Muscle Performance in Neck Pain

Introduction[edit | edit source]

In the presence of neck pain and injury there is evident changes in muscle function in terms of motor control, strength, endurance, and patterns of activation. [1] To know which muscles are affected, it is very essential to know the muscles present on cervical region and their function.

Muscles of Neck[edit | edit source]

It can be simplified based upon the location and depth. Grossly it can be divided into Anterior and vertebral cervical region in relation to sternocleidomastoid muscles.[2]

Muscles of anterior neck

Muscles in anterior region[edit | edit source]

Muscles in vertebral region[edit | edit source]

These are the muscles with surround the vertebra to form a musculoskeletal column. It can be further classified into anterior (prevertebral), lateral (paravertebral) and posterior in relation to cervical vertebrae.

Anterior vertebral muscles (Prevertebral)[edit | edit source]

These are also termed Deep cervical flexors. It includes:


Lateral vertebral muscles (Paravertebral)[edit | edit source]

Scalenes - anterior, middle, posterior and minimus scalene muscles


Posterior vertebral muscles[edit | edit source]

It can be further divided into intrinsic and extrinsic muscles.

Extrinsic muscles: Trapezius and Levator scapulae

Intrinsic muscles:


Muscle of neck divided based upon function[edit | edit source]

When classifying muscles, it is useful for us to think of them conceptually as global movers and local stabilisers.[6] See more at Core Muscles

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

  1. Superficial cervical flexors: Sternocleidomastoid and Scalene anterior
  2. Superficial cervical extensors:
    • Level 1: levator scapulae, upper trapezius
    • Level 2: Splenius capitis and cervicis

Local stabilisers are the deeper muscles that control 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 (local stabilisers) :

  1. The deep cervical flexors - longus colli, longus capitus, rectus capitis anterior and posterior
  2. The deep neck extensors - semispinalis cervicis and capitis, and multifidus (segmental stabiliser).
  3. The suboccipital muscles - rectus capitus posterior major & minor, and obliquus capitus superior and inferior.[7]
    • Suboccipital group of muscles are important to provide proprioception and they have input into the visual and vestibular systems. They control cranio-cervical lordosis and small head-on-neck movements. Dysfunction results in sensorimotor impairment, altered kinesthetic sense such as reduced balance, joint position, altered oculomotor control and can lead to cervicogenic dizziness.

Cervical muscle function in the presence of pain[edit | edit source]

  • Reduced activity of the the deep cervical flexor muscles occurs together with an increase in activity and neuromuscular inefficiency of the superficial muscles even under low load and with non-functional tasks [1] [8] [9] 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] [9]
  • Patients with neck pain struggle to relax the superficial neck flexor muscles even after an activity has ceased. [9]
  • These changes in muscle function occur soon after the pain started and do not automatically return to normal once the pain resolves. [9]
  • Changes in function in the deep cervical muscles has an influence on function as it affects the support and control of the cervical spine and could lead to overload on specific segments [9][1]
  • Research has shown that both the cervical flexors and extensors lose strength and endurance in the presence of neck pain,[8][9][10] and that co-activation of ceases especially with functional tasks. [1]
  • Superficial cervical muscles will fatigue quicker[9]
  • Endurance is reduced in the cervical muscles for both maximal and low contractions [1]
  • The feed forward activation is lost - this influences the timing of activation and can be seen when the patient is doing rapid arm movements. [1] When a patient without neck pain rapidly lifts his/her arm the cervical muscles will activate within 50ms of deltoid activation, in patients with neck pain there is a significant deficit for both the superficial and deep neck flexors which can result in an increase strain on the cervical spine. [9]
  • 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 chronic insidious-onset of neck pain [1][11]
  • Research suggests the survivors of head and neck cancer with temporomandibular and cervical pain have multiple active trigger points suggestive of peripheral and central sensitization[12]

Assessment[edit | edit source]

Cranio-cervical flexion test (CCFT)[edit | edit source]

The CCFT has been found to be a valid and reliable test, which can be used as an assessment tool in clinical practice.[13] Motor control assessment of the longus capitis and colli activation and isometric endurance, while observing their interaction with sternocleidomastoid and anterior scalene muscles.[1]

The PBU is positioned suboccipitally and then inflated to 20 mmHg.[1]

  1. The patient is instructed to move the head vertically (as if saying ‘yes’). The movement is performed gently and slowly . This nodding action causes the pressure in the inflated pressure sensor to increase. For the first stage of the test the pressure should increase by 2 mmHg to 22 mmHg while the superficial muscles stay relaxed.
  2. The patient is told to maintain this position for 10 seconds.
  3. Then the patient relaxes back to 20 mmHg to increase the pressure again this time to 24 mmHg using the same action and hold for 10 seconds. The patient has to do repeat this action until a pressure of 30 mmHg is reached.

Flexion of the neck requires activation of the deep cervical flexors. The superficial cervical flexors cannot be used to 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 reach stage 1 or 2 before they loose the neutral position or the superficial neck muscles contract. [1]

Neck Flexor Endurance Test[edit | edit source]

  • Patient in supine position with knees bend. Patient has to tuck the chin (cranio-cervical flexion). The patient then has to lift the head 2.5 cm above the plinth while keeping the chin tuck position. [14]
  • This test has been found to have good intra-rater reliability when used with patients with neck pain [14]
  • The test was shown to be a reliable tool to measure the rehabilitation progress of a patient with neck pain[14]
  • Different studies have recorded times for this test[14]
    • Asymptomatic Men (mean = 25 seconds), asymptomatic woman (20 seconds) - (Olson et al. 20016)
    • Asymptomatic Men (mean = 63.73 seconds), asymptomatic woman (38.43 seconds) - (Olson et al. 20016)
    • Male patients with neck pain have a longer neck flexor endurance than females.[15]
    • Even though the duration times differ, multiple studies have found that men have a longer hold time than woman and that this should be considered when interpreting the test
    • Asymptomatic group (mean = 39 seconds), group with neck pain (mean - 24 seconds) - (Harris et al, 2005)

Neck flexor endurance test video provided by Clinically Relevant

Neck Extensor Endurance Tests[edit | edit source]

  • The patient lies in prone with the head over the edge of the bed. The head could be supported on a stool with arms at the patient's side. The patient is then asked to do a chin tuck (cranio-cervical flexion) and hold the head steady in this position while the stool is removed. The patient has to maintain the head in a horizontal position. [15]
    • Easy test to do because no tools are needed, however the test may take up valuable time that could be spent on other tests. [15]
  • With patient in prone on elbows and the cranio-cervical region in neutral -test cervical extension of the deeper cervical group. Rotation can also be assessed in this position. [1]

Correlating the Neck Flexor Endurance Test with the Neck Extensor Endurance Test shows that the neck extensor muscles have significantly higher endurance than the neck flexor muscles in the neck pain population. These results are the same for acute to chronic neck pain patients through different ages. [15]

Rehabilitation[edit | edit source]

Muscle performance or muscle strength is “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’)"[16]. For a muscle to control a body segment it must first have sufficient strength. [16] To train muscle performance the muscle has to do a repeated action against some resistance (either the body segment or added weight), around a rotation axis in a single plane. This type of training has been shown to improve proprioception of that segment for e.g. when people with neck pain do a controlled head lift exercise. [16]

Early rehabilitation with patients should be emphasized and an exercise program should include both motor control and general strengthening of the neck muscles. [9]

Neck Flexors[edit | edit source]

Deep neck flexor training has been shown to reduce neck pain.[17][18] [19] The CCF exercises was compared to passive mobilisation with assisted CCF in a study of 18 participants with chronic neck pain that were randomised in 2 intervention groups. Both groups showed decrease in pain relief but only the exercise group had improvement in motor function and decreased activation of the superficial neck flexors during the CCFT. [8] Endurance and strength training of the DNF muscles of a person with neck pain reduces the perceived neck pain of that patient. [14]

Stage 1 [1]

  • Cranio-cervical flexion (CCF) motor control should be retrained [1]
    • Retrain the correct movement without activating the superficial muscles (the patient can place their hand on the muscles to feel when they contract)
    • Train endurance of the deep neck flexors with the use of a pressure biofeedback.
      • Progression - work towards 10 repetitions of 10 sec holds at 22, 24, 26, 28, and 30 mmHg,[1] then repeat exercise by doing it with your eyes closed [16]
  • Functional training should be incorporated from the start and should be repeated throughout the day [1]
    • The patient should try to “lift the base of their skull off the top of their neck in a neck lengthening maneuver” [1]

Stage 2 [1]

Increase endurance and strength by increasing the load with added gravity during the head lift exercise.

  • Patient is sitting with the head against the wall and does the Cranio-cervical flexion movement by sliding the head up the wall, the head is then moved just off the wall and held there for 10 seconds. Progress to 10 repetitions. The patient’s hands can be placed on the superficial muscles.
  • Progress by moving away from the wall and repeating the exercise
  • Progress to doing the exercise in supine and then in different body position
  • Progress further by adding this movement in functional tasks specific to the individual including combined movements.

Neck Extensors[edit | edit source]

Stage 1 [1]

  • Patient prone on elbow or in a quadruped position depending on scapula control
    • The patient starts with the head in cranio-cervical flexion and performs the following movements:
      • cranio-cervical extension
      • rotation
      • cervical extension (C2-C7)
    • progressing to 3 sets of 10 repetitions through full ROM without fatigue
    • while doing rotation and cervical extension the patient should keep the neck in cranio-cervical flexion - a way to cue the movement is to tell the patient to keep their eyes focused down (like looking down at a book) while doing the movements

Stage 2 [1]

  • Adding load starting with 0.5kg. Neck specific resistance equipment could be used or weights could be added to something like a bike helmet.

Neck rotation proprioception and speed training[edit | edit source]

Resources[edit | edit source]

References[edit | edit source]

  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 1.19 1.20 Brukner P. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill; 2012.
  2. 2.0 2.1 2.2 Drake R, Vogl AW, Mitchell AW. Gray's anatomy for students E-book. Elsevier Health Sciences; 2009 Apr 4.
  3. Prevertebral muscles of the neck | Longus cervicis & capitis , Rectus capitis anterior & Lateralis. Available from: lasted accessed: 2021-7-24
  4. Paravertebral Muscles - The Scalenus Anterior muscle| Attachments | Nerve supply| Action | Relations. Available from: Lasted accessed: 2021-7-24
  5. Available from: lasted accessed: 2021-07-24
  6. Page P, Frank CC, Lardner R. Assessment and treatment of muscle imbalance: the Janda approach. Human kinetics; 2010.
  7. Cleland J. Orthopaedic clinical examination: an evidence-based approach for physical therapists. Saunders; 2005.
  8. 8.0 8.1 8.2 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. Manual therapy. 2014 Feb 28;19(1):25-31.[Accessed 6 June 2018] Available from:
  9. 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 Falla D. Unravelling the complexity of muscle impairment in chronic neck pain. Manual therapy. 2004 Aug 1;9(3):125-33. [Accessed 6 June 2018] Available from:
  10. 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.
  11. Smith AC, Albin SR, Abbott R, Crawford RJ, Hoggarth MA, Wasielewski M et al. Confirming the geography of fatty infiltration in the deep cervical extensor muscles in whiplash recovery. Sci Rep. 2020;10:11471.
  12. 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.
  13. 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.
  14. 14.0 14.1 14.2 14.3 14.4 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. [Accessed 8 June 2018] Available from:
  15. 15.0 15.1 15.2 15.3 Parazza S, Vanti C, O’Reilly C, Villafañe JH, Moreno JM, De Miguel EE. The relationship between cervical flexor endurance, cervical extensor endurance, VAS, and disability in subjects with neck pain. Chiropractic & manual therapies. 2014 Dec;22(1):10.  [Accessed 8 June 2018] Available from:
  16. 16.0 16.1 16.2 16.3 Clark NC, et al., Proprioception in musculoskeletal rehabilitation. Part 2: Clinical assessment and intervention,Manual Therapy (2015), [Accessed 7 Jun 2018] Available from:
  17. Jull GA, O'leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. Journal of Manipulative & Physiological Therapeutics. 2008 Sep [Accessed 7 Jun 2018] 1;31(7):525-33. Available from:
  18. 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.
  19. Suvarnnato, T., Puntumetakul, R., Uthaikhup, S. and Boucaut, R., 2019. 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. Journal of pain research, 12, p.915.
  20. Rehab My Patient. Cervical Proprioception LASER Points In Range Rotation Eyes Open 2 Published on Aug 30, 2017 [Accessed 6 June 2018] Available from:
  21. Rehab My Patient. Cervical Proprioception LASER Points In Range Rotation Eyes Closed 2. Published on Aug 30, 2017 [Accessed 6 June 2018] Available from:
  22. Motion Guidance. Cervical Rotation Neck Proprioception Exercise with Motion Sensor. Published on Apr 23, 2018 [Accessed 6 June 2018] Available from: