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Muscle Performance in Neck Pain

Original Editor - Tarina van der Stockt

Top Contributors - Tarina van der Stockt, Jess Bell, Manisha Shrestha, Kim Jackson, Ewa Jaraczewska, Jorge Rodríguez Palomino, Admin, Simisola Ajeyalemi, Vidya Acharya, Lucinda hampton, Tony Lowe and Robin Tacchetti

Introduction

Neck pain and injury are associated with changes in muscle function, including altered motor control, strength, endurance, and patterns of activation.[1] [2] Understanding the muscles of the cervical region and their function is essential for identifying which muscles are affected.[3]

Muscles of the Neck

The cervical muscles can be classified based on their location and depth. Broadly, they can be divided into anterior and vertebral regions in relation to the sternocleidomastoid.[4] The vertebral region can be further subdivided into prevertebral, paravertebral and posterior groups.

Muscles of the anterior neck

Muscles of the Anterior Region

The anterior neck muscles can be grouped as follows:

Muscles of the Vertebral Region

These are the muscles that surround the vertebrae to form a musculoskeletal column.

Prevertebral (Anterior Vertebral)

These are also called the deep cervical flexors. They include:

[5]

Lateral Vertebral Muscles

The scalenes muscles include the anterior, middle, posterior and minimus.

[6]

Posterior Vertebral Muscles

These can be further divided into intrinsic and extrinsic muscles. The extrinsic muscles are trapezius and levator scapulae.

The intrinsic muscles consist of a superficial layer (splenius capitis and splenius cervicis) and a deep layer. The deep layer includes the suboccipital group (rectus capitis posterior major and minor, obliquus capitis inferior and superior), the transversospinalis muscles (semispinalis capitis and cervicis, rotatores cervicis and multifidus) and the interspinales and intertransversarii. The transversospinalis muscles are also known as the deep neck extensors.[4]

[7]

Functional Classification of Cervical Muscles

When classifying muscles, it is useful for us to think of them conceptually as global movers and local stabilisers.[8] See more at Core Muscles.

Global movers are involved in the generation of torque and movement. They function in a phasic manner (i.e, on/off) and their activation is direction-dependent. When dysfunctional, there is spasm, pain and restricted range of movement. Trapezius, levator scapulae, sternocleidomastoid, splenius and the scalenes are superficial muscles that act as global movers in the cervical region.

  1. Superficial cervical flexors: sternocleidomastoid and anterior scalene
  2. Superficial cervical extensors:
    • Level 1: levator scapulae, upper trapezius
    • Level 2: splenius capitis and cervicis

Local stabilisers are the deeper muscles that provide segmental control and neutral positioning of a joint. Their activity is tonic rather than phasic, and they operate at much lower levels of contraction for long periods of time. Dysfunction in the local muscles results in inhibition of function, delayed timing or recruitment deficiencies, and loss of segmental control and neutral joint positioning.

There are three main groups of cervical muscles that form a sleeve around the vertebral column and enable control of posture and segmental movements:

  1. The deep cervical flexors: longus colli, longus capitis, rectus capitis anterior and lateralis
  2. The deep neck extensors: semispinalis cervicis and capitis, and multifidus (segmental stabiliser)
  3. The suboccipital muscles: rectus capitis posterior major and minor, and obliquus capitis superior and inferior.[9]

The suboccipital muscles are important for providing proprioception, and they have input into the visual and vestibular systems. They control craniocervical lordosis and small head-on-neck movements. Dysfunction results in sensorimotor impairment and altered kinaesthetic sense, including reduced balance and joint position sense, as well as altered oculomotor control. This can lead to cervicogenic dizziness.

Cervical Muscle Function in the Presence of Pain

Reduced activity of the deep cervical flexor muscles occurs together with an increase in activity and a decrease in neuromuscular efficiency of the superficial muscles, even under low load and with non-functional tasks.[1] [10] [11] This change in activation can be seen in functional, as well as cognitive tasks and is not dependent on the cause or the duration of neck pain.[1] [11] Patients with neck pain also struggle to relax the superficial neck flexor muscles even after an activity has ceased.[11]

These changes in muscle function occur soon after the pain starts and do not automatically return to normal once the pain resolves.[11] Because changes in activation of the deep cervical muscles affect the support and control of the cervical spine, this could lead to overload on specific segments.[11][1]

Research has shown that both the cervical flexors and extensors lose strength and endurance in the presence of neck pain,[10][12][13] and that co-activation of these muscle groups ceases, especially with functional tasks.[1] The superficial cervical muscles also fatigue more quickly,[11] and cervical muscle endurance is reduced for both maximal and low contractions.[1]

Feedforward activation is lost, which influences the timing of activation. This can be seen when performing rapid arm movements:[1] in people without neck pain, the cervical muscles activate within 50ms of deltoid activation, whereas in patients with neck pain, there is a significant deficit for both the superficial and deep neck flexors. This can result in increased strain on the cervical spine.[11]

Muscle atrophy occurs in the cervical muscles of patients with neck pain.[1] Fatty infiltration has been identified in the deep flexor and extensor muscles of people with chronic whiplash-associated disorder, but not in those with chronic insidious-onset neck pain.[1][14][15]

Research also suggests that survivors of head and neck cancer with temporomandibular and cervical pain have multiple active trigger points, which is suggestive of peripheral and central sensitisation.[16]

Assessment

Craniocervical Flexion Test

The craniocervical flexion test (CCFT) is considered a valid and reliable test of neuromuscular control.[17] It assesses the activation and isometric endurance of the longus capitis and longus colli, and their interaction with sternocleidomastoid and anterior scalene.[1]

Procedure

The pressure biofeedback unit (PBU) is positioned suboccipitally and inflated to 20 mmHg.[1]

The patient is instructed to gently and slowly nod their head (as if saying "yes"). This action causes the pressure in the PBU to increase.

During the first stage, the pressure should increase by 2 mmHg to 22 mmHg while the superficial muscles remain relaxed. The patient holds this position for 10 seconds, then relaxes back to 20 mmHg.

This sequence is repeated, increasing the target pressure by 2 mmHg each time (to 24, 26, 28, and 30 mmHg), with a 10-second hold at each stage.

Interpretation

Craniocervical flexion requires activation of the deep cervical flexors; the superficial cervical flexors cannot perform this movement. With each stage, the range of motion should increase. Individuals who do not have neck pain will be able to hold the contraction for 10 seconds at stage 3 (26 mmHg) or higher. Someone with neck pain usually only reaches stage 1 or 2 before they lose the neutral position or the superficial neck muscles contract.[1]

Neck Flexor Endurance Test

Procedure

The patient lies in supine with their knees bent and performs a chin tuck (craniocervical flexion). They then lift their head 2.5 cm above the plinth while maintaining the chin tuck position. The examiner records the time the patient can hold this position.[18]

Reliability

This test has good intra-rater reliability when used with patients with neck pain and is a reliable tool for measuring rehabilitation progress.[18]

Normative Values

Different studies have recorded varying hold times for this test.[18] In asymptomatic individuals, reported means range from 39 to 64 seconds for men and 29 to 38 seconds for women.[18][19] In people with neck pain, mean hold times are lower.[20] Across all studies, men demonstrate longer hold times than women, which should be considered when interpreting results. Adults show longer hold times than children, with endurance appearing to stabilise after age 20.[18][21]

Neck flexor endurance test video provided by Clinically Relevant

Neck Extensor Endurance Test

Procedure

The patient lies in prone with their head over the edge of the bed, arms at their side. The head may initially be supported on a stool. The patient performs a chin tuck (craniocervical flexion) and holds their head steady while the stool is removed. The examiner records the time the patient can maintain their head in a horizontal position.[20]

Alternative Position

An alternative position is prone on elbows with the craniocervical region in neutral. This can be used to assess cervical extension of the deeper cervical group, and rotation can be added.[1]

Comparison with Neck Flexor Endurance Test

The neck extensor muscles have significantly higher endurance than the neck flexor muscles in people with neck pain. This finding is consistent across acute to chronic presentations and different age groups.[20]

Rehabilitation

The terms muscle performance and muscle strength are often used to describe “the ability of a muscle to produce force, regardless of the action (isometric vs. isotonic), load (body segment vs. free weight), or intensity (‘low load’ vs. ‘high load’)"[22]. For a muscle to control a body segment, it must first have sufficient strength.[22] To train muscle performance, the muscle must perform repeated actions against some resistance (either the body segment or added weight), around a rotational axis in a single plane. This type of training has been shown to improve proprioception of that segment—for example, when people with neck pain perform a controlled head lift exercise.[22]

Early rehabilitation should be emphasised, and an exercise programme should include both motor control and general strengthening of the neck muscles. [11]

Neck Flexors

Deep neck flexor training has been shown to reduce neck pain.[23][24] [25] A study of 18 participants with chronic neck pain compared craniocervical flexion (CCF) exercises with passive mobilisation combined with assisted CCF. Participants were randomised into two intervention groups. Both groups showed a decrease in pain, but only the exercise group demonstrated improvement in motor function and decreased activation of the superficial neck flexors during the CCFT.[10]

Stage 1

Goal: Retrain craniocervical flexion motor control.[1]

The correct movement should be retrained without activating the superficial muscles (the patient can place their hand on the muscles to feel when they contract). Endurance of the deep neck flexors is trained with the use of a pressure biofeedback unit, working towards 10 repetitions of 10-second holds at 22, 24, 26, 28, and 30 mmHg.[1] This can be progressed by repeating the exercises with eyes closed.[22]

Functional training should be incorporated from the start and should be repeated throughout the day.[1] A useful cue is to ask the patient to try to “lift the base of their skull off the top of their neck in a neck lengthening maneuver”.[1]

Stage 2

Goal: Increase endurance and strength by increasing the load with the addition of gravity during the head lift exercise.

The patient sits with their head against the wall and performs the craniocervical flexion movement by sliding their head up the wall. They then move their head just off the wall and hold this position for 10 seconds. This is progressed to 10 repetitions. The patient’s hands can be placed on the superficial muscles to monitor for activation.

Progressions include:

  • moving away from the wall and repeating the exercise
  • performing the exercise in supine and then in different positions
  • incorporating this movement into functional tasks specific to the individual, including combined movements

Neck Extensors

Stage 1[1]

Goal: Retrain motor control of the deep cervical extensors.

The patient is positioned in prone on their elbows or in quadruped, depending on their scapula control. Starting with their head in craniocervical flexion, the patient performs craniocervical extension, rotation and cervical extension (C2-C7). They progress to 3 sets of 10 repetitions through full range of motion without fatigue.

While performing rotation and cervical extension, the patient should maintain craniocervical flexion. A useful cue is to ask the patient to keep their eyes focused down (as if looking down at a book) while doing the movements.

Stage 2[1]

Goal: Increase strength by adding load.

Load is added, starting with 0.5kg. Neck-specific resistance equipment may be used, or weights can be added to something like a bike helmet.

Sensorimotor Training

The following videos show examples of sensorimotor training.
[26]
[27]
[28]

Resources

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 Brukner P. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill; 2012.
  2. ↑ Almeida MB, Moreira M, Miranda-Oliveira P, Moreira J, Família C, Vaz JR, Moleirinho-Alves P, Oliveira R. Evolving Dynamics of Neck Muscle Activation Patterns in Dental Students: A Longitudinal Study. Sensors (Basel). 2024 Sep 1;24(17):5689.
  3. ↑ Müller-Thyssen-Uriarte J, Lucha-López MO, Hidalgo-García C, Sánchez-Rodríguez R, Vicente-Pina L, Ferrández-Laliena L, Vauchelles-Barré P, Tricás-Moreno JM. Electromyographic Activity of Cervical Muscles in Patients with Neck Pain and Changes After Dry Needling: A Narrative Review. J Clin Med. 2024 Nov 30;13(23):7288.
  4. ↑ 4.0 4.1 4.2 Drake R, Vogl AW, Mitchell AW. Gray's anatomy for students E-book. Elsevier Health Sciences; 2009 Apr 4.
  5. ↑ Prevertebral muscles of the neck | Longus cervicis & capitis , Rectus capitis anterior & Lateralis. Available from: https://www.youtube.com/watch?v=pTWev6kO-Eg lasted accessed: 2021-7-24
  6. ↑ Paravertebral Muscles - The Scalenus Anterior muscle| Attachments | Nerve supply| Action | Relations. Available from: https://www.youtube.com/watch?v=yAYXUh2eO6A Lasted accessed: 2021-7-24
  7. ↑ Available from: https://www.youtube.com/watch?v=ySC8bDz7IOU lasted accessed: 2021-07-24
  8. ↑ Page P, Frank CC, Lardner R. Assessment and treatment of muscle imbalance: the Janda approach. Human kinetics; 2010.
  9. ↑ Cleland J. Orthopaedic clinical examination: an evidence-based approach for physical therapists. Saunders; 2005.
  10. ↑ 10.0 10.1 10.2 Lluch E, Schomacher J, Gizzi L, Petzke F, Seegar D, Falla D. Immediate effects of active cranio-cervical flexion exercise versus passive mobilisation of the upper cervical spine on pain and performance on the cranio-cervical flexion test. Man Ther. 2014 Feb;19(1):25-31.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 Falla D. Unravelling the complexity of muscle impairment in chronic neck pain. Man Ther. 2004 Aug;9(3):125-33.
  12. ↑ Pardos-Aguilella P, Ceballos-Laita L, Cabanillas-Barea S, Pérez-Guillén S, Ciuffreda G, Jiménez-del-Barrio S, Carrasco-Uribarren A. Correlation between Neck Muscle Endurance Tests, Ultrasonography, and Self-Reported Outcomes in Women with Low Cervical Disability and Neck Pain. Applied Sciences. 2023; 13(18):10106.
  13. ↑ Reddy RS, Meziat-Filho N, Ferreira AS, Tedla JS, Kandakurti JK, Kakaraparthi VN. Comparison of neck extensor muscle endurance and cervical proprioception between asymptomatic individuals and patients with chronic neck pain. Journal of Bodywork and Movement Therapies. 2021;26:180-6.
  14. ↑ Smith AC, Albin SR, Abbott R, Crawford RJ, Hoggarth MA, Wasielewski M, Elliott JM. Confirming the geography of fatty infiltration in the deep cervical extensor muscles in whiplash recovery. Sci Rep. 2020 Jul 10;10(1):11471.
  15. ↑ Snodgrass SJ, Weber KA 2nd, Wesselink EO, Stanwell P, Elliott JM. Reduced Cervical Muscle Fat Infiltrate Is Associated with Self-Reported Recovery from Chronic Idiopathic Neck Pain Over Six Months: A Magnetic Resonance Imaging Longitudinal Cohort Study. J Clin Med. 2024 Jul 31;13(15):4485.
  16. ↑ Ortiz-Comino L, Fernández-Lao C, Castro-Martín E, Lozano-Lozano M, Cantarero-Villanueva I, Arroyo-Morales M, Martín-Martín L. Myofascial pain, widespread pressure hypersensitivity, and hyperalgesia in the face, neck, and shoulder regions, in survivors of head and neck cancer. Supportive Care in Cancer. 2019 Nov 21:1-8.
  17. ↑ Araujo FX, Ferreira GE, Scholl Schell M, Castro MP, Ribeiro DC, Silva MF. Measurement Properties of the Craniocervical Flexion Test: A Systematic Review. Phys Ther. 2020;100(7):1094-1117.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 Painkra JP, Kumar S, Anwer S, Kumar R, Nezamuddin M, Equebal A. Reliability of an assessment of deep neck flexor muscle endurance test: A cross-sectional study. International Journal of Therapy and Rehabilitation. 2014 May;21(5):227-31.
  19. ↑ Domenech MA, Sizer PS, Dedrick GS, McGalliard MK, Brismee JM. The deep neck flexor endurance test: normative data scores in healthy adults. PM R. 2011 Feb;3(2):105-10.
  20. ↑ 20.0 20.1 20.2 Parazza S, Vanti C, O'Reilly C, Villafañe JH, Tricás Moreno JM, Estébanez De Miguel E. The relationship between cervical flexor endurance, cervical extensor endurance, VAS, and disability in subjects with neck pain. Chiropr Man Therap. 2014 Mar 3;22(1):10.
  21. ↑ Tiwari D, Saini S, Babar R. Normative Scores and Test-Retest Reliability of Neck Strength, Endurance, and Proprioception Tests in Children and Adolescents. JOSPT Open. 2024 Oct;2(4):348-53.
  22. ↑ 22.0 22.1 22.2 22.3 Clark NC, Röijezon U, Treleaven J. Proprioception in musculoskeletal rehabilitation. Part 2: Clinical assessment and intervention. Man Ther. 2015 Jun;20(3):378-87.
  23. ↑ Chaiyawijit S, Kanlayanaphotporn R. McKenzie neck exercise versus cranio-cervical flexion exercise on strength and endurance of deep neck flexor muscles, pain, disability, and craniovertebral angle in individuals with chronic neck pain: a randomized clinical trial. J Man Manip Ther. 2024 Dec;32(6):573-583.
  24. ↑ Nazari G, Bobos P, Billis E, MacDermid JC. Cervical flexor muscle training reduces pain, anxiety, and depression levels in patients with chronic neck pain by a clinically important amount: A prospective cohort study. Physiother Res Int. 2018;23(3):e1712.
  25. ↑ Suvarnnato T, Puntumetakul R, Uthaikhup S, Boucaut R. Effect of specific deep cervical muscle exercises on functional disability, pain intensity, craniovertebral angle, and neck-muscle strength in chronic mechanical neck pain: a randomized controlled trial. J Pain Res. 2019 Mar 7;12:915-925.
  26. ↑ Rehab My Patient. Cervical Proprioception LASER Points In Range Rotation Eyes Open 2 Published on Aug 30, 2017 [Accessed 6 June 2018] Available from: https://www.youtube.com/watch?v=h-0ny-oJLXM
  27. ↑ Rehab My Patient. Cervical Proprioception LASER Points In Range Rotation Eyes Closed 2. Published on Aug 30, 2017 [Accessed 6 June 2018] Available from: https://www.youtube.com/watch?v=_mkveStrW8k
  28. ↑ Motion Guidance. Cervical Rotation Neck Proprioception Exercise with Motion Sensor. Published on Apr 23, 2018 [Accessed 6 June 2018] Available from: https://www.youtube.com/watch?v=EflMNYITmBw
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