.) from Sherman College of Chiropractic.

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