The neck supports the head. It is made up of seven bones (vertebrae) stacked one on top of the other. The vertebrae are connected by two facet joints and a disc. The vertebrae are also bound together with ligaments. Muscles provide movement and vital support for all structures of the neck.

The neck is very mobile, to allow us to see in all directions. Strains from poor postures, trauma and degenerative diseases, such as arthritis, are the most common causes of neck pain. There is good evidence to show that exercise helps reduce these symptoms.

Neck pain can generally be successfully treated by physiotherapists, although there are other options such as osteopathy, chiropractic or remedial massage to consider. If you need short-term pain relief from medication, talk to your doctor or pharmacist.

Treatment depends on the cause, but may include:

• information on how to look after your neck to prevent unnecessary strains from work and everyday activities
• specific exercise programs to retrain and then strengthen the neck muscles
• posture training exercises
• passive joint mobilisation or manipulation
• soft tissue massage
• taping to guide correction of posture
• relaxation therapy.

Poor sitting or working postures commonly cause neck pain by putting extra strain on the joints and muscles. Sitting and working with the shoulders slouched and chin poking forward, such as when working for many hours on a computer, may strain the neck as may playing with devices with your head down for long periods of time.

Sleeping on your stomach with your head turned around to breathe may also be a strain on your neck.

Suggestions on how to prevent posture-related neck pain include:

• Ensure your workstation is set up to help you sit in a good supported posture. When using a computer, ensure the screen is at a height so that your head is upright and the centre of the computer is viewed when you lower your eyes slightly.
• Change your posture regularly when either sitting or standing. To do this, grow tall by rolling up from your pelvis. Then gently elongate the back of your neck and draw your shoulders back. Use no more than 10 per cent effort. Hold the position for 10 seconds and then relax.
• Perform posture correction frequently while you are working (two to three times per hour). This exercise keeps tone in the supporting muscles of the neck.
• Combat the tight or tired feeling of your neck by regularly performing the posture exercise.
• Try not to sleep on your stomach, which may strain your neck.
• Check whether your pillow is the right size for you. Choice of pillows is very individual – there is no one pillow that suits everyone. Check the distance between the side of your neck and your shoulder. That gives you an idea of the pillow height you need to keep your head and neck supported when you sleep on your side.
• Move and exercise regularly to improve muscle tone and posture.

Osteoarthritis is a common type of arthritis that affects many people. Its incidence increases as we grow older. Osteoarthritis can result from:

• previous joint injury
• overuse
• overweight (in cases of hip or knee osteoarthritis)
• genetic predisposition (in some people).

Symptoms of osteoarthritis include pain and stiffness and weakening of the muscles. Commonly affected areas include the neck, lower back, hands, hip and knee. There is no cure for osteoarthritis, but it can be managed well with exercise. Keeping the joints mobile and the muscles strong are the best ways to manage osteoarthritis.

Osteoarthritis in the joints of the neck commonly results in local neck pain. If the upper joints of the neck are affected, the neck pain may develop into a headache as well.
Osteoarthritis may occasionally cause some irritation of the nerves as they exit the neck. If you experience shooting pains down your arm, or numbness or lack of power in your arm or hand, then see your doctor, as you may need further investigations, such as an x-ray.

You can manage neck pain related to osteoarthritis with:

• advice and education on how to care for and self-manage your neck
• pain management – speak to your doctor about taking pain relieving medication or using a heat pack to relieve neck pain
• gentle active mobilisation exercises to maintain neck movement
• gentle exercises focussing on retraining and maintaining muscle function
• gentle soft-tissue and joint mobilisation
• posture exercises
• strengthening exercises.

Wry neck is the term used to describe a condition where your neck temporarily becomes stiff and painful. It can occur at any age, but is more common in the teenage or young adult population. Turning your head to the side (generally one side more than the other) and looking up can produce an acute pain.

One or both sides of the neck may also go into spasm, and pain may be felt from the top of the neck down to the shoulder blade and even out to the top of the shoulder.

Causes of wry neck

There are many causes including:

• sleeping in an awkward posture
• a sudden flicking or jerking of the head
• carrying heavy unbalanced loads – such as a suitcase
• viral infection.

Treatment for wry neck

In most cases, if treated early, wry necks respond well to treatment in a few days. Heat and passive joint mobilisation can be used to loosen the neck joints and reduce the pain and muscle spasm.

In rare cases, particularly for people over 40, or very rarely in infants, wry neck can be caused by a medical condition. Your doctor or therapist can help with this diagnosis and give you a referral for appropriate care.

Self-care of wry neck

While you are recovering from wry neck:

• avoid sitting or lying with your neck in an awkward position
• avoid going out in the cold without being well wrapped up
• keep moving your neck (as pain allows)
• use a small heat pack (such as a wheat pack or similar) at home or at work for pain relief, or hot showers can help
• keep warm.

Talk to your doctor or pharmacist about pain medication if your pain is severe.

Available evidence indicates that acupuncture for neck pain may provide better pain relief compared to no treatment. There is some evidence that spinal manipulation may help relieve neck pain, but much of the research on has been of low quality.

The Evidence Base

• The evidence base on efficacy of spinal manipulation and acupuncture for neck pain consists of several systematic reviews. The evidence base on efficacy of massage for neck pain is based on several small studies of poor quality and a 2013 systematic review.

Efficacy

• Manual therapies. Reviews of research on manual therapies (primarily manipulation or mobilization) and acupuncture for chronic neck pain have found mixed evidence regarding potential benefits and have emphasized the need for additional research. A 2015 Cochrane review of 51 randomized controlled trials involving a total of 2,920 participants concluded that there is some evidence to support the use of thoracic manipulation versus control for neck pain, function, and quality of life; however, results for cervical manipulation and mobilization are few and diverse. The reviewers noted that these findings suggest that manipulation and mobilization present similar results for each outcome at immediate-, short-, and intermediate-term followup. Multiple cervical manipulation sessions may provide better relief of pain and improvement in function than certain medications at immediate-, intermediate-, and long-term followup. Because there is risk of rare but serious adverse events for manipulation, more rigorous research is needed on mobilization, and comparing mobilization and manipulation versus other treatment options. A 2007 review noted that clinical guidelines often endorse the use of manual therapies for neck pain, although there is no overall consensus on the status of these therapies.
• Massage therapy. A 2016 review of four randomized controlled trials found that massage therapy may provide short-term benefits from neck pain. However, a 2013 Cochrane reviewof 15 trials on massage therapy for neck pain showed “very low level evidence” that certain massage techniques may have been effective in reducing pain and improving function. Authors of the review concluded that no recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.

Safety

• Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were treated. Although there have been rare reports of serious complications such as stroke, a large 2009 study did not find a relationship between spinal manipulation and vertebrobasilar artery stroke, which involves the arteries that supply blood to the back of the brain. Safety remains an important part of ongoing research.
• Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.

Results of an NCCAM-funded study found that multiple 60-minute massages per week were more effective than fewer or shorter sessions for people with chronic neck pain, suggesting that several hour-long massages per week may be the best “dose” for people with this condition. Researchers from Group Health Research Institute, University of Washington, The University of Vermont College of Medicine, and Oregon Health and Science University published their findings in the Annals of Family Medicine.

Researchers enrolled 228 people with chronic neck pain into five randomly assigned groups receiving various “doses” of massage: a 4-week course of 30-minute sessions two or three times each week, or 60-minute sessions one, two, or three times each week. Other participants were assigned to a 4-week wait list, which served as the control group. Therapists used a wide range of massage techniques and were not allowed to make any self-care recommendations.

The researchers found that 30-minute massages two or three times per week did not provide significant benefits compared with the wait-list control group. However, beneficial effects of 60-minute massages increased with dose and were particularly evident for participants receiving massages two or three times per week. Compared with the control group, participants were three times more likely to have clinically meaningful improvement in neck function if they received 60-minute massages twice per week and five times more likely if they received 60-minute massages three times per week. However, the researchers noted that longer and more frequent massages might be challenging for many patients due to financial and time constraints. They also noted that future studies of massage for neck pain should include multiple 60-minute massages per week for the first 4 weeks of treatment, self-care recommendations, and longer-term followup.

Chronic Neck Pain

Research results on the effectiveness of qi gong for chronic neck pain are mixed, but the people who were studied and the way the studies were done were quite different.

• A 2009 clinical study by German researchers showed no benefit of qi gong or exercise compared with no therapy in 117 elderly adults (mostly women) with, on average, a 20-year history of chronic neck pain. Study participants had 24 exercise or qi gong sessions over 3 months.
• In a 2011 study, some of the same researchers observed that qi gong was just as effective as exercise therapy (and both were more effective than no therapy) in relieving neck pain in the 123 middle-aged adults (mostly women) who had chronic neck pain for an average of 3 years. Exercise therapy included throwing and catching a ball, rowing and climbing movements, arm swinging, and stretching, among other activities. People in the study had 18 exercise or qi gong sessions over 6 months.

Back Pain

• In people who had low-back pain for at least 3 months, a program of tai chi exercises reduced their pain and improved their functioning.

What is spinal manipulation?

• Spinal manipulation is also called spinal manipulative therapy. It’s a technique where practitioners use their hands or a device to apply a controlled thrust (that is, a force of a specific magnitude or degree in a specific direction) to a joint of your spine. The amount of force can vary, but the thrust moves the joint more than it would on its own. Spinal manipulation is different from spinal mobilization, which doesn’t involve a thrust (and is performed within a joint’s natural range of motion and can be controlled by the patient).
• Most spinal manipulations are done by chiropractors (chiropractic treatment often involves spinal manipulation), although other licensed professionals including osteopathic physicians and physical therapists also do spinal manipulations.
• Spinal manipulation is one of the most common complementary health approaches used by adults and children in the United States, the 2012 National Health Interview Survey (NHIS) showed.

Why do people use spinal manipulation?

Among U.S. adults who used chiropractic or osteopathic manipulation, about 67 percent used it to treat a specific health condition, and 53 percent used it for wellness, the 2012 NHIS found. Specifically:

• 43 percent used it for general wellness or disease prevention
• 25 percent used it because it focuses on the whole person—their mind, body, and spirit
• 16 percent used it for improved energy
• 11 percent used it for better immune function
• 5 percent used it to improve memory or concentration.

Previous research found that people report positive experiences and reduced pain as a result of receiving spinal manipulation, the NHIS authors noted.

Who uses spinal manipulation and has usage changed?

Between 2012 and 2017, U.S. adults’ use of chiropractic care (which usually involves spinal manipulation) during the past year increased slightly, from 9.1 percent to 10.3 percent, a comparison of NHIS data from the two years showed. The data also show that women were more likely than men to see a chiropractor, and that adults between the ages of 45 and 64 were more likely than people aged 18-44 or 65 and over to have visited one during the past year. According to the same national survey (by the Centers for Disease Control and Prevention’s National Center for Health Statistics), non-Hispanic white adults were much more likely to visit a chiropractor (12.7 percent) than Hispanic (6.6 percent) or non-Hispanic black (5.5 percent) adults.

Among children, there was no significant difference in the use of chiropractic care between 2012 and 2017 (3.5 percent versus 3.4 percent). Older children (age 12 to 17) were more likely than younger ones (age 4 to 11) to have seen a chiropractor, but there was no significant difference in the use of chiropractic care between girls and boys. Non-Hispanic white children were more likely than non-Hispanic black or Hispanic children to have seen a chiropractor.

What are some of the pain conditions for which spinal manipulation has been used?

For Sciatica

• Sciatica is pain associated with the sciatic nerve, which controls muscles in the back of the knee and the lower leg; it also provides feeling to the back of the thigh, part of the lower leg, and the sole of the foot.
• Manipulation isn’t widely used to treat sciatica but it may help, a 2015 research review of a variety of sciatica treatments suggests. However, the studies had many limitations, the authors noted.
• In a 2014 study of 192 people with leg pain associated with back pain, participants who received spinal manipulation, personal instruction, and exercises had less pain after 12 weeks and used less medication a year later than participants who received only personal instruction and exercises. However, leg pain was the same for both groups after 1 year.

For Low-Back Pain

Many noninvasive treatments are available for low-back pain, and these include drugs and nondrug options. In its 2017 clinical guidelines, the American College of Physicians (ACP) suggests that spinal manipulation is one of a number of therapeutic options that may help people with acute or chronic low-back pain (although the ACP says the quality of the evidence is low).

• Spinal manipulation was better than placebo for immediate, short-term relief from acute or subacute low-back and neck pain, a 2010 research review concluded. Manipulation was also better than acupuncture for chronic low-back pain. However, the results of studies comparing spinal manipulation to massage, medication, or physical therapy were mixed.
• A 2011 review of 26 studies concluded that for chronic low-back pain, spinal manipulation works as well as other commonly recommended approaches, including exercise or physical therapy. However, the effect on pain was minimal.
• Twelve sessions of spinal manipulation may be the best “dose,” according to a 2014 NCCIH-funded study of 400 people with chronic low-back pain.
• In a 2014 study of 110 participants with chronic low-back pain, those who received spinal manipulation had less sensitivity to painful stimuli right after getting spinal manipulation, compared to people who got sham spinal manipulation. But after a couple of weeks the two groups had similar amounts of pain and disability, the study showed. The study was supported by NCCIH.
• The Agency for Healthcare Research and Quality (AHRQ) systematic review of noninvasive nonpharmacologic treatment for chronic pain reported that spinal manipulation was associated with slightly greater effects than sham manipulation, usual care, an attention control, or a placebo intervention in the short term (i.e., 1-6 months following treatment) and intermediate term (i.e., 6-12 months). The report concluded the strength of the evidence was low. In addition, the report concluded that there was no evidence of differences between spinal manipulation versus sham manipulation, usual care, an attention control, or a placebo intervention in short-term pain, but manipulation was associated with slightly greater effects than controls on intermediate-term pain. The standard of evidence was considered low for short-term effects and moderate for intermediate-term effects.
• The research on spinal manipulation for acute low-back pain is generally mixed and has many limitations.
  • Spinal manipulation is no more effective for acute low-back pain than sham (fake) spinal manipulation, or when added to another treatment such as standard medical care, a 2012 research review of 20 studies found. Spinal manipulation appeared to be safe when compared to other treatment options.
  • In a 2015 study of 220 people with acute low-back pain, participants who received physical therapy, which included spinal manipulation, fared no better than those who received standard care.
  • However, a 2015 NCCIH-funded study of 107 adults with recent-onset acute and subacute low-back pain found that those receiving spinal manipulation got greater short-term relief, compared to participants getting standard medical care. Furthermore, the study compared two different techniques—manual thrust manipulation (MTM) and mechanical assisted manipulation (MAM)—and found MTM led to greater short-term reductions in self-reported pain and disability than MAM or usual care.
  • A 2017 analysis examined data from 15 randomized controlled trials with almost 1,700 participants. The researchers concluded that spinal manipulative therapy can modestly improve pain and function in people with acute low-back pain.
• Results of a 2018 study with 750 active duty U.S. military personnel with low-back pain found that those who received chiropractic care in addition to usual care had better short-term improvements in low-back pain intensity and pain-related disability than those who only received usual medical care.

For Neck Pain

• For patients with acute neck pain, either spinal manipulation or home exercises appeared to be more effective than medication in the short and long term, an NCCIH-funded study of 272 patients showed in 2012. A 2015 research review that looked at results from 51 trials with 2,920 participants also reported that there’s weak evidence that spinal manipulation may provide short-term relief from acute or chronic neck pain.

For Headache

• For preventing migraines, spinal manipulation may be one of several complementary health approaches (including massage therapy) that’s as helpful as medications used for migraine prevention, but the research isn’t conclusive.
• The AHRQ systematic review of noninvasive nonpharmacologic treatment for chronic pain reported spinal manipulation therapy was associated with slight to moderate improvements in function compared to usual care on the Headache Impact Test and the Headache Disability Inventory (scale 0-100) and in pain over the short term (i.e., 1-6 months) in one trial. The standard of evidence was rated as low.

For Other Conditions

• Researchers have studied spinal manipulation for many other conditions, including fibromyalgia, children’s ear infections, chronic obstructive pulmonary disease (COPD), infant colic, and bedwetting, but there’s too little evidence to know if it helps with these problems.
• Spinal manipulation doesn’t help with asthma, hypertension, or menstrual pain, studies show.

Is spinal manipulation safe?

Spinal manipulation is relatively safe when performed by a trained and licensed practitioner. The most common side effects of spinal manipulation are temporary muscle soreness, stiffness, or a temporary increase in pain.

Serious complications, deaths, and delays in diagnosis of serious illnesses have been associated with spinal manipulation, including in children, but are very rare.

Strokes and Artery Tears

• A type of spinal manipulation that focuses on the neck has been linked to small, potentially dangerous tears in the artery walls in the neck, called cervical artery dissections (CAD). These tears are rare but can lead to a stroke. Any kind of sudden neck movement, such as playing sports, getting whiplash, and violent vomiting or coughing may also increase the risk of tears. The available evidence suggests that the incidence of CAD in people getting spinal manipulation is low, but patients need to be informed of this potential risk.

Spinal Manipulation and Pregnancy

• There are few reports of spinal manipulation causing problems during pregnancy or in the period after childbirth, a 2012 research review reported. The problems that have been reported ranged from mild, temporary pain to life-threatening injuries. Serious adverse events occurred only after cervical spinal manipulation.

NCCIH-Funded Research

NCCIH-supported studies have been investigating:

• The clinical impact spinal manipulation/chiropractic may have on chronic low-back pain in U.S. veterans
• How spinal manipulation compares with prescription drug therapy for long-term management of chronic low-back pain in older adults
• How to optimize spinal manipulation treatment protocols for patients with low-back pain
• Patients’ experiences and satisfaction with chiropractic care for chronic neck pain
• How to best provide chiropractic care for veterans with musculoskeletal pain and mental health disorders.

More to Consider

• In a 2017 clinical practice guideline, the ACP suggested that spinal manipulation remains a recommended treatment option for chronic low-back pain, saying that it is one of several options that show some evidence of effectiveness.
• Before selecting a chiropractor:
  • Ask about the chiropractor’s education and licensure.
  • Tell the chiropractor about all of your medical conditions.
  • Ask if the chiropractor has specialized training or experience treating your condition.
  • Ask about how many sessions you’ll need and typical out-of-pocket costs and insurance coverage. (Medicare Part B covers manual manipulation of the spine if it is determined to be medically necessary.)
  • Tell the chiropractor about any medications (prescription or over-the-counter) and dietary supplements you take. If the chiropractor suggests a dietary supplement, ask about potential interactions with your medications or other supplements.
• Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.