Neck and Back Pain at the Same Time

You have pain in two places. Your lower back, and your neck. That can feel like being unlucky twice over, or like a sign that something bigger is going on.

Let me deal with both of those worries straight away, because neither is true.

First, having pain in more than one place is the normal pattern, not the unusual one. When researchers ask people with ongoing low back pain whether they hurt anywhere else, only somewhere between 1 and 3 in every 10 say the back is the only place. The rest have pain somewhere else too, and the neck is the commonest companion. You are in the majority, not the minority.

Second, and this is the important one: your pain stays put. It does not travel down your legs. It does not go into your arms. It does not turn into headaches. That absence tells us a great deal, and almost all of it is good. Section 4 explains why.

This guide is not saying your pain is in your head. Your pain is completely real.

One thing before you start. This guide assumes I have examined you and ruled out the serious causes. If nobody has examined you yet, read section 12 first.

Read it in chunks. There is no test at the end.

The short version

• Pain is an alarm. It protects you. It does not measure damage.
• Two sore areas usually means one system turned up, not two things broken.
• Pain that stays local, with nothing travelling into your arms or legs, is the most reassuring pattern there is.
• There is a gate in your spinal cord. It controls how much of the warning signal reaches your brain.
• When pain lasts a long time, the alarm gets more sensitive. That is learned, so it can be unlearned.
• Scans of people with no pain at all are full of wear and bulges, in both the neck and the back.
• One side hurting more than the other does not mean you are wonky, twisted, or out of alignment.
• The same few things drive both areas: sleep, stress, load and strength. That is good news, because one plan covers both.

1. Pain is an alarm, not a damage meter

Your body has danger sensors. They fire when tissue is stretched, squashed or irritated. They send warning signals to your spinal cord, and then to your brain. None of that is pain yet. It is just information.

Then your brain weighs that information against everything else it knows. What were you doing? What happened last time? What do you think this means? How stressed are you? Did you sleep?

Then it decides: how much danger am I in, and how much pain does this person need to feel to keep them safe?

Pain is the answer. Your brain produces it.

That is why damage and pain match up so badly:

• A paper cut really hurts. There is almost no damage.
• Soldiers get badly hurt and feel very little until they are safe.
• People who have lost a limb can still feel pain in it.

So how much pain you feel does not tell you how much damage there is. It tells you how protective your body is being right now.

2. The pain gate

In 1965, two researchers called Ronald Melzack and Patrick Wall came up with an idea that changed pain medicine. It is still one of the most useful pictures we have.

Picture a gate in your spinal cord. Warning signals have to pass through it to reach your brain. When the gate is open, lots get through and you feel more pain. When it is closed, fewer get through and you feel less. Nothing in your back or neck has changed. Only the gate has.

What closes the gate

• Touch, rubbing, heat and hands-on treatment. Touch signals travel on bigger, faster nerves than danger signals, and they crowd them out. It is why you rub your elbow after you bang it.
• Moving and exercise. They release your body's own painkillers.
• Feeling safe and calm.
• A decent night's sleep.
• Understanding what is going on. Reading this counts.

What opens the gate

• Stress and worry, especially worrying about what the pain means.
• Broken sleep.
• Low mood, and feeling that nobody has listened.
• Checking both areas over and over to see if they are still sore.
• Being afraid of a movement. If your brain expects a movement to be dangerous, it will make it hurt more to stop you doing it.
• Being told frightening things about your spine.

Here is the key bit. Your brain does not just receive signals at that gate. It sends signals down and changes the settings. That is why the same working week is fine one month and unbearable the next.

3. Why two places at once

This is the question most people want answered, so let me take it properly.

Two sore areas almost never means two separate injuries. It would be quite a coincidence.

What it usually means is that the whole system has become more protective. The gate described in section 2 is not one gate. It runs the length of your spinal cord. When the settings get turned up, they tend to get turned up broadly rather than in one small spot.

On top of that, your neck and your lower back share nearly all of the same drivers:

• The same sleep. A bad week of sleep does not choose one area.
• The same stress. Neither does that.
• The same daily load. The same desk, the same car, the same job, the same hours sitting still.
• The same overall fitness and strength. If you have got weaker over a few years, both ends of your spine notice.

So one set of causes, showing up in two places. Which is genuinely good news, because it means one plan treats both. You are not facing two separate problems needing two separate solutions.

One more thing, because people ask it every time. Hurting more on one side than the other, or in one area more than the other, does not mean you are twisted, wonky, or out of alignment. Nobody is symmetrical. Perfectly healthy pain free people are lopsided in all sorts of ways. Asymmetry is normal, and it is not the reason you hurt.

4. What your pattern tells us, and why it is reassuring

Your pain stays where it is. Nothing travels into your arms, your legs, or your head.

This matters more than most people realise. Here is what that absence rules out.

No pain going down your leg means your lower back's nerve roots are almost certainly not irritated. That is what sciatica is, and you do not have it. The disc problems that frighten people most are the ones that press on or inflame a nerve root, and they announce themselves by sending pain down the leg. Yours is not doing that.

No pain going down your arm, and no pins and needles or numbness in your hands, means the same for your neck.

No headaches means your neck is not referring pain up into your head.

Put together, that leaves what we call non-specific, or mechanical, spinal pain. That is not a fudge or a way of saying we do not know. It is by far the commonest kind of spinal pain there is, and it is the kind with the best outlook.

It means the pain is coming from the ordinary working parts of your spine, the joints, discs, muscles and ligaments, all of which are perfectly capable of producing pain without anything being damaged or dangerous.

It also means the things you are most likely to be worried about have already been considered and are unlikely. Keep an eye on section 12, and tell me straight away if anything starts to travel, but as things stand, your pattern is the reassuring one.

5. When the alarm gets too sensitive

This section matters more for you than for someone with pain in one spot.

When a pain system has been busy for months or years, it does not wear out. It gets better at its job. The sensors fire more easily. The spinal cord turns signals up. The brain decides there is danger more quickly.

Think of a car alarm. When it was fitted, it went off if someone tried to force the door. Years later it goes off when a cat walks past.

The alarm is not broken. It is not lying. It is just set far too sensitive for the actual level of threat.

With pain in two areas, this is very often a large part of what is going on. The system as a whole has turned its sensitivity up, so places that would once have coped are now complaining.

That sounds worse than it is. It is actually the more hopeful explanation. Sensitivity is a setting, and settings can be changed. You cannot change the shape of a disc. You can absolutely change how protective your nervous system is being, and the rest of this guide is largely about how.

6. What scans show

Researchers scanned people who had no pain at all, in both the neck and the lower back, then counted what showed up.

In the lower back, in people with no pain:

• At age 20, about 3 in 10 already had a disc bulge. By 80, more than 8 in 10 did.
• At 60, about 9 in 10 had disc degeneration.

In the neck, in people with no pain:

• A study of 1,211 people with no neck symptoms at all found nearly 9 in 10 had disc bulging somewhere.

These findings are the inside version of grey hair. They are so common in people with no pain that finding one does not, by itself, mean it is causing yours.

Words like degeneration, wear and tear, arthritis and slipped disc sound frightening. Frightening words raise threat. Threat opens the gate. People told their spine is damaged move less and guard more, which makes sense, and they hurt more. With your pattern, a scan is very unlikely to change anything. Scans earn their place when we suspect something specific from section 12. As a routine explanation for pain that stays local, they mostly hand you something new to worry about.

If you have already had one and been given frightening words, bring the report in. We will go through what it actually says.

7. What turns your pain up and down

Pain has a volume dial, not an on and off switch. These move the dial for both areas at once, which is exactly why they are worth your attention.

• Sleep. Poor sleep is one of the strongest signs of a bad pain day ahead. It is not a soft factor.
• Stress and life load. Work, money, family. It all feeds into the threat calculation.
• Mood. Low mood and pain feed each other, both ways.
• What you believe. Thinking your spine is damaged and fragile is one of the strongest signs of a poor outcome. It is also something you can change.
• Activity. Too much too soon turns it up. So does too little for too long.
• Staying still. Long drives, long meetings, long stretches at a desk. Sustained anything.
• General health. Smoking, being unfit, and other health conditions all add to the load.
• Work. Feeling unsupported or stuck at work predicts who does badly better than most physical tests do.

Almost everything on that list is something you can influence. That is more than can be said for the shape of a disc.

8. Moving is safe, and strength is treatment

Your spine is strong, at both ends. It is built to bend, lift, twist and carry. It is not fragile, it is not unstable, and it does not go out of place.

Resting and guarding make this worse, not better. Muscles get weaker, the range you actually use quietly shrinks, and your nervous system gets more protective of whatever you avoid. Avoiding a movement teaches the alarm that the movement really was dangerous.

Some soreness while you build back up is expected. It does not mean damage. A good rule: pain that rises while you move and settles back to normal within about a day is fine. Pain still up the next day means you did a bit too much, not that you did harm.

• Here is the part that matters most for you. Because both areas share the same drivers, general fitness and strength work does more for you than fiddling about with either area on its own.
• Get generally strong, twice a week. Whole body, not spot treatment. Legs, back, shoulders. Real resistance, not a token band.
• Walk, regularly. It is the most underrated thing on this list.
• Move often through the day. Changing position beats finding a perfect one.
• Pick something you will actually keep doing. Trials comparing exercise types keep finding the same thing: the type matters far less than sticking with it.

Do not go hunting for the one perfect exercise for your right lower back and another for your neck. That is not how this works, and it keeps your attention on the sore spots, which opens the gate.

9. Pacing, and the boom and bust trap

Almost everyone knows this cycle. A good day comes. You seize it and get everything done. Then you pay for it for three days and do almost nothing. Over months, the trend quietly goes down, and so does your confidence.

Pacing is the way out:

• Work out what you could manage on almost any day, including a bad one.
• Do that amount consistently, good days and bad, rather than as much as you can manage.
• Once it feels easy, add about a tenth more each week.
• Break bigger jobs into chunks. Take breaks before you need them, not after.

It feels annoyingly slow for the first few weeks. Over a few months it is reliably the fastest route there is.

10. Flare-ups

Flare-ups are normal. They do not mean you are back to square one, and they do not mean new damage.

They are usually a pile-up rather than one dramatic moment: a hard week, two bad nights, a stressful conversation, a long drive, a sudden burst of activity, all stacking up.

Expect them to be uneven. Your neck may flare while your back is fine, or the other way round, or both together. That unevenness is normal and it does not mean something new has happened in one place.

• Your flare-up plan:
• Keep moving, gently. Do less rather than stopping.
• Drop back to your baseline for a few days, then build again.
• Use whatever settles it: heat, short walks, changing position often, medication as advised.
• Remind yourself, deliberately, that this has settled before and it will settle again. That is not just positive thinking. It lowers the threat and closes the gate.
• Get in touch if it is not settling as it normally does, if anything starts travelling into an arm or leg, or if anything in section 12 applies.

11. What treatment does, and what it does not

Hands-on treatment works through the mechanisms above. It closes the gate. It calms the sensitivity. It relaxes muscles that have tightened to protect you. It gives you a spell where moving feels easier and safer. That is a real effect and it is worth having.

What it does not do is rearrange your spine. Nothing is out of place. Nothing needs putting back in. The clicks and pops you sometimes hear are gas moving inside a joint, the same as cracking a knuckle. Not the sound of anything being repositioned, and a treatment that makes a noise is not better than one that does not.

Think of a session as a window. A stretch of time where you can move more freely, and use that freedom to build up what you can handle. The moving and the strengthening are what change things in the long run.

That is why hands-on treatment on its own rarely settles pain that has been around a while. The best results come from three things together: hands-on care, gradually building activity and strength, and understanding what is going on. Each does a different job.

And because your pain is in two places, we treat you rather than treating two areas. If we spend every appointment chasing whichever spot is loudest that week, we will both be busy and neither of us will get anywhere.

One note on progress. Pain scores bounce around week to week and can be disheartening, and with two areas there are twice as many numbers to be disheartened by. Better questions: what can I do now that I could not do three months ago? Am I sleeping better? Can I sit through a film, get through a working week, do a full shop? Function usually improves before pain does, and pain follows function.

12. When to get urgent help

Almost all neck and back pain, including a bad flare-up, is not an emergency. A few things are. They are rare, but they are worth knowing by name so you can act quickly instead of worrying. Tell me straight away if your pain starts travelling into an arm or a leg, or if you start getting headaches. That is not an emergency, but it changes the picture and I would want to look at you again.

Go straight to A&E, or call 999

Do not wait to see if these settle. If you are offered a routine appointment, say you are worried about cauda equina syndrome and ask to be seen today.

• Numbness or a changed feeling between your legs, around your back passage or genitals. Including toilet paper feeling different when you wipe.
• Trouble starting to wee. Not being able to feel it coming out. Losing the feeling of a full bladder. Any new loss of control of your bladder or bowels.
• New numbness during sex, or new trouble getting an erection.
• New or worsening weakness in one or both legs, or your legs giving way.
• Any sign of stroke. Face drooping on one side, weakness in one arm, slurred or muddled speech. Think FAST.
• Sudden, severe neck pain or headache unlike anything you have had before, especially with double vision, slurred speech, trouble swallowing, veering when you walk, or sudden severe dizziness.
• Severe pain straight after a bad fall or a car crash.

Contact your GP or NHS 111 today

• Signs of pressure on the spinal cord in your neck. These start subtly: dropping things, getting clumsy with your hands, struggling with buttons, zips or coins, changed handwriting, feeling unsteady on your feet, heavy legs.
• Pain in either area with a fever, shivering, or feeling generally unwell.
• Neck stiffness with fever, severe headache, dislike of bright light, or a rash that does not fade when you press a glass on it.
• Pain with weight loss you cannot explain, night sweats, or a past history of any cancer.
• Pain that is much worse at night, wakes you every night, or is not eased by any change of position.
• New weakness anywhere that is getting worse day by day.

Worth mentioning at a normal appointment

Because you have pain in more than one place, there are two patterns worth ruling out. Neither is likely, and neither is an emergency, but both are much easier to deal with once named.

• An inflammatory pattern. Stiffness lasting more than half an hour in the morning, pain that is worse after rest and better once you get moving, pain waking you in the second half of the night, or a strikingly good response to anti-inflammatory tablets. Especially if it started before you were 45, or if you or a close relative have psoriasis, inflammatory bowel disease, or repeated painful red eyes.
• A more widespread pattern. Pain spreading well beyond these two areas, alongside deep fatigue, sleep that never leaves you refreshed, and difficulty concentrating.

Everything else, including a bad flare-up, can wait for a normal appointment.

13. If you want to read or watch more

Start here

• Tame the Beast. A five minute animation by Professor Lorimer Moseley. The best possible starting point. tamethebeast.org
• Flippin' Pain. A UK campaign about long lasting pain, with animations and real stories. flippinpain.co.uk
• Retrain Pain. Free, very short illustrated lessons. retrainpain.org
• NHS advice on back pain. nhs.uk/conditions/back-pain
• NHS advice on neck pain. nhs.uk/symptoms/neck-pain-and-stiff-neck

Practical help

• The Pain Toolkit, by Pete Moore, who lives with long lasting pain himself. Very good on pacing and boom and bust. paintoolkit.org
• Recovery Strategies, by Greg Lehman. A free illustrated workbook, one idea per page. greglehman.ca/recovery-strategies-pain-guidebook

Books

• Explain Pain, by David Butler and Lorimer Moseley. The standard patient friendly version of the science in this guide.
• The Explain Pain Handbook: Protectometer, by the same authors. A workbook for finding your own gate openers and closers.
• Painful Yarns, by Lorimer Moseley. The same ideas as short, funny stories.

The research behind this guide

• Melzack R, Wall PD. Pain mechanisms: a new theory. Science, 1965. The original pain gate paper.
• Distribution and prevalence of musculoskeletal pain co-occurring with persistent low back pain: a systematic review. BMC Musculoskeletal Disorders, 2021. The source of the co-occurrence figures at the start of this guide.
• Brinjikji W et al. Imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 2015. The low back scan figures in section 6.
• Nakashima H et al. Abnormal findings on MRI of the cervical spine in 1211 asymptomatic subjects. Spine, 2015. The neck scan figures in section 6.
• Hartvigsen J et al. What low back pain is and why we need to pay attention. The Lancet, 2018.
• Louw A et al. The effect of pain neuroscience education in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation, 2011.
• NICE guideline NG59: Low back pain and sciatica in over 16s.

Bring any of this to your next appointment. Especially the parts that did not sit right, or that felt uncomfortably familiar. Those are usually the most useful things to talk through.

This guide is general information. It does not replace the advice I give you in clinic.