[ CLINICAL COMMENTARY ]

SHAUN O’LEARY, PT, PhD¹š:;8EH7><7BB7"PT, PhD²

JAMES M. ELLIOTT, PT, PhD³š=M;D:EB;D@KBB"PT, PhD4

Muscle Dysfunction in Cervical

Spine Pain: Implications for
Assessment and Management
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eck pain can be a disabling and recurrent disorder ing the alleviation of symptoms.67 There

N characterized by periods of remission and exacerbation.9 It

has been estimated that in any 6-month period 54% of adults
will experience neck pain, with approximately 5% having
substantial activity limitations due to their neck disorder.8 Alarmingly,
is an ever growing number of mechanistic
studies identifying muscle dysfunction in
individuals with MNP.10,21,32,56 Pertinent
to clinical practice, programs to retrain
muscle function have shown favorable re-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

a cross-sectional study has suggested that only 6.3% of individuals who sponses in terms of improvements in neck
suffered from neck pain in the previous year were free of recurrence.60 pain, disability, and function.37,79 A recent
systematic review suggests that the com-
This tendency for chronicity of some heavy dependency of the cervical verte- bination of exercise and manual therapy
mechanical neck pain (MNP) disorders bral column on its muscles for its physical are the most efficacious of all conserva-
may at least in part be attributed to inad- support.58 Similar to findings in low back tive managements for subacute or chron-
equate recovery of cervical muscle func- pain, cervical muscle dysfunction does not ic MNP.28 While the evidence indicates
tion postinjury, especially considering the appear to spontaneously recover follow- the importance of assessing and training
cervical muscle function in the manage-
Journal of Orthopaedic & Sports Physical Therapy®

T SYNOPSIS: There is irrefutable evidence of an assessment and management of cervical muscle ment of MNP, the development of clinical
association between mechanical neck pain (MNP) dysfunction is still a work in progress. One obstacle guidelines for its optimal implementation
and dysfunction of the muscles of the cervical spine. in researching the efficacy of cervical muscle train- in clinical practice requires additional ef-
A myriad of impairments have been demonstrated ing is that, as yet, we do not possess the capacity to forts. The myriad of muscle impairments
that include changes in the physical structure optimally measure and classify those patients most identified and heterogeneity of patients
(cross-sectional area, fatty infiltration, fiber type), as likely to respond to different methods of training that
presenting with MNP continue to chal-
well as changes in behavior (timing and activation would enrich clinical practice. While gains in this
area are emerging, the ability of a clinician to best lenge the acumen of even the most astute
level), of the cervical muscles. Such changes sug-
identify the need and implement the most appropri- clinician, with regard to assessment and
gest an impaired capacity of the cervical muscles
ate method of training cervical muscle function is clinical relevance of such deficits. In ac-
to generate, sustain, and maintain precision of
still largely dependent on a comprehensive exami- cordance, we have yet to reach consensus
the required levels of torque needed for optimal
nation of the patient that considers all aspects of
function. In the context of physical support, these about the optimal method of measuring,
the patient’s disorder and functional requirements.
changes potentially have deleterious consequences classifying, and training cervical muscle
for the cervical region, which relies heavily on its TB;L;BE<;L?:;D9;0 Level 5. J Orthop Sports
function.39
muscles for mechanical stability. While interventions Phys Ther 2009;39(5):324-333. doi:10.2519/
jospt.2009.2872 The following clinical commentary is
focused on the retraining of cervical muscle function
divided into 3 sections: the first provides
have shown favorable responses in alleviating MNP, TA;OMEH:I0 mechanical neck pain, rehabilita-
the development of best practice strategies for the tion, therapeutic exercise an overview of the evidence concerning
muscle dysfunction in MNP, and the sec-

1
Specialist Musculoskeletal Physiotherapist, NHMRC Post-Doctoral Research Fellow, NHMRC Centre for Clinical Research Excellence in Spinal Pain, Injury and Health, The
University of Queensland, Brisbane, Australia. 2 Associate Professor, Centre for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg
University, Aalborg, Denmark. 3 Post-Doctoral Research Fellow, NHMRC Centre for Clinical Research Excellence in Spinal Pain, Injury and Health and Centre for Magnetic
Resonance, The University of Queensland, Brisbane, Australia. 4 Professor of Physiotherapy, NHMRC Centre for Clinical Research Excellence in Spinal Pain, Injury and Health,
The University of Queensland, Brisbane, Australia. Address correspondence to Shaun O’Leary, Physiotherapy Division, University of Queensland, St Lucia Queensland 4072,
Australia. E-mail: [email protected]

324 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 ond and third sections consider the im- of muscles envelope the cervical vertebral
plications of the evidence for assessment column, and it is these deep muscles that
and training of cervical muscle function are best suited to provide precise control
in clinical practice. While evidence from of segmental motion.7,46 Certainly, the an-
mechanistic and interventional studies gle of the cervical column has been asso-
have justified the need to address cervi- ciated with the morphology and physical
cal muscle dysfunction in MNP, research integrity of deep muscles such as longus
into cervical muscle dysfunction is in its colli46 and semispinalis cervicis.63 With
infancy and has only just begun to in- such reliance on active support mecha-
form the assessment and management nisms, it is feasible that aberrant neu-
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of the complex cervical motor system for romuscular control of the cervical spine
the varied MNP presentations managed may irritate pain-sensitive cervical struc-
in clinical practice. Clinicians working tures and contribute to, or perpetuate, <?=KH;'$T1-weighted axial magnetic resonance
within an evidence-based practice frame- MNP.36,57 Recent studies support this no- imaging at the C5 segmental level in a patient
with chronic whiplash, illustrating signal intensity
work are still dependent on integrating tion by identifying specific changes in the
change (bright) throughout the cervical extensor
their individual clinical expertise with the physical structure, behavior, and function musculature, indicative of muscular degeneration
available evidence62 to comprehensively of the cervical muscles in patients with (fatty replacement). As can be observed, there
assess and train cervical muscles tailored MNP. is signal change present in the deep multifidus,
to the individual patient’s needs. It should semispinalis cervicis (orange arrow), and semispinalis
capitis bilaterally (white arrows).
be noted that it is beyond the scope of this 9^Wd][i_dF^oi_YWbIjhkYjkh[
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

commentary to comprehensively detail Radiological imaging studies have shown

assessment and training procedures of alterations in the physical structure of inflammatory responses to injury, with
the cervical motor system, and for this cervical muscles in patients with chron- subsequent demyelinated nerve tissue.10,12
the reader is directed elsewhere.36 ic MNP. Changes include widespread The mechanism of injury itself appears
atrophy, pseudo hypertrophy, and fatty to play a role in the observed changes in
CKI9B;:OI<KD9J?ED replacement of the cervical extensor some patients. For example, fatty replace-
?DC;9>7D?97BD;9A muscles.1,10,40 These changes are most ment of the cervical extensor muscles
:?IEH:;HI notable in the suboccipital and deep was observed in patients with whiplash-
multifidus muscles, possibly due to their associated disorders10 (<?=KH;') but was
Journal of Orthopaedic & Sports Physical Therapy®

high density of type I fibers and muscle not found in patients with MNP of an

T
he cervical spine is a region of
sophisticated motor function. The spindles,7 but also occur in the more su- insidious onset.12 The reported group
cervical muscles serve the sensory perficial layers such as the semispinalis differences in fatty changes of the cervi-
systems and support and orientate the capitis muscle.8,32 Additionally, biopsy cal extensors suggest that the findings
head in space relative to the thorax.36 studies have shown fiber type changes are unique to traumatic whiplash. How-
Further to this, the motor system of the in both the ventral and dorsal muscles ever, it is noteworthy that the subjects
cervical region complements other vital of the cervical spine in individuals with with whiplash in this study12 had much
functions such as respiration, phonation, longstanding neck pain that appear to higher levels of pain and disability when
and swallowing.48 The cervical vertebral be unique to type I slow-twitch fibers.73 compared to subjects with persistent in-
column is highly dependent on the active The mechanisms underlying these ob- sidious onset neck pain, which may also
support of muscles for physical support. served changes in muscle structure and explain the observed group differences.
Patients’ complaints of a “heavy head” their precise relationship to the func-
make sense when one considers that tional and physical impairments known 9^Wd][i_dCkiYb[8[^Wl_eh
buckling of a cervical vertebral column to characterize patients with traumatic Changes in the behavior of the cervi-
that is devoid of muscles occurs with neck disorders is not fully understood.10 cal muscles, as measured using electro-
loads of less than 20% to 25% the weight Nevertheless, there are some reasoned myography, are consistently observed in
of the head.58 Biomechanical models hypotheses. people with MNP. These changes indicate
suggest that control of buckling and un- It has been suggested that changes a reorganization of the motor strategy to
wanted rotary intersegmental motion, in cervical muscle structure in patients perform specific tasks. In contrast to the
which can result from the contraction with MNP may be related to many dif- consistent functional muscle synergies
of large multisegmental muscles during ferent factors, including but not limited that are present in pain-free individuals
daily tasks, is dependent on precise con- to (1) injury, (2) presence of pain, (3) gen- to generate multidirectional patterns of
trol of the deeper muscles.78 A deep sleeve eral disuse, (4) nerve pathology, and (5) force,6,74 neck pain is associated with dis-

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 325
 [ CLINICAL COMMENTARY ]
60 60 limb movements.13,24,51 Thus, heightened
activity of the superficial muscles appears
to be independent of the task, suggesting

Right SCM Normalized RMS (%)

Left SCM Normalized RMS (%)

* * * * * * * * that neck pain is associated with a loss of

40 40
* * * * * * * * * * * * * * * the well-defined preferred directions of
muscle action that are observed in indi-
viduals free of neck pain.6,74 Augmented
20 20 activity of the superficial neck muscles
may be compensatory for changed activa-
tion of the deep cervical muscles, which,
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0 0 on the contrary, show signs of inhibition

10 s 60 s 120 s Post 10 s 60 s 120 s Post
in neck pain,21 including a delay in the
speed of their activation when challenged
Condition Condition
by postural perturbations.18
Control Idiopathic Whiplash Experimental studies suggest that
the reorganization of functional muscle
synergies observed in patients with MNP
<?=KH;($Boxplots representing (25th quartile, mean, 75th quartile, and 95% confidence intervals) normalized
reflects a change in the neural strategy
root-mean-square (RMS) values for sternocleidomastoid (SCM) muscle bilaterally in patients with whiplash-
induced neck pain, idiopathic neck pain, and control subjects. Normalized RMS values are presented at specific
to permit motor and force output to be
time points (10, 60, and 120 seconds) during the performance of a 150-second repetitive unilateral upper-limb maintained in the presence of pain, by
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

task. In addition, RMS values are presented 10 seconds after completion of the repetitive upper-limb task (post). redistributing loads between synergists
Note the higher values of SCM EMG amplitude bilaterally for both patient groups and the reduced ability to relax and antagonist muscles specific to the
the SCM muscle postcontraction. *Significant differences between groups (P .05). Reprinted with permission
task performed.15,25 Although these adap-
from Falla et al.13
tations may seem to be optimal responses
to the painful condition for the motor
1.4 output to be maintained, the substantial
changes in activation of the cervical mus-
1.2
cles may have long-term consequences.
1.0 For instance, prolonged overactivity of
Journal of Orthopaedic & Sports Physical Therapy®

the superficial cervical muscles may have

0.8
deleterious effects on the properties of
SMD

0.6
the muscle fiber membrane, resulting in
greater muscle fatigability.14
0.4 There are numerous mechanisms that
may underlie the described changes in
0.2
muscle behavior. These include reflex-
0 mediated adaptation of motor neuron dis-
MVC 50% End 20% End 20% Acc charges to pain,22,65 alterations in cortical
excitability and changes in the descend-
<?=KH;)$Standardized mean differences (SMD) (error bars, 95% confidence intervals) between patients with
ing drive to muscles,44 changes in muscle
mechanical neck pain (MNP) and healthy controls, for 4 different craniocervical flexion performance variables: spindle sensitivity through sympathetic
maximal voluntary contraction (MVC), endurance at 50% of MVC (50% End), endurance at 20% MVC (20% End), activation,59 as well as other adverse ef-
and accuracy of sustained contraction at 20% MVC (20% Acc). The data illustrate that changes in muscle function fects of stress, fear, and anxiety.2,52
in MNP occur over a spectrum of performance variables compared to the control group (0 represents no group
differences).51
9^Wd][i_d<kdYj_ed
turbed neural control of the cervical mus- coactivation of the superficial cervical flex- The changes in structure (cross-sectional
cles. Changes in muscle behavior include or and extensor muscles during isometric area, fatty tissue, and fiber type) and be-
heightened activity of the superficial mus- contractions.23 The superficial cervical havior (timing and activation level) of
cles such as the sternocleidomastoid and flexor muscles also appear to be slower the cervical muscles have implications
anterior scalene muscles during cranio- to relax following movement or muscle for the muscles’ capacity to generate and
cervical flexion21,32 and upper-limb move- contraction,13 as does the upper trapezius sustain torque to the cervical spine and
ments13 (<?=KH;(), as well as heightened muscle in response to repetitive upper- head (<?=KH;)) with the necessary preci-

326 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 sion required for the intricate function of to generate and sustain force have been that are not available in most clinical
the region. For example, when compared shown to be a feature of these disorders. settings. Some clinical settings may have
to control populations, studies have Although research into cervical mus- access to dynamometry devices that can
shown that patients with MNP have de- cle dysfunction in MNP continues, suf- be utilized to detect changes in muscle
ficiencies in maximal strength,31,56,76 en- ficient evidence already exists to indicate maximal strength,31,56,76 endurance,16,56,76
durance,16,56,76 precision during dynamic that assessment of cervical muscle func- and precision56 of contraction that have
movement64 and sustained isometric tion should be routine in the clinical ex- been identified in both the cervical flexor
contractions,56 efficiency of contraction,16 amination of patients with MNP. and extensor muscle groups in patients
and repositioning acuity.41,71 Of particu- with MNP. Other clinical tests not re-
lar note, changes in the endurance,16,56 9B?D?97B7II;IIC;DJE< quiring dynamometry devices have been
Downloaded from www.jospt.org at University of Otago on September 7, 2014. For personal use only. No other uses without permission.

precision,56 and efficiency16 of cervical 9;HL?97BCKI9B;<KD9J?ED described to quantify aspects of perfor-

muscles to sustain torque have been mance27,36,45 of these muscle groups; how-
found at moderate and low intensities of ever, they do rely on the observational

T
he challenge for clinicians
contraction (20%-50% maximal), which assessing muscular deficits in the skill of the clinician to determine the
resemble the effort intensity commonly cervical region is the fact that me- point of test failure, perhaps lessening
used in many activities of daily living. Ad- chanical neck disorders are not homog- the objectivity of the measure. Within
ditionally, it is speculated that changed enous. MNP can manifest as motor the cervical flexor and extensor muscle
afferent input from neck muscles due to impairments in 1 or more directions of group, and based on the anatomical con-
pain or impaired neuromuscular control motion, may involve the neighboring figuration of the deep cervical muscles,
may influence gaze stability due to the re- thorax and shoulder girdle, and may there is also justification to assess the
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

flex interactions between visual input and potentially have a multitude of biologi- muscles of the craniocervical region sep-
afferent input from cervical structures,4 cal and psychological contributions.36 arately from the muscles of the typical
and may contribute to the disturbed oc- Additionally, the physical conditioning cervical region. Dynamometry methods
ulomotor control observed in people with requirements of patients presenting with have been used in research settings to
MNP.72,77 MNP are not homogenous. For example, measure the performance of these cran-
Functionally, these impairments could the strength and endurance demands on iocervical muscles56,76; however, the best
affect the patient’s ability to optimally cervical and axioscapular muscle function validated quantifiable measure of their
orientate the cervical column or to pro- in a storeman lifting heavy boxes repeti- performance available for clinical use
vide the support required of the motion tively above chest height will be different to date is the craniocervical flexion test,
Journal of Orthopaedic & Sports Physical Therapy®

segments during daily tasks involving to those required by a screen-based key- particularly in its capacity to assess deep
movement of the head and neck or up- board operator. A comprehensive initial cervical flexor muscle function.21,35
per limbs. It should be noted, however, patient interview is necessary to ascertain Caution should be taken in weight-
that potentially, individuals might re- the individual’s functional requirements ing too heavily quantitative measures of
main symptom free in the presence of and problematic activities to permit ap- cervical muscle strength and endurance.
the impairments if their functional de- propriate goal setting. They measure only one element of muscle
mands do not exceed the physiological In the physical assessment, clinicians performance, and there may be difficulty
capacity of their impaired cervical motor can utilize both quantitative and obser- in establishing criteria as to normal ver-
system. However, clinicians will be famil- vational clinical tests to detect changes in sus impaired performance, particularly
iar with the patient’s history suggestive cervical muscle function (eg, inability to due to the varied methods and technolo-
of symptom-free function until the com- generate and sustain force with accuracy), gies used, the spectrum of age ranges of
mencement of a new activity or increased which have been informed by research. patients seen in clinical practice, and the
intensity of a pre-existing activity. In such varied functional requirements of pa-
circumstances, it is likely that the de- GkWdj_jWj_l[7ii[iic[dj tients with respect to strength and endur-
mands required of the patient’s cervical Conventional methods to quantify ele- ance requirements.
muscle system exceeded its physiological ments of cervical muscle dysfunction
capacity. have focused on specific uniplanar cer- EXi[hlWj_edWb7ii[iic[dj
vical muscle groups and, in particular, Cervical muscle performance in terms
A[oFe_dji the flexor and extensor muscle groups. of its control in the orientation and mo-
Changes in physical structure and behav- Many of these research methods utilize tion of the head and cervical spine can
ior of the cervical muscles are evident in sophisticated techniques, such as electro- be assessed during the observation of
MNP disorders and, in accordance, defi- myography (muscle behavior)18,21,35 and functional activities, particularly those
cits in the capacity of the cervical muscles imaging (muscle physical structure),11,40 reported by the patient to be problem-

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 327
 [ CLINICAL COMMENTARY ]
atic for, or aggravating of, their disor- ioscapular function is addressed. Clini-
der. Commonly in patients with MNP, cal observations where patients report
these activities may involve prolonged that upper-limb activities aggravate their
sitting postures, movements towards MNP are common. In addition, patients
the extremes of range, such as cervical often demonstrate poor control of scapu-
extension, or repetitive, prolonged, or lar orientation and motion (considered
strenuous upper-limb activities. to be indicative of axioscapular muscle
The observation of dynamic postural dysfunction) during weight-bearing and
control (the patient’s ability to actively non–weight-bearing (<?=KH; *7) upper-
control spinal posture) of the cervi- limb tasks. Assisting the patient to cor-
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cal spine, although not usually directly rect scapular orientation (<?=KH;*8) and
quantifiable, is cornerstone in the clini- then observing the patient’s capacity to
cal assessment of cervical muscle func- replicate the corrected scapular posi-
tion. Much work is being performed to tion unassisted,49,50 as well as maintain
better understand and identify the role the corrected scapular position while the
of cervical muscle dysfunction in the upper-limb tasks (<?=KH;*7) are repeated,
control of spinal posture.19,69,70 Posture are helpful clinical tests of axioscapular
orientation of the cervicothoracic spine muscle function. As abnormal orienta-
will impact on the distribution of load tion of the scapula also appears to be
between anterior and posterior cervi- present in some healthy individuals with
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

cal vertebral elements.42 Studies inves- no history of neck pain, the relevance of
tigating prolonged sitting postures in any observed altered scapular orientation
patients with neck pain have shown the to a patient’s neck pain disorder needs to
angle of the cervical lordosis to change be established. Comparing the patient’s
in response to an increasing thoracic painful neck symptoms, painful cervical
kyphosis over time, changes that were <?=KH;*$Observation of scapula orientation movements, and palpable tenderness in
not observed in those without neck relative to the thorax during upper-limb tasks, such axioscapular muscles, immediately before
pain.19,69 Associated with these postural as (A) isometric shoulder abduction (resisted by the and after repositioning of the scapula, are
therapist’s hand), may be used to clinically assess
changes were altered activation of the helpful assessment strategies.36 Reposi-
the capacity of the axioscapular muscles to orientate
Journal of Orthopaedic & Sports Physical Therapy®

cervical extensor and upper trapezius the scapula under load. If the scapula appears poorly tioning of the scapula with the assistance
muscles.70 Although it is convenient to orientated, such as in A (eg, downwardly rotated, of strapping tape may permit any changes
infer cause and effect from these obser- protracted, and winging of the medial border [internal in symptoms suggestive of axioscapular
vations and MNP, scientific validation of rotation] and inferior angle [anterior tilt]), it can be involvement to be evaluated over a longer
repositioned with the assistance of the therapist (B),
a correlate between postural deviation after which the patient’s capacity to replicate the
period.
and neck pain remains inconclusive, corrected position unassisted can be assessed.
and the clinical assessment of posture A[oFe_dji
remains challenging.26,76,80 Nevertheless, in the assessment of neck disorders. Ab- No single test is conclusive or all en-
patients who report specific postures as errant axioscapular muscle function is of- compassing in the assessment of cervi-
an aggravating factor, who demonstrate ten observed in patients with MNP. Such cal muscle function. Clinicians rely on
poor cervicothoracic postural habit findings include disturbed axioscapular a battery of clinical tests, including both
when asked to mimic their aggravating muscle activity during repetitive upper- quantifiable and observational tests, to
activity, and in whom there is a lessening limb tasks13,51 and morphological and his- gain information concerning the patient’s
of symptoms with postural corrections tological changes in the upper trapezius cervical muscle function.
strategies, could be considered at least muscle.38,43 Due to their superior attach- The clinical assessment should de-
in part to have a postural component to ments, muscles such as levator scapulae termine if the patient’s disorder fits a
their disorder that usually requires a re- and upper trapezius have the capacity to pattern consistent with cervical muscle
training approach combining correction induce motion and abnormally load cer- dysfunction that may include aberrant
strategies at the cervical, thoracic, and vical motion segments in the presence of performance during dynamic postural
lumbar regions. 36 impaired axioscapular muscle function. 3 tasks, active movements of the cervi-
Shoulder girdle function and, in partic- From a clinical perspective, some indi- cal spine and shoulder girdle, and spe-
ular, scapular control during tasks of the viduals with MNP presentations appear cific performance tests of select muscle
upper limb are important considerations recalcitrant to improvement unless ax- groups.

328 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 ?CFB?97J?EDI<EHJ>;
JH7?D?D=E<9;HL?97B
CKI9B;<KD9J?ED

T
raining aimed at improving the
performance of the cervical muscles
is effective for the alleviation of pain
and improvement of disability and func-
tion associated with mechanical neck
disorders.28,39 The challenge for clinicians
Downloaded from www.jospt.org at University of Otago on September 7, 2014. For personal use only. No other uses without permission.

is to optimize the training of muscles to

best address the patient’s key functional
deficits. Appropriate progression of a pa-
<?=KH;+$Training of the deep lower cervical extensor
tient’s training program is dependent on muscles. The exercise can be performed in the
diligent monitoring of the patient’s re- positions of prone on elbows (as in this figure), 4-point
sponse to exercise in terms of change in kneeling, or sitting. The patient is instructed to let the
pain and disability, improvement in func- head and neck move into flexion, then to return to
the starting position to train the eccentric/concentric
tional activities, and change in motor per-
function of the cervical extensors. During the exercise,
formance. The patient’s response to tests the patient is encouraged to maintain a neutral
of cervical muscle function will change as craniocervical position, and, instead, the flexion/
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the stage and severity of the disorder im- extension motion is encouraged at the lower cervical
proves. The following section will address spine, facilitated in this figure by the therapist’s
fingers. Based on anatomical configurations of the
key questions regarding clinical manage-
extensor muscles, we propose that this maneuver
ment of cervical muscle dysfunction, to encourages training of the deep lower cervical
highlight the clinical reasoning process extensors while minimizing activity of the more
required to manage the diverse presen- superficial extensors such as the semispinalis capitis
tations of muscle dysfunction commonly muscles that attach to the occiput.
encountered in the clinical setting.
from a physical therapist, when correct-
Journal of Orthopaedic & Sports Physical Therapy®

M^WjI^ekbZ=k_Z[;n[hY_i[Fh[iYh_fj_ed ing an upright sitting posture, results in

\ehj^[CWdW][c[dje\D[YaFW_d5 better activation of key cervical postural
Exercise prescribed to train cervical muscles, such as the deep cervical flexor
muscle function is commonly directed muscles, as compared to a patient’s at-
towards individual muscle groups or to- tempt to sit in an upright posture with no <?=KH;,$Progression of exercise to train cervical
flexor muscle function. (A) Craniocervical flexion
wards the training of, or a component prior instruction.20 Patients are encour-
training with an emphasis on the coordinated action
of, a problematic functional activity, or aged to incorporate their postural cor- and low-load endurance of the deep and superficial
a combination of both. Regardless of the rection strategies into their daily sitting cervical flexor muscles. Correct performance and
approach, the focus underlying all exer- practices, making use of memory joggers progression of this exercise can be enhanced with
cise strategies is towards the restoration or reminders to encourage regular prac- the use of the Stabilizer pressure biofeedback
device. (B) A progression of flexor muscle training.
of the patient’s key functional deficits, tice and the acquisition of good postural
The head is gently lifted off, then lowered down
and this should be reflected in all exer- habit. Postural training may be enhanced to the supporting surface, while maintaining the
cise prescription. This function-oriented by the addition of specific exercises, as craniocervical region in mild flexion to train the
approach is meaningful to the patient indicated by the physical examination, to inner-range concentric and eccentric performance
and encourages patient compliance. For enhance training of key postural muscles of all cervical flexor muscles. This exercise should be
commenced carefully and within the capabilities of
example, in a patient with neck pain as- such as the deep lower cervical extensor
the patient, instructing them at first to only partially
sociated with prolonged sitting postures, muscles (<?=KH;+) and the deep craniocer- lift the weight of the head, progressing, as able, to
incorporating practice of sitting posture vical flexor muscles (<?=KH;,7), which are lifting the full weight of the head off the supporting
correction skills (ie, correction strate- important postural synergists, especially surface. (C) Training is progressed to an upright
gies at the lumbar, thoracic, cervical, in controlling forward head postures. position so that the outer range eccentric and
concentric performance of the flexors can be trained,
and shoulder girdle regions, as required) Specific training of more challenging
progressively training further towards the extreme of
should be included immediately. We have functional activities, such as extension range within the patient’s capability.
previously shown that specific instruction of the head and neck in an upright pos-

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 329
 [ CLINICAL COMMENTARY ]
ture, which requires an eccentric action M^Wj?dj[di_joe\JhW_d_d]?i8[ijje MVC) intensities, in which the superficial
of the cervical flexor muscles, is often too ?cfhel[j^[F[h\ehcWdY[e\9[hl_YWb muscles markedly increase their activity.54
challenging in the early stages of reha- CkiYb[i5 In accordance, training at lower intensi-
bilitation and may provoke pain. Instead, With respect to the intensity of training ties has been shown to translate to great-
specific training of the cervical flexor of individual muscle groups, more than 1 er changes in the coordination between
muscle group may need to be gradually mode of exercise has shown positive ben- the deep and superficial cervical muscles
progressed, at first incorporating coordi- efits in the management of painful neck compared to higher-load programs.33,55
nation training of the deep and superfi- disorders.30,37,61,79 Significant clinical ben- This is not to say that exercise at higher
cial cervical flexors and, subsequently, efits have been gained in studies utilizing load is not important. Patients whose
low-load endurance training of the deep either low-intensity training designed to lifestyle demands higher-level endurance
Downloaded from www.jospt.org at University of Otago on September 7, 2014. For personal use only. No other uses without permission.

cervical flexors (<?=KH; ,7).33,55 It may train the coordinated function between and strength conditioning of muscles will
progress, as able, to incorporate concen- deep and superficial muscles,37 as well require exercise to be progressed towards
tric and eccentric contraction of the cer- as exercise performed at higher loads these outcomes. Exercise programs utiliz-
vical flexors in their inner range, utilizing designed to improve muscle strength ing higher-load endurance and strength
the weight of the head (<?=KH;,8), then, and endurance.79 The fact that enough protocols have shown superior gains in
as able, progress to functional upright ex- patients experienced improvement with cervical muscle strength, endurance, and
tension to train eccentric performance of these different programs to gain an over- fatigability compared to low-load pro-
the flexors in their outer range of motion all group benefit in controlled trials sug- grams.17,55 The point is that higher-load
(<?=KH;,9). gests that both protocols are appropriate conditioning of muscles, when indicated,
Training may also need to be directed for the management of MNP. Perhaps a should be commenced as soon as possi-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

towards axioscapular muscle function, more salient point is that these different ble and done within the capabilities (and
particularly in patients who report activi- exercise approaches may represent differ- within symptom tolerance) of the patient,
ties of the upper limb to be problematic ent stages on a training continuum. Pa- and only when an acceptable baseline of
and have examination findings demon- tients may respond to different exercise control at low load has been achieved.
strating signs of poor active control of the protocols, depending on the stage of their
scapula. A priority is first given towards disorder and factors such as their level of >emIeed<ebbem_d]?d`khoI^ekbZ
the patient attaining active control of pain, disability, and muscle impairment. JhW_d_d]9ecc[dY[5
scapular orientation, facilitated by the For example, there is some preliminary There is sound support within the lit-
therapist (<?=KH;*8) and then practiced evidence that gentle low-load exercise erature that attention to muscle function
Journal of Orthopaedic & Sports Physical Therapy®

by the patient.49,50 Once correct orienta- produces a superior immediate hypoal- should be given early following injury.
tion of the scapula is acquired, training gesic effect than higher-load exercise.53,55 Impairment of cervical muscle func-
can then be progressed by challenging Accordingly, low-load exercise may be a tion occurs early following injury to the
the maintenance of the new scapular po- better approach to management in the neck,66 and experimental pain studies
sition under load, using weight-bearing initial stages of rehabilitation when pain suggest that pain has an immediate effect
and non–weight-bearing tasks of the up- is a key issue. on the behavior of muscles.15 It is, there-
per limb, consistent with the functional Apart from avoiding the aggravation fore, suggested that exercise to address
requirements of the patient. While ad- of symptoms, there appear to be other observed impairment of muscle function
ditional exercise may also be directed benefits of commencing exercise pro- be commenced early in rehabilitation and
towards training of specific axioscapular grams of specific cervical muscle groups in a pain-free manner.
muscles,29 we contend that maintaining at low load. Gentle low-load exercise has
the patient’s underlying focus towards the added benefit of permitting the pa- :e[i?jCWjj[h?\;n[hY_i[?iFW_d\kb5
orientation of the scapula facilitates the tient to train in a manner that facilitates It is logical that exercise that is provoca-
coordinated action of all axioscapular the coordinated action of the deep and tive of pain may be counterproductive,
muscles together, and this is needed to superficial cervical muscles,33,55 which, with the knowledge of the detrimental
control the multidirectional rotations and based on the evidence presented previ- effects that pain has on motor control.15
translations capable by the mobile scapu- ously, may be vital in patients with MNP. This is consistent with our clinical ob-
lae.47 Although much is yet to be explored It has previously been shown that exer- servations in patients for whom exercise
concerning axioscapular muscle function, cise at low load (20% maximal voluntary was commenced at too high a level, or
initial studies have suggested that even a contraction [MVC]) facilitates a more progressed too quickly. Provoking the
simple correction of scapular orientation selective activation of the deeper cervical patient’s symptoms with overzealous ex-
requires the coordinated action of all 3 muscles compared to exercise at mod- ercise could result not only in compliance
portions of the trapezius muscle.50 erate (50% MVC) and maximal (100% issues to an exercise program, but in fur-

330 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 ther alterations of cervical neuromuscular has also been shown to have immediate Headache. 1996;36:372-378.
3. Behrsin J, Maguire K. Levator scapulae action
control.15 In the initial stages of rehabili- pain-modulating effects53 that interest-
during shoulder movement: a possible mecha-
tation the dosage of exercise prescribed ingly differs to that observed for passive nism for shoulder pain of cervical origin. Aust J
should reflect a volume permitting stim- cervical manual therapy.75 Passive cervical Physiother. 1986;32:101-106.
ulus of muscle performance but remain- manual therapy has been shown to elicit 4. Bexander CS, Mellor R, Hodges PW. Effect of
gaze direction on neck muscle activity during
ing short of symptom reproduction. As immediate hypoalgesic responses both
cervical rotation. Exp Brain Res. 2005;167:422-
rehabilitation is progressed to a dosage local and remote to the cervical spine, as 432. http://dx.doi.org/10.1007/s00221-005-
reflecting higher-load strength and en- well as concurrent sympathetic nervous 0048-4
durance protocols,5 diligent monitoring system excitation suggestive of systemic  +$ Bird SP, Tarpenning KM, Marino FE. Designing
resistance training programmes to enhance
of patients symptoms is recommended to pain modulation.68,75 In contrast, specific muscular fitness: a review of the acute pro-
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ensure that any discomfort experienced cervical muscle training was shown to gramme variables. Sports Med. 2005;35:841-
during exercise associated with fatigue evoke a hypoalgesic response local to the 851.
is not sustained between sessions, which cervical spine only, that was not associat-  ,$ Blouin JS, Siegmund GP, Carpenter MG, Inglis
JT. Neural control of superficial and deep
may suggest accumulative and potentially ed with concurrent sympathetic nervous neck muscles in humans. J Neurophysiol.
injurious fatigue. system excitation.53 These differences in 2007;98:920-928. http://dx.doi.org/10.1152/
the pain-modulating properties of spe- jn.00183.2007
I^ekbZ;n[hY_i[8[F[h\ehc[Z_d cific cervical muscle training and passive 7. Boyd-Clark LC, Briggs CA, Galea MP. Muscle
spindle distribution, morphology, and density in
9ecX_dWj_edM_j^Ej^[h?dj[hl[dj_edi5 cervical manual therapy might in part longus colli and multifidus muscles of the cervi-
The strongest evidence of efficacy for the explain the complementary benefits of cal spine. Spine. 2002;27:694-701.
management of subacute and chronic these interventions when combined. 39 8. Cote P, Cassidy JD, Carroll L. The Saskatchewan
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

MNP from exercise is when it is per- Health and Back Pain Survey. The prevalence of
neck pain and related disability in Saskatchewan
formed in combination with manual 9ED9BKI?ED adults. Spine. 1998;23:1689-1698.
therapy techniques.28,39 Based on clinical 9. Cote P, Cassidy JD, Carroll LJ, Kristman V. The
observation, this would seem logical, as in annual incidence and course of neck pain in the

A
ssessment and training of cer-
general population: a population-based cohort
many patient presentations muscle func- vical muscle function is a funda-
study. Pain. 2004;112:267-273. http://dx.doi.
tion appears to be hindered by painful or mental component of informed org/10.1016/j.pain.2004.09.004
limited mobility of local tissues that seem clinical practice when managing MNP. 10. Elliott J, Jull G, Noteboom JT, Darnell R, Gal-
to be improved with the administration of Underpinning this approach is a mount- loway G, Gibbon WW. Fatty infiltration in
the cervical extensor muscles in persistent
appropriate manual therapy techniques. ing body of evidence that implicates
whiplash-associated disorders: a mag-
Journal of Orthopaedic & Sports Physical Therapy®

The combined exercise and manual ther- cervical muscle dysfunction as a feature netic resonance imaging analysis. Spine.
apy approach is also superior to results of MNP and demonstrates training of 2006;31:E847-855. http://dx.doi.org/10.1097/01.
found for manual therapy intervention cervical muscle function to be a ben- brs.0000240841.07050.34
11. Elliott J, Jull G, Noteboom JT, Galloway G. MRI
alone.28 It is logical that improvement in eficial intervention for the management
study of the cross-sectional area for the cervical
painful or limited mobility achieved with of patients with MNP. While research extensor musculature in patients with persistent
manual therapy techniques may be lon- progressively informs clinical practice, whiplash associated disorders (WAD). Man Ther.
ger lasting if combined with exercise to a clinician’s capacity to optimally assess 2008;13:258-265. http://dx.doi.org/10.1016/j.
math.2007.01.012
facilitate muscle function and mobility in and retrain cervical muscle function is 12. Elliott J, Sterling M, Noteboom JT, Darnell
the region. It would appear that exercise still largely dependent on astute clini- R, Galloway G, Jull G. Fatty infiltrate in the
and manual therapy are complementary cal skill and a research-informed reha- cervical extensor muscles is not a feature of
to each other, providing additive benefits bilitative program that is relevant to the chronic, insidious-onset neck pain. Clin Radiol.
2008;63:681-687. http://dx.doi.org/10.1016/j.
in terms of pain relief. Certainly, both ap- functional requirements of the individual crad.2007.11.011
pear to have pain-modulating properties patient. T 13. Falla D, Bilenkij G, Jull G. Patients with chronic
that may have some neurophysiological neck pain demonstrate altered patterns of
basis.53,75 Traditionally, improvement in muscle activation during performance of a func-
H;<;H;D9;I tional upper limb task. Spine. 2004;29:1436-
neck pain following muscle training was 1440.
considered to reflect enhancement of 14. Falla D, Farina D. Muscle fiber conduction veloc-
1. Andary MT, Hallgren RC, Greenman PE, Rechtien
physical support for the cervical vertebral ity of the upper trapezius muscle during dy-
JJ. Neurogenic atrophy of suboccipital muscles namic contraction of the upper limb in patients
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ance,79 fatigability,17 and proprioceptive 2. Bansevicius D, Sjaastad O. Cervicogenic head- '+$ Falla D, Farina D, Dahl MK, Graven-Nielsen T.
acuity34 of the cervical muscles and spine. ache: the influence of mental load on pain level Muscle pain induces task-dependent changes
and EMG of shoulder-neck and facial muscles. in cervical agonist/antagonist activity. J Appl
However, specific cervical muscle training

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 331
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Neurophysiol. 2004;91:1250-1259. http://dx.doi. )+$ Jull G, Kristjansson E, Dall’Alba P. Impairment in and subjects’ ability to learn the exercise. Man
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P. Gender-specific differences in electromyo- trapezius myalgia. Pain. 1998;78:191-196. +)$ O’Leary S, Falla D, Hodges PW, Jull G, Vicenzino
graphic changes and perceived pain induced 39. Kay TM, Gross A, Goldsmith C, Santaguida B. Specific therapeutic exercise of the neck
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Babat LB, Dvorak J. Critical load of the human ,-$ Sterling M, Jull G, Vicenzino B, Kenardy J,
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