Addressing Old School Explanations for Cervical Pain | Modern Manual Therapy Blog

Addressing Old School Explanations for Cervical Pain

A case I evaluated today was very ingrained in pathoanatomy. She presented with cervical Sx with bilateral radiating arm and hand pain for 1 year.

She was told

  • your neck has arthritis - from a neurologist after x-rays
  • your shoulder and neck are weak - from a well meaning MT
  • you neck keeps going out of place, and don't get massages anymore, it makes your neck go out of place
    • ironically she felt worse after adjustments and better after a massage - go figure!
After hearing her say these things, I step by step educated her on the realities of her condition
  • 87% of asymptomatic people have positive MRIs, including arthritis and disc issues
  • your nervous system is under threat and needs to have novel and non-threatening input that is reinforced (by her) to reduce the perceived threat
  • you don't like having the same meal over and over for months, right? It may taste great at first, but eventually you get tired of it, or it does not have the same "wow" factor
    • the same goes for massage, adjustments, or any treatment she had received over and over again
    • once an input is no longer novel, it loses the effectiveness
  • passive treatments like massage, adjustments are like having someone exercise for you and expecting to be fit/stronger without doing your own work
  • education on The Window of Improvement and Resetting Pain/Movement Thresholds
    • once reset, the "safety" needs to be reinforced with continuous movement to end range for the brain to give the area in danger a green light
Since her main complaints were neck and arm/hand pain with gardening, cooking, and repetitive use of her arms, I avoided the term "postural correction" and instead described it as...
  • cervical retraction with overpressure centralized her constant hand pain and abolished it
  • sitting in her normal, forward head position reproduced it
  • I described her peripheral nervous system as sensitized and sitting or standing with head and shoulders forward as giving a light tug upward on the "strings"
  • the tug upward combined with repetitive use of down downward in repetitive ADLs is perceived as threatening
  • giving the top of the strings some slack in a cervical retracted position gives more wiggle room and less sensations of "pulling" 
  • the nervous system has this normal motion built in until it is sensitized
  • the nervous system also craves variability, so the longer you are repeating an activity that is associated with danger, the more you have to reinforce safety with the directional preference (in this case cervical retraction with overpressure)
The education maybe took 25-30 minutes, and the only manual treatment was light IASTM to occiput, cervical patterns and upper traps. This made the cervical retraction with overpressure much easier for her to perform and more of a green light rather than a yellow light.

Keeping it Eclectic...


  1. Any good recommendations for good pain science texts/literature. As a new grad, it would be nice to expand me knowledge in this area that seems to be the new foundation for treating most patients. Thanks!

  2. The textbook with my highest recommendation is Therapeutic Neuroscience Education Thanks!

  3. Really good education points, Dr. E. That makes such a difference in reducing perceived threat. Those examples are helpful to all clinicians regardless of experience or skill level. Thank you!

  4. You're welcome! Shared your latest blog today!

  5. "Why Do I Hurt" is the shorter, patient-focused version of the TNE by Aadrian Louw. It's a good one to have in the clinic and utilize with patients and is something pts can get for themselves. Only $10-12

  6. Patrick BergeronJune 25, 2015 at 7:55 AM

    Interesting diagnostic theories but far fetch. Was this patient having a cervical disc herniation? Was an MRI ordered to confirm the basic text book case? This case study is missing examination findings so we can better follow the therapeutic theories given. For someone with cervical disc issus, the treatment would be the same as what you've proposed i.e. distraction. I am still gratefull for you great work. A

  7. Well, it's not far fetched, it is using modern clinical guidelines recommended by Pain Science Education Research. It's not the diagnosis that matters, in fact, patients who received an MRI did worse than patients who did not who received equal conservative PT treatment according to one study. Why? The "bad news" of scans, and pathoanatomical diagnosis (degeneration, pinched nerve, disc bulge) lead to catastrophization, which worsens outcomes. This is unwarranted as we do not change these findings which are quite normal in up to 87% of subjects in the cervical spine according to a study with over 1000 asymptomatic subjects. The education on how to modulate pain and restore function and movement is more important than figuring out "why" which is often an educated guess based on scans that have too much false positives.

    Also, I didn't use distraction, it was cervical retraction as a movement. I try not to distract as the patient cannot usually perform this on their own, and what gets patient's better fastest is home program, not what we do in the clinic. Thanks for reading!

  8. Agreed, here is the link!

  9. awesome-thanks!

  10. Ruairi O'DonohoeJune 27, 2015 at 7:17 PM

    Hey Dr. E, great one again.
    Just wondering if you had the references for the following studies you mentioned, it would be good to have on file to return to every now and then if needed.

    'patients who received an MRI did worse than patients who did not who received equal conservative PT treatment according to one study'

    'findings which are quite normal in up to 87% of subjects in the cervical spine according to a study with over 1000 asymptomatic subjects.'

    Thanks very much,
    Ruairi O'D

  11. Thanks! Email me thru my site! Have a great weekend!