Barbell Medicine - From Bench to Bedside

Have you ever suffered from neck pain? Perhaps you woke one morning with a “crick” in your neck, or you’ve been diagnosed with “whiplash” after an accident.  Maybe you’ve experienced numbness and tingling in your arms or hands and been told that this is coming from your neck. If these situations sound familiar, then this article series is for you. We will aim to provide clarity about neck pain as well as a practical path forward. We must begin with establishing some important background information, including what neck pain is, and what sorts of things relate to its development.

Neck pain is defined as having pain symptoms for at least 24 hours in the cervical spine region, which includes the first 7 bones in the neck known as the C1-C7 vertebrae. Neck pain may also include symptoms that radiate into the arms. Millions of individuals worldwide experience neck pain each year. A recent review found 288 million cases of neck pain worldwide, ranking it in the top 25 leading causes of global disability. Kim 2018 GBD 2019 Safiri 2020 Men between the ages of 45-49 and women between 45-54 experience the highest burden from neck pain (see figure 3). Safiri 2020 

 While many people assume that neck pain implies that something is wrong with the structure of their neck, it turns out that there are lots of other factors that can influence the experience of neck pain. This is actually good news, since it means that we have lots of things we can work on when experiencing pain. In the following sections we will discuss some of these factors that increase or decrease the risk of developing neck pain.

What factors relate to the onset and recurrence of neck pain?

“Risk factors” are variables that can influence the development of a condition like neck pain. There are two main categories of risk factors:

  1. modifiable – variables that we can influence, such as obesity, physical activity habits, and smoking. These often represent targets we can work to improve.
  2. non-modifiable – variables that we cannot influence, such as age or a prior history of neck pain. These are things that we can’t do anything about

Risk factors that influence the development or recurrence of neck pain can be divided into three general categories: physical, individual, and psycho-social factors. Kim et al A discussion of these risk factors can help us focus our efforts when managing neck pain.

In the following sections we will use numbers to describe the strength of relationship between a given variable and neck pain. A value of 1.0 indicates no relationship between a variable and neck pain, a value less than 1.0 indicates that the variable is associated with a LOWER risk of neck pain (known as a “protective factor”), and a value greater than 1.0 indicates that the variable is associated with a HIGHER risk of neck pain (known as a “risk factor”). See figure 2 for a summary of these concepts. We will focus on the most influential factors here, although many other variables have been studied as well.

Individual Risk Factors 

Individual factors describe things specific to an individual that relate to the risk of neck pain.

A major contributor to the risk of neck pain in this category is Body Mass Index (BMI). Body mass index is a measure of body size that can be a useful screening tool for excess body fat. The details of BMI, its limitations, and its interpretation are discussed further in the following Barbell Medicine video.

 High BMI (> 30 kg/m2) is associated with 2.21 times higher odds of experiencing neck pain, indicating that obesity has a strong relationship with neck pain. Since obesity is a modifiable risk factor – meaning we can do something about it – this finding suggests that this is likely an area where we should focus attention when managing neck pain.

 Other individual risk factors with moderate-strength relationships include:

  • Marital status; being widowed associated with 1.8 times higher risk of neck pain
  • Family size; 3 children associated with 1.5 times higher risk of neck pain, and ≥4 children associated with 1.7 times higher risk of neck pain
  • Male with “low income” had 1.8 times higher odds of neck pain, while women in this category had 1.6 times higher odds of neck pain. (This category is drawn from Swedish data; in today’s US Dollars, 0 – $13,753.33/year) Palmlöf et al
  • High perceived financial stress with low income had 2.0 times higher odds of neck pain

 Physical Risk Factors

 Physical risk factors describe things specific to the body and the demands placed upon it.

Factors with moderate influence on the risk of neck pain include workspace setup and demands. For example, not having the ability to adjust sitting positions at work (1.80 times higher odds) and working in sustained or “awkward” positions (1.6 times higher odds) are associated with pain. In the research, “awkward” was defined using a questionnaire with questions relating to: Luime 2004

  1. Working with hands above shoulder level 
  2. Lifting greater than 25 kg 
  3. Using force with arms or hands
  4. Bending or turning the torso frequently per hour
  5. Working in uncomfortable positions
  6. Prolonged work in the same position of the body
  7. Repetitive movements with arms or hands frequently per hour

Researchers combined bending or turning the torso frequently per hour and working in uncomfortable postures to define “awkward postures”. The use of “awkward” to describe a posture is subjective and may be based on an individual’s experience of discomfort or fatigue. However, not everyone may share this experience, which makes it difficult to define “awkward” postures that apply to all people. This label further drives expectations and ideas about “correct” or “perfect” postures – which don’t actually exist. Korakakis 2019 Korakakis 2020 

Psychosocial Risk Factors

 Psychosocial factors include individual psychological characteristics, as well as social and inter-personal variables. Of the variables studied, psychological and social factors seem to hold stronger relationships with the risk of neck pain compared to individual or physical factors. Kim 2018

Many of these relate to workplace stressors, such as high perceived job demands (2.14 times higher risk), imbalances between the effort required by the job and the rewards received (1.66 times greater risk), and a perception of low support from co-workers (2.43 times higher risk). Other psychosocial risk factors include:

  • “Poor” self-rating of health (2.4 times higher risk)
  • High perception of muscular tension (4.0 times higher odds)
  • Personal history of neck pain (2.24 times higher odds)
  • Depression (3.36 times higher odds)

Another important risk factor is the perception of high “quantitative demand” at work (2.32 times higher odds). “Quantitative demand” describes the amount of work and time pressure a person deals with (e.g., ‘‘do you have too much to do?’’ and ‘‘do you have to work overtime?’’) Christensen 2014 High role conflict is another major risk factor (2.61 times higher odds of neck pain), assessed by questions like ‘‘do you receive conflicting requests from 2 or more persons?’’ Christensen 2014 

Protective Factors

In contrast to the factors discussed above that were associated with increased risk of neck pain, we also have other variables that are associated with decreased risk of neck pain. These are also worth reviewing in order to guide what we can do in the face of neck pain symptoms.

Leisure-time physical activity has been associated with a 30-40% reduction in the odds of developing long-term neck pain. Palmlöf et al Interestingly, leisure time physical activity may not affect prognosis for those already dealing with neck pain. Physical activity done at work doesn’t seem to affect the risk or prognosis of neck pain.

Daily walking is a good example of leisure-time physical activity that can reduce the risk of developing neck pain. For example, one study found that a modest increase in daily step count (8190 steps vs. 7044 steps) decreased the risk of neck pain by 78% over a 6-month period – and this is not to mention all the other health benefits that can be obtained by increasing daily activity through walking. Sitthipornvorakul 2020 These findings have been echoed in other research finding that exercise substantially reduces the risk of developing neck pain. de Campos 2018  A 2010 study found that the average daily step count in a group of U.S. adults was 5117 steps per day, indicating that there is room for improvement on this front! Bassett 2010

Neck muscle endurance also appears to relate to the risk of developing chronic neck pain over time. While the effect is modest, having folks directly work on neck muscle endurance is fairly easy to do using an isometric hold for time. See a video HERE for an example of this exercise. Shahidi et al

There are several protective factors in the context of the workplace as well. A survey of 1200 Norwegian workers found that “empowering leadership” at work was associated with a 68% reduction in odds of neck pain. This was assessed using questions like, “does your immediate superior encourage you to speak up if you disagree?” They similarly found that a “high social climate” was associated with a 55% reduction in odds of neck pain. Social climate describes the culture at work, for example being “relaxed and pleasant”. Christensen 2014 Having a less stressful, more supportive and enjoyable work environment seems to protect against the development of neck pain.

Contrast these findings with the risk factors discussed above, where individuals with high workplace demands, low levels of support, and inter-personal conflict all increased the risk of neck pain. The researchers concluded that, “Overall, this substantiated the hypothesis that non-physical aspects of work can exert considerable influences on pain problems.” Christensen 2014 In other words, they found that neck pain is influenced by lots of factors outside of just the neck itself. 

What are the major takeaways?

In part one of this series on neck pain, we’ve spent time discussing the prevalence of the issue, associated risk factors, as well as protective factors. Neck pain is common, with prevalence increasing in our 40s and 50s. Neck pain is also complex, and it can relate to many other factors than one simple thing being “wrong” in a person’s neck. Many risk factors pertain to the individual – how a person views themselves (e.g., poor health), their perception of their neck (e.g., a perception of neck tension), as well as the individual’s coping strategies to handle work and financial stressors.

We may not be able to directly influence all risk factors, but there are many where we do have opportunities for improvement. This means that an approach to managing neck pain must look at the whole person, and not focus exclusively on just the neck. The strength of relationships described between the above risk factors and protective factors can help us focus on those that will get us the biggest return on our investment of time and effort.

 Since general health, obesity, and one’s self-perception of health have strong relationships with the risk of neck pain, these are important areas to target. One approach can involve increasing general physical activity through daily walks and other forms of exercise that an individual enjoys and can maintain consistently over time. There are also specific exercise-based treatments targeted to the neck that we will discuss further in subsequent sections of this article series. A discussion of other important health-related factors can be found in our article Where should my priorities be to improve my health?. 

Work stressors have strong relationships with neck pain, and include high work demands, interpersonal conflicts, and a mismatch between rewards and the amount of effort required to earn them. This becomes a complex discussion of job enjoyment, having supportive co-workers and leadership, and autonomy within your role to make decisions. It’s easy to tell someone to simply find a different job if a person feels as though these standards aren’t met, but things can obviously be much more complex in the real world. Having coping strategies such as talking to a trusted colleague, human resources, friends, family members, and qualified healthcare professionals may be beneficial for addressing work related stressors.

Additional work and physical stressors include maintaining sustained body positions for prolonged periods of time. There are things that can be done to mitigate or cope with neck pain symptoms. For example, standing desks have become popular in the workplace. Although the common claims surrounding standing desks are often inaccurate, these desks do typically afford more options for changing position while working, for example adjusting from high to low based on comfort. With this option a person can regularly change positions from seated, standing, kneeling, half-kneeling, dual kneeling, etc. to accommodate sustained work demands. We should be clear that there is no one “correct” or “optimal” posture, but if a person becomes sensitive to a particular position, then we can use this as a cue to change to the next position. Having the workplace setup to afford various postures throughout the day may help when managing neck pain.

In the next part of this article series, we will focus more specifically on common ideas about neck pain and posture, in order to dispel myths before moving on to discuss how the healthcare system typically approaches the issue, and how we approach it differently.


  1. Kim R, Wiest C, Clark K, Cook C, Horn M. Identifying risk factors for first-episode neck pain: A systematic review Musculoskeletal Science and Practice. 2018; 33:77-83.
  2. Vos T, Lim SS, Abbafati C, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019 The Lancet. 2020; 396(10258):1204-1222.
  3. Safiri S, Kolahi A, Hoy D, et al. Global, regional, and national burden of neck pain in the general population, 1990-2017: systematic analysis of the Global Burden of Disease Study 2017 BMJ. 2020.
  4. Palmlöf L, Skillgate E, Alfredsson L, et al. Does income matter for troublesome neck pain? A population-based study on risk and prognosis J Epidemiol Community Health. 2012; 66(11):1063-1070.
  5. Luime JJ, Kuiper JI, Koes BW, Verhaar JA, Miedema HS, Burdorf A. Work-related risk factors for the incidence and recurrence of shoulder and neck complaints among nursing-home and elderly-care workers Scand J Work Environ Health. 2004; 30(4):279-286.
  6. Korakakis V, O’Sullivan K, O’Sullivan PB, et al. Physiotherapist perceptions of optimal sitting and standing posture Musculoskeletal Science and Practice. 2019; 39:24-31.
  7. Korakakis V, O’Sullivan K, Whiteley R, et al. Notions of “optimal” posture are loaded with meaning. Perceptions of sitting posture among asymptomatic members of the community Musculoskeletal Science and Practice. 2020.
  8. Christensen JO, Knardahl S. Time-course of occupational psychological and social factors as predictors of new-onset and persistent neck pain: A three-wave prospective study over 4 years. 2014; 155(7):1262-1271.
  9. Palmlöf L, Holm LW, Alfredsson L, Magnusson C, Vingård E, Skillgate E. The impact of work related physical activity and leisure physical activity on the risk and prognosis of neck pain – a population based cohort study on workers BMC Musculoskelet Disord. 2016; 17(1).
  10. Sitthipornvorakul E, Sihawong R, Waongenngarm P, Janwantanakul P. The effects of walking intervention on preventing neck pain in office workers: A randomized controlled trial. J Occup Health. 2020 Jan;62(1):e12106. doi: 10.1002/1348-9585.12106. Epub 2019 Dec 18. PMID: 31849170; PMCID: PMC6970409.
  11. de Campos TF, Maher CG, Steffens D, Fuller JT, Hancock MJ. Exercise programs may be effective in preventing a new episode of neck pain: a systematic review and meta-analysis. J Physiother. 2018 Jul;64(3):159-165. doi: 10.1016/j.jphys.2018.05.003. Epub 2018 Jun 19. PMID: 29908853.
  12. BASSETT, DAVID R. JR.1; WYATT, HOLLY R.2; THOMPSON, HELEN2; PETERS, JOHN C.3; HILL, JAMES O.2 Pedometer-Measured Physical Activity and Health Behaviors in U.S. Adults, Medicine & Science in Sports & Exercise: October 2010 – Volume 42 – Issue 10 – p 1819-1825 doi: 10.1249/MSS.0b013e3181dc2e54
  13. Shahidi B, Curran-Everett D, Maluf KS. Psychosocial, Physical, and Neurophysiological Risk Factors for Chronic Neck Pain: A Prospective Inception Cohort Study The Journal of Pain. 2015; 16(12):1288-1299.

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.

Read More by Michael Ray

About Austin Baraki

Dr. Austin Baraki is a practicing Internal Medicine Physician, competitive lifter, and strength coach located in San Antonio, Texas. Originally from Virginia Beach, Virginia, he completed his undergraduate degree in Chemistry at the College of William & Mary, his doctorate in medicine at Eastern Virginia Medical School, and Internal Medicine Residency at the University of Texas Health Science Center in San Antonio.

Read More by Austin Baraki