What Is Neck Pain?Do you suffer from neck pain? This acute or chronic pain condition can have a huge impact on your quality of life — your work, your relationships, your joy. In this article, we discuss the major aspects of neck pain conditions, including methods for finding neck pain relief.
Neck pain is a condition that develops quite often in adults, especially women. More specifically, reports show that 15% and 25% of males and females, respectively, whose ages range from approximately 21 to 55 years of age experience both neck and shoulder pain during their lifetime. In addition, this condition often becomes the cause of chronic pain and discomfort. Furthermore, there is some evidence to support the notion that a large number of individuals who experience pain in the neck may continue to suffer from it up to six months after the pain has begun.
In other words, neck pain tends to be recurrent, and a specific event that causes neck pain increases the susceptibility of experiencing frequent neck pain. Clinicians also report that patients who are aware of the incident that initiated their neck pain tend to suffer from this condition more frequently than those who never had a problem with neck pain. As a result, a previous condition or injury to the neck dramatically increases the probability of suffering from recurrent neck pain.
Although neck pain is typically localized to a small region, it can lead to dramatic functional and mobility impairments. Subsequently, the serious complications that neck pain may cause has been linked to a high number of disability cases, most of which hinder individuals from working properly and even functioning normally at home. In actuality, more than 10% of people who have persistent pain in neck have to discontinue working. It is, therefore, not surprising that neck pain is now reported as one of the main health issues that have a negative impact on the economy.
Decreased work productivity and significant increases in medical treatment have also been attributed to recurring neck pain. In particular, studies have reported that up to 50% of patients who have neck pain need to receive medical treatment to help manage their discomfort and painful symptoms. Accordingly, theoretical as well as empirical research regarding neck pain is gaining an increased amount of attention. For the past decade, research has specifically focused on identifying factors that indicate the onset of neck pain. Furthermore, clinical trials are being continuously conducted to determine if various types of treatments can effectively reduce neck pain or completely alleviate the symptoms.
Must Watch Video – What Is Neck Pain?
Anatomy of the neck
The region of the spine positioned near the bottom of the head is known as the cervical spine and this area is typically held responsible for the onset of neck pain. However, muscle, ligament, and tissue damage in any part of the neck may contribute to this condition as well. Furthermore, the spine is surrounded by cerebrospinal fluid (CSF), which is a protective substance that cushions the nerves within the spine. The CSF and spinal cord are both held in position by a rigorous membrane known as the spinal canal. Spinal nerves that are embedded within the spinal cord provide signal transmission throughout the entire body as well as the brain. There are also cervical facet joints or small connective bones that are positioned within the neck. These joints are shaped differently from facet joints in lower parts of the spine so that the neck can move in a variety of directions. Damage or injury to the cervical facet joints, however, can result in inflammation, pain, stiffness, or soreness in the neck, upper back, or the shoulders. This is why neck and shoulder pain occur so frequently, as well as neck and headache pain.
The examination that is performed for cervical pain usually involves a medical history questionnaire and a physical evaluation. A comprehensive examination helps a doctor diagnose the source of the neck pain correctly, although the cause of neck pain cannot be determined in some cases. When this happens, the doctor will instead try to rule out other potential causes. For instance, the doctor can perform an evaluation that could exclude problems with the spinal cord or nerve roots. The doctor could also evaluate the degree to which the neck pain is causing mobility issues and limiting activities. This type of evaluation allows the doctor to determine if yellow flags are present, which subsequently provide an indication of what the treatment and follow-up strategies should be.
If signs of spinal problems or nerve damage are present, it does not necessarily mean that this health issue is causing the neck pain, although it does indicate that the patient has an increased risk of suffering from neck pain. Additional testing is usually recommended in such cases before a particular treatment is recommended. The main factors that doctors consider, however, involve assessing the degree of limited movements due to the neck pain and whether the symptoms may indicate that a problem other than neck pain is occurring simultaneously. Find out more about the anatomy of the spine at Patient.Info.
Neck Pain CausesDue to the complex structure of the neck and cervical spine, neck pain can develop from a variety of issues. The degeneration of muscle or tissue in the neck, which may gradually occur over time, often causes neck pain. Ligament, muscle, or joint damage in the neck are also among the primary causes of acute or persistent neck pain. Even though these types of problems commonly result in neck pain, sometimes the source cannot be accurately identified.
The cervical spine is the highest portion of the spine and it is connected to the base of the head. This spinal region appears to cause neck pain in the majority of cases. The cervical spine contains seven spinal bones called vertebrae, which are connected to each other by facet joints. The facet joints in the neck can easily become irritated, inflamed, or damaged. Fractured or dislocated spinal bones tend to cause neck pain as well, especially if these conditions are not treated.
An additional condition that can lead to neck and back pain is stenosis. This is a condition in which the spine becomes compressed and causes the spaces between the spinal bones as well as the tissue that surrounds them to become very narrow. There are several common causes of stenosis. However, the primary cause is scar tissue formation on the spinal cord. In addition, neck pain may be the result of bulging disc syndrome, which causes discs that are located between the spinal vertebrae to push outward. This leads to the painful compression and irritation of spinal nerves.
A similarly, common problem that causes neck and headache pain is whiplash, which refers to a quick jolt that causes the neck and head to jerk back and forth. Rollercoaster rides and car accidents are highly associated with the occurrence of whiplash. Whiplash has never proven to be fatal, although it can lead to persistent pain. An injury such as this damages neck muscles, spinal bones, and the ligaments as the neck abruptly whips forward and backward.
Various factors can increase a person’s risks of developing chronic neck pain. A few include gender, due to women being more susceptible to neck pain than men, having a frequent history of neck pain, a loss of function in the wrists or hands, cycling on a regular basis, a quality of life that is poor, frequent anxiety attacks or stress, and age, especially for adults over 40. Check out Spine-Health.com for more information about specific causes of neck pain, or use Everyday Health’s symptom checker to find more information about your neck pain.
Finding Neck Pain ReliefThe number of potential underlying issues that may result in neck and cervical pain warrant a thorough discussion of the specific symptoms that are being experienced with a doctor who can determine what the most appropriate treatment plan should be. Furthermore, as the incidence of neck pain continues to increase so does the amount of research regarding this health issue. More importantly, several current interventions that are typically used to help patients find neck pain relief have been studied extensively through empirical research.
Clinically, it has been shown that the disabling symptoms and pain that may develop as a result of neck or cervical pain do not exclusively arise due to bodily injuries or illnesses. It is actually now understood that certain unexpected factors may also contribute to pain intensity and disability level. For instance, a patient’s feelings about the pain and personal beliefs regarding how disabilities are defined can influence the intensity of an individual’s pain and their level of mobility impairment. In addition, persistent pain can elicit an emotional response and cause psychological stress that can affect the amount of pain that is experienced as well.
Therefore, individuals with major concerns regarding whether their neck pain will limit them long-term should speak with a doctor who can address their apprehensions. Once a thorough examination has been performed, the doctor can more specifically address questions about the neck pain prognosis as well as potential treatment options. Moreover, the doctor can offer helpful information and even educational pamphlets about this painful condition. However, if the pain in neck is not serious and has not resulted in mobility problems, a doctor will probably suggest that the patient slowly begin to engage in easy activities that were a part of the normal routine before the pain started.
Neck pain exercises and physical therapy
Conventional treatments such as physical therapy have repeatedly been shown to improve the symptoms of almost all patients who were suffering from pain in the cervical spine. This treatment approach involves showing patients how to perform strengthening techniques and stretching exercises that promote an increased range of motion and elasticity in the neck muscles.
Some treatment approaches, however, focus specifically on reducing the degree of the physical impairment a patient has as well as symptoms that have become disabling. The primary goal for individuals who have lost a significant amount of time from work, for example, is to be able to start working again. In other words, the treatment plan will work towards ensuring that the patient does not become permanently disabled as this would hinder the individual from returning to their job. If a person who has intense neck pain and limited mobility does not find ways to remain somewhat active, however, their quality of life will begin to decrease and the symptoms may become recurrent.
In addition, treatment may also need to focus on modifying a patient’s emotional response to the condition. It has been well-documented that stress and tension can be detrimental for the body by making it difficult to properly handle daily frustrations. More specifically, one typical complaint that accompanies reported neck and shoulder pain problems is muscle tension. People who sit at a desk or computer for most of the day place themselves at an extremely high risk of suffering from tension in the muscles.
Biofeedback for neck pain
An alternative method that has received support in terms of helping people reduce these types of emotionally-related symptoms is called biofeedback training. In particular, research has shown that biofeedback training is quite effective at improving pain and muscle tension, although it does not completely eliminate it. Nonetheless, this method is non-invasive and does not require the use of any medication as it involves teaching patients how to recognize emotionally-triggered symptoms so that they can learn ways to reduce and prevent them.
In order to be able to accomplish this task, patients are presented with physiological recordings in real-time while they are prompted about the physiological responses they are having. The device that is used for biofeedback training can detect the slightest physiological changes and displays the alterations on a computer screen that the patient watches. During the procedure, patients are also taught several exercises that reduce stress as this enables them to actually change their own physiological responses and exert much more control during stressful situations. This type of internal regulation also allows patients to dramatically decrease the negative effects that stress can have on their neck pain.
The following physiological systems are typically recorded for the biofeedback sessions:
- Thermal feedback: To measure the temperature of the skin
- Electrocardiogram (ECG): To measure the heart rate
- Electroencephalography (EEG): To measure brain wave activity
- Galvanic skin response (GSR): To measure the degree of moisture that develops on the skin
- Electromyogram (EMG): To measure the degree of muscle tension
During the session, patients practice how to alter their bodily processes through the use of the visual cues along with the exercises that the trained biofeedback technician teaches them. For the purpose of improving neck pain, the recommended imaging tools are usually an EMG, an ECG, and a respiratory machine that can measure breathing patterns. Furthermore, patients are taught how to cope and relax in order to allow them to reduce neck pain on their own.
Chiropractic care for neck pain
If a patient’s case of neck pain has not resulted in any disability or serious impairment, other forms of conventional treatments that are not invasive are usually recommended. For example, chiropractic care has been shown to afford numerous patients who were suffering from cervical pain and spine problems with dramatic pain relief. This form of intervention has also been associated with enhanced well-being.
A chiropractic adjustment entails applying thrusts of a controlled pressure to the spine in order to improve the mobility of restricted joints. In regards to improving neck pain through chiropractic care, the pressure is applied to facet joints located in the neck region to decrease pain. This type of procedure does pose certain side effects and risks such as heightened discomfort, headaches, fatigue, complications due to manipulating the cervical and lumbar spine, and inflammation in regions that were not targeted during the adjustment. However, if side effects such as these occur, they usually develop immediately after the treatment and have resolved within the first 48 hours.
If blunt trauma did not cause a patient’s neck pain and the affected region is not inflamed, a certain degree of the discomfort and pain may be reduced through a therapeutic massage that is also known as active release technique. This approach entails using the fingers and the thumbs to manipulate the soft tissue of the irritated region through the application of deep pressure. During the application of the pressure, the patient is directed to carry out repetitive actions in order for the muscles to expand and contract repeatedly. It is believed that this eventually restores the normal texture of the irritated soft tissue. In addition, this massage technique decreases additional symptoms such as pain, inflammation, and stiffness. The occurrence of abnormal tissue fusion, tearing, and scarring is also reduced as a result of undergoing this massage.
Acupuncture for neck pain
Additional treatments for the management of neck are also available. One such treatment is acupuncture, which reduces pain through the strategic placement of fine needles to depths of one to ten centimeters at different areas of the body. The manner in which the needles are placed depends on the region the pain is originating from although other regions that contribute to the discomfort are targeted as well.
Acupuncture is very popular in Chinese medicine and it is considered to be a very low risk approach for the treatment of neck pain. In regards to side effects, patients usually report minor soreness, bleeding, and bruising at sites where the needles were placed. Similarly, electroacupuncture might be utilized, though this method may cause a patient to experience a mild form of skin irritation at the areas where the needles were inserted. Evidence also indicates that both electroacupuncture and traditional acupuncture can boost fluid circulation as well as blood flow to the inflamed area and that this leads to significantly less pain, a shorter recovery period, and a boost in muscle strength. Moreover, this approach is well recognized by medical organizations as an effective therapeutic choice for several conditions.
Neck pain medication options
Another commonly recommended treatment option for pain in the cervical spine is pharmacotherapy. Naproxen and ibuprofen are non-steroidal anti-inflammatory drugs (NSAIDs) that are used widely because they effectively reduce pain and inflammation. Most NSAIDs can be purchased over-the-counter, but they may still cause a few side effects such as ulcers, bleeding, and gastrointestinal problems, especially if they are taken long-term. Therefore, NSAIDs should only be taken temporarily to relieve pain and they are not generally recommended for chronic neck pain cases.
The use of antidepressants for neck pain that has become chronic has been demonstrated through empirical research as being effective. The most comprehensively studied form of antidepressants are amitriptyline, doxepin, and clomipramine, which are tricyclics. The manner in which antidepressants elicit analgesic effects has not been clearly elucidated, although it has been hypothesized that this type of drug blocks neurotransmitter (e.g., serotonin, norepinephrine) activity in the brain which leads to pain relief.
Recently, two additional types of antidepressants have become increasingly popular for neck pain relief. The first is serotonin-and-norepinephrine reuptake inhibitors (SNRIs) that include desvenlafaxine, venlafaxine, and duloxetine. The second is selective-serotonin reuptake inhibitors (SSRIs) that include fluoxetine, fluvoxamine, and citalopram. Nowadays, some doctors prefer to prescribe the newer types because patients report experiencing fewer side effects as opposed to those who take tricyclics. However, the mechanism behind the newer class is not completely clear either. Clinical trials have demonstrated that SNRIs and SSRIS can specifically decrease chronic cervical pain, but whether these antidepressants actually have analgesic properties remains unclear. Some patients whose pain has persisted for extended periods often suffer from depressive symptoms such as a loss of appetite, hopelessness, or withdrawal and these types of symptoms improve after taking SNRIs or SNRIs.
Muscle relaxants are another form of medication that are commonly prescribed for neck problems. Muscle relaxants can be divided into the following two groups: antispastic and antispasmodic. Antispasticity medications reduce muscle spasticity or extreme stiffness and include baclofen and dantrolene. Antispasmodic medications reduce the muscle spasms that are frequently reported along with neck conditions. These include non-benzodiazepines and benzodiazepines. According to empirical research, muscle relaxants can provide temporary neck pain relief. Certain anticonvulsants (e.g., gabapentin) may be prescribed as well in order to alleviate neck pain, especially if the pain is the result of nerve damage. The means by which anticonvulsants reduce pain is unclear, although it is proposed that they increase the gamma-aminobutyric acid (GABA)/glutamate ratio. However, they also elicit an effect on ion channels and increase the production of GABA, both of which may also be responsible for their efficacy.
Some patients have reported that skin patches that contain capsaicin provide them with a certain degree of neck pain relief. Similar to anticonvulsants, the patches work well for neuropathic pain. Capsaicin is isolated from chili peppers and it binds to receptors that are located in the skin. This activity leads to the excitation of neurons. The excitation initially increases sensory stimulation that may be felt as burning, itching, or pricking, but this brief period soon subsides and the sensory sensitivity decreases. After the skin patches have been applied repeatedly, a patient will begin to notice that the desensitization in the region of the neck that is affected becomes long-lasting. Clinical trials have demonstrated the efficacy of capsaicin in comparison to a placebo in terms of providing pain relief.
Opiates for neck pain
Individuals whose neck pain is debilitating, severe, or has not responded to conventional approaches such as chiropractic treatment or over-the-counter medication, might want to discuss a trial period of opioids with their clinician. These include codeine, tramadol, oxycodone, or morphine. This type of medication is only recommended for treatment resistant chronic neck pain cases. The pain relieving effects of opioids are due to their ability to bind to appropriate receptors in the brain. Research has offered ample evidence regarding the use of opioid treatment for short periods of time to reduce intense pain in the neck region.
The prolonged use of this type of medication results in side effects such as sexual impotence, sweating, dizziness, and constipation, but these side effects tend to gradually fade away. More serious concerns arise in regards the risk of abusing or misusing opioids and therefore, the long-term use of this medication is not recommended. Find out more about our opioid protocol.
Interventional methods for finding neck pain relief
Back surgery has been shown to lead to neck pain in some cases, although this is rare. The spine and back consists of a very complex combination of muscles, tissues, and bones that begin at the top of the neck and extend down into the pelvis. For instance, the spine is referred to as a robust bony structure which keeps the body upright by supporting its weight while protecting vital nerves within the spine that transmit essential signals. There are numerous individual spinal bones positioned in a ladder-like pattern that are connected by spinal discs and facet joints that enhance flexibility and support. The actual spinal cord that contains the nerves sits inside of the bony column. An unsuccessful surgical procedure may lead to scar tissue that forms on spinal nerves or causes injury to nerves that travel into the neck. These types of complications can cause neck strain or pain.
If this occurs, a treatment approach called the lysis of adhesions is usually suggested to alleviate the pain. The technique involves using a catheter that has been placed through a needle to administer a chemical (i.e., hyaluronidase) near the scar tissue. This type of chemical leads to the degradation of the scar tissue and this relieves pressure on the nerves. Recently, a clinical trial demonstrated that this technique provides relief.
A spinal disc that bulges or ruptures can lead to cervical pain and a procedure called a percutaneous discectomy is usually necessary at this point. The procedure is not very invasive and the purpose is to extract the material and tissue around the inflamed spinal disc because it is proposed that dead tissue is responsible for the subsequent neck pain and persistent discomfort. In order to be able to properly visualize the affected tissue, a doctor visualizes the procedure by using a type of X-ray that is called a fluoroscope, so that the apparatus that will be used to remove the tissue will be properly placed. After the correct positioning of the apparatus has been confirmed, radio waves or heat signals are delivered in order to degrade and destroy the affected tissue. After the procedure, patients usually need a day or two to recover. Pressure that was being placed on the spinal nerves by the inflamed tissue decreases as a result of this technique and this provides dramatic relief.
The American Academy of Orthopaedic Surgeons has more information on neck pain surgery options.
Epidural injections for neck pain
Epidural steroid injections can be administered to treat neck pain that is the result of stenosis (inflamed nerves). Epidural injections for neck pain are delivered through the skin into the targeted location, which is usually the space between spinal bones in order to decrease pain. A steroid and pain reliever is injected through the back into the epidural space that is located between spinal vertebrae. A fluoroscope allows the doctor to see where the medication is being injected.
Steroids reduce inflammation that typically occurs in spinal nerves. Injections of steroids into the cervical spine have been shown to be beneficial as well. These outpatient procedures do not require any form of surgery and they are performed quickly. Steroid injections usually afford patients with rapid relief that may completely alleviate their symptoms. Research that focused on the effects of receiving multiple injections with steroids demonstrated how receiving repeated injections over a one-year period dramatically improved the results, especially for patients who did not feel much relief after the initial injection.
Side effects that may develop after a steroid injection include gastric ulcers, mood changes, arthritis, and weight gain. A nerve block is another type of treatment that provides longer lasting results than steroid injections. This approach involves the injection of medication that completely blocks nerves from transmitting pain signals. Side effects include nausea, chest problems, and numbness at the injection site. A blood vessel may accidentally become punctured as well, but this rarely occurs.
Watch one of our own doctors perform a cervical epidural steroid injection for cervical pain now!
Botox injections for neck pain
Different types of pain are also being treated nowadays with Botox injections. Botox is made up of a pure extract of a neurotoxin called botulinum that is isolated from bacteria called Clostridium botulinum. The toxin leads to the temporary paralysis of muscles when it is injected in small amounts.
Botox treatment effectively provides relief from neck and shoulder pain (or “sneck” pain) by hindering the activity of overactive spinal nerves. The toxin also prevents neurotransmitters that regulate the transfer of pain signals from being released. A patient can expect to feel relief from anywhere from three weeks to eight weeks after receiving an injection. Studies that compared Botox treatment groups to placebo groups show that Botox is effective.
Vertebroplasty for neck pain
A fractured vertebra may also result in cervical spine pain and the treatment approach for this condition involves repairing the vertebra. An effective method is called vertebroplasty. This treatment entails injecting cement into the fractured vertebra in order to restabilize it.
Although this appears to be an invasive approach, it is only intrusive to a minimal degree and it is an outpatient technique. When the cement hardens, the treated vertebra has its original length, which relieves nerve compression, and also promotes proper spinal support. This is a fairly novel approach that has demonstrated the ability to effectively relieve cervical spine pain. Complications that may arise include bleeding, infections, and headaches as well as nerve damage that may cause possible paralysis. Intense inflammation may arise as well if the cement accidentally leaks.
Radiofrequency ablation for neck pain
Radiofrequency ablation is another technique that is minimally invasive and involves placing electrothermal probes throughout the back near nerves that are inflamed. The probes are used to administer high-frequency pulses to the nerves in order to block their transmission. This process hinders nerves from sending information regarding pain and inflammation to the brain. Accidental injury to motor nerves, infections, and bleeding may occur after this procedure.
Spinal cord stimulation for neck pain
There are certain, rare cases in which neck pain does not respond to direct injections or treatment of spinal nerves. In such cases, an unconventional method may prove to be useful. Spinal cord stimulation is one such method that works well for failed back surgery or resistant pain. This form of stimulation involves the insertion of electronic devices in close proximity to the spine. The devices emit electrical impulses that disrupt pain signals. A controller is usually provided to the patient who is taught how to control the level of the impulses. In addition, severe and persistent pain may be treated with intrathecal pump implants. These implants are also inserted near the spine, but deliver pain-blocking medication as opposed to electronic impulses. The pumps have proven to be especially effective at relieving cervical spine pain. Risks that are involved with both of these techniques include bleeding, infections, and potential punctures. The implants may also displace from the inserted location and ultimately fail to work, but this rarely occurs.
The interventions that have been discussed have undergone extensive investigations before being utilized regularly for clinical treatment. The complexity of neck pain as well as the numerous causes of this condition can make it difficult to diagnose so it is important to discuss various treatment options with a medical professional. Mayo Clinic gives an in-depth discussion of how to prepare for your first doctor’s appointment if you’re suffering from neck pain.
ConclusionNeck and cervical pain is a potentially disabling and common condition that affects different components of the cervical spine as well as the shoulders. Most individuals with this condition will experience neck pain at least one or more times during their lives. Neck pain may even result in dramatic functional impairments and mobility issues. Therefore, cervical pain has been associated with increased cases of disability that detrimentally affect an individual’s ability to function properly at work and at home. Moreover, neck pain tends to be recurrent and a specific event that causes neck pain increases the susceptibility of experiencing frequent neck pain. The degeneration of muscle or tissue in the neck, which may gradually occur over time, often causes neck pain. However, ligament, muscle, or joint damage due to injury is also a primary cause of acute or persistent neck pain. Even though these types of problems commonly result in neck pain, sometimes the source cannot be accurately identified.
Conventional treatments such as pain relievers, acupuncture, and physical therapy have repeatedly been shown to improve the symptoms of almost all patients who are suffering from pain in the cervical spine. These treatment approaches aim at increasing a patient’s limited range of motion and elasticity in the neck muscles. However, additional research should be conducted to investigate the relationship between psychological aspects (e.g., emotions) and the response to pain as this may also help doctors select the appropriate treatment.
Additional alternative as well as unconventional treatment approaches may also be performed for resistant pain. These include steroid injections, biofeedback training, and spinal cord stimulation with implants. Scar tissue removal may also be targeted through the use of specific techniques (e.g., vertebroplasty) that are minimally invasive. A number of novel approaches have demonstrated the ability to effectively reduce neck pain. Talking with a clinician is an important step in receiving the best medical care for your pain.
Finally, know that finding neck pain relief can be hard. It’s difficult living with a chronic neck pain condition. We encourage you to reach out to others who are struggling with chronic pain on our Facebook pain support group. Medicine.net also provides questions and answers from neck patients. Finally, subscribe to our blog to keep up on the latest neck pain news!
- Birnbaum K. Percutaneous cervical disc decompression. Surg Radiologic Anatomy. 2009;31(5):379-387.
- Cheek D. Therapy of persistent pain states: I. Neck and shoulder pain of five years’ duration. Amer J Of Clin Hypnosis. 1966;8(4):281-286.
- Dang D, Baig MN, Christoforidis G, Chiocca EA, Gabriel J. C2/C3 pathologic fractures from polyostotic fibrous dysplasia of the cervical spine treated with percutaneous vertebroplasty. European Spine J. 2007;16(3 Suppl):250-254.
- Deer TR, Skaribas IM, Haider N, et al. Effectiveness of Cervical Spinal Cord Stimulation for the Management of Chronic Pain. J International Neuromodulation Society. Sep
- Falco FJ, Manchikanti L, Datta S, et al. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: An update. Pain Physician. 2012;15(6):E839-868.
- Falla D, O’Leary S, Farina D, Jull G. Association between intensity of pain and impairment in onset and activation of the deep cervical flexors in patients with persistent neck pain. Clin J Pain. 2011;27(4):309-314.
- Gangi A, Tsoumakidou G, Buy X, Cabral JF, Garnon J. Percutaneous techniques for cervical pain of discal origin. Seminars in Musculoskeletal Radiology. 2011;15(2):172-180.
- Grooten W. Predictors for persistent neck/shoulder pain, medical care-seeking due to neck/shoulder pain and sickness absence. Clin Rehab. 2007;21(7):648-659.
- Gustavsson C, Denison E, von Koch L, Self-management of persistent neck pain: A randomized controlled trial of a multi-component group intervention in primary health care. European J Pain. 2010;14(6):e1-e11.
- Klessinger S. Radiofrequency neurotomy for the treatment of therapy-resistant neck pain after ventral cervical operations. Pain Medicine. 2010;11(10):1504-1510.
- Ma C, Szeto GP, Yan T, Wu S, Lin C, Li L. Comparing biofeedback with active exercise and passive treatment for the management of work-related neck and shoulder pain: A randomized controlled trial. Arch Phys Med Rehabil. 2011;92(6):849-58.
- Marcon RM, Cristante AF, Teixeira WJ, Narasaki DK, Oliveira RP, Barros TE. Fractures of the cervical spine. 2013;68(11):1455-1461.
- Miller J, Gross A, D’Sylva J, et al. Manual therapy and exercise for neck pain: a systematic review. Manual Therapy. 2010;15(4):334-354.
- Park CH, Lee SH, Lee SC. Preliminary results of the clinical effectiveness of percutaneous adhesiolysis using a Racz catheter in the management of chronic pain due to cervical central stenosis. Pain Physician. 2013;16(4):353-358.
- Sjaastad O, Wang H, Bakketeig L. Neck pain and associated head pain: Persistent neck complaint with subsequent, transient, posterior headache. Acta Neurologica Scandinavica. 2006;114(6):392-399.
- Teichtahl AJ, McColl G. An approach to neck pain for the family physician. Australian Family Physician. 2013;42(11):774-777.
- Weiner D, Ernst E. Complementary and Alternative Approaches to the Treatment of Persistent Musculoskeletal Pain. Clin J Pain. 2004;20(4):244-255.