Our fourth and final article in the neck pain series will discuss our approach to managing neck pain (see here for Parts I, II, and III), Whereas the traditional “impairment-based” approach involves searching for problems in the neck and trying to target them, we will instead advocate for an approach that aims to restore function for a person’s daily activities and individual goals. Worsfold 2020
Once “red flags” — situations where there is an ominous underlying cause of pain needing specific intervention — have been ruled out, we shift away from unnecessarily worrying about the meaning of symptoms, and instead address the unique goals of the person. Many clinicians choose passive approaches to care, where things are done “to” a patient to supposedly treat a specific impairment in the neck. These include things like joint manipulations, massage, TENS therapy, or ultrasound, among others. However, these claims remain largely unsupported. We prefer a more active approach to care, involving the patient in the treatment to aid with symptom reduction, building confidence, and progressing towards desired activities.
We categorize activity goals into daily activities (e.g., looking both ways to cross the street) and extracurricular activities (e.g., overhead pressing, cycling, or rock climbing). Clinical practice guidelines strongly recommend physical activity for neck pain, including whiplash-associated disorder, as well as other forms of neck pain that may include symptoms radiating into the arms. Corp 2020 Lin 2019 Parikh 2019 Blanpied 2017 Kjaer 2017
Although remaining physically active and exercising based on tolerance are strongly recommended management strategies, the best “dosage” of activity remains unknown. de Zoete 2021 We do not view this as a problem; instead, this simply means we should adapt and individualize our activity recommendations according to current symptoms, tolerance level, activity history, and goals. This article will provide general recommendations and guidance for finding an entry point into activity, and slowly building over time. If you are in need of more individualized advice, we recommend contacting a trusted local clinician or reach out to us for remote consultation.
As we have discussed in much of our prior content on pain and rehabilitation, managing musculoskeletal pain is a process that can take time. Recall from part 3 in our article series that most folks experience marked improvements in pain symptoms and function in the weeks to months after onset, but there will be ups and downs throughout the process (see figure 1 above). There are also many variables outside of the neck that can influence the experience and intensity of pain such as life stress, sleep, activity demands, and mood or emotional states. As a result, fluctuations in neck pain don’t necessarily mean damage or harm is being done to the neck.
To aid with coping through the process, our usual recommendation is that pain symptoms shouldn’t increase to the point of significantly reduced function or remain exacerbated for several days after a bout of physical activity or exercise. If pain symptoms are regularly increasing during or after activity, modifications to the activity should be made — for example changing the intensity, duration/volume, frequency, or type of activity. Attention should also be paid to the other variables that may be associated with increases in pain intensity such as marked increases in life stress, poor sleep, or other disturbances in mood or emotional states. Fluctuations in these other variables may necessitate alterations in the exercise programming.
Range of Motion
In the early stages of dealing with neck pain, we may need to specifically address range of motion to aid with daily activities. Individuals often notice pain and/or reductions in range of motion when looking up, down, side to side, tilting the head, or with combinations of these movements. Depending on the severity of symptoms, starting rehab may simply involve moving through these ranges of motion based on tolerance. For example, performing 2 sets of 15 repetitions in each direction with 60 seconds rest between sets, done once per day. (see this video for a tutorial on active neck range of motion). As time progresses, shifting from range of motion to more functional tasks will be necessary. Here are a few examples:
- Reversing a vehicle (rotation)
- Tying shoes while seated (flexion/extension)
- Crossing a road (rotation / lateral flexion)
- Washing hair in shower (flexion/extension)
- Picking up an object from the ground in front of the body (deadlifts and squats)
- Shaving the face or applying makeup (rotation)
- Smelling coffee (protraction/retraction)
These task-based approaches help shift away from an internal focus on the neck region, and instead look externally towards completing a particular activity or goal. Worsfold 2020 The above list can even be practiced by mimicking the movements without specifically performing the tasks in the usual setting (e.g. driving a car). The point is to increase volume of the activity over time, while aiding with symptom reduction and task performance.
As range of motion and symptoms improve, we can add in resistance-based activities. For example, there are three main devices available to directly load the neck and head through specific ranges of motion:
The iron neck offers more loading options in various ranges of motion but also involves a higher price tag. Harnesses or bands are perfectly adequate for most purposes as well.
See Table 2 for a sample program that can be completed at a frequency of 1-3 times per week. It’s important to keep in mind that RPE in this context is a subjective rating of difficulty, fatigue, AND pain. Throughout this process, loading of the neck and upper extremities may be limited by the influence experiencing pain has on RPE, and that’s ok given this will not always be the case. Also, we have a YouTube video for review regarding resistance activities specific to the neck region.
Return to Sport
Many of our readers may be trying to return to specific resistance training movements such as the overhead press, bench press, clean and jerk, or snatch. When individuals are experiencing significant symptoms with these activities, the dosage of these movements should be adjusted throughout this process based on individual tolerance. Upper body exercises play an integral role in the rehabilitation of individuals experiencing neck symptoms that radiate into the arms. In the beginning stages of this process we often advise temporarily transitioning away from explosive, plyometric-type movements (e.g. burpees or handstand push-ups) and other dynamic overhead movements such as push-press, power jerk, split jerk, snatch, etc, with plans for reintroduction later on.
Ideally we can find an entry point into the activities that are relevant for an individual’s goals. Let’s use the example of a strict overhead press. While athletes often warm-up with a barbell, in this situation that may provide too large of an external load at the start. Instead, we might attempt a strict overhead press using dumbbells, since they provide far more loading options. Typically a specific, controlled tempo is applied in this situation to help mitigate excessive loading early on, and many folks find slowing a movement down helps to build their confidence as well. We can take a similar approach to barbell bench press by subbing in dumbbell bench presses.
Isolation movements also have utility for individuals experiencing symptoms that radiate into the arms. For example, an individual may be dealing with cervical radiculopathy, a condition characterized by neck pain, as well as numbness/tingling or weakness in a region of the arm(s). Let’s say these symptoms are happening in the triceps. Instead of avoiding any loading of this area, we would have the person use tricep-specific movements as a part of their rehab. There’s no perfect answer for which triceps exercise is best; most decisions around exercise selection relate to the person’s prior training history and equipment availability. A few examples could include, dumbbell “skullcrushers”, single-arm triceps cable pressdown, dumbbell kickbacks, bench dips, or close-grip push-ups. Again, we would likely use a controlled tempo for the eccentric portion of each of these movements (for example, a 5-count tempo when lowering the weight). See table 2 for a suggested outline for re-introducing overhead pressing and triceps exercises.
A few important caveats: depending on symptoms, tolerance for loading, and response, the dosage of activity should be altered. This might include changing exercise selection, frequency, volume, and exercise intensity (e.g., via lowering RPE targets). If a more structured template is desired, our shoulder rehab template would be appropriate for these scenarios, or we can offer remote consultation and individualized guidance via our Pain and Rehab division.
In closing, neck pain (with or without arm symptoms) doesn’t typically require a unique approach from other body regions we’ve discussed in prior articles. Once the ominous “red flag” situations have been ruled out, we can begin working on introducing activity and goal-specific exercises to tolerance. It is relatively rare for these scenarios to require further investigation (e.g. medical imaging) and specific interventions such as passive treatment modalities or surgery. Rather, most folks will experience marked improvements in pain and function in the weeks and months after onset.
Staying active based on individual tolerance is a great self-management approach, but in the beginning stages some movements may need to be regressed or temporarily not programmed. During this time we can focus on staying positive, being patient with the process, and using appropriate programming that progresses back towards desired activities. In addition, this is an opportune time to recognize and work on all the other variables we’ve discussed that can influence our pain experience, such as life, occupation, or financial stressors, our emotional state, our sleep quality and consistency, and many other individual and social factors.
If you are struggling with neck symptoms and need assistance, we’d be happy to consult with you. Please complete our intake paperwork here. This wraps up our neck series, we hope this has been helpful.
- Corp N, Mansell G, Stynes S, et al. Evidence‐based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines Eur. J. Pain. 2020; 25(2):275-295.
- Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review Br J Sports Med. 2020; 54(2):79-86.
- Parikh P, Santaguida P, Macdermid J, Gross A, Eshtiaghi A. Comparison of CPG’s for the diagnosis, prognosis and management of non-specific neck pain: a systematic review BMC Musculoskelet Disord. 2019; 20(1).
- Blanpied PR, Gross AR, Elliott JM, et al. Neck Pain: Revision 2017 J Orthop Sports Phys Ther. 2017; 47(7):A1-A83.
- Kjaer P, Kongsted A, Hartvigsen J, et al. National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy Eur Spine J. 2017; 26(9):2242-2257.
- de Zoete RM, Armfield NR, McAuley JH, Chen K, Sterling M. Comparative effectiveness of physical exercise interventions for chronic non-specific neck pain: a systematic review with network meta-analysis of 40 randomised controlled trials Br J Sports Med. 2021; 55(13):730-742.