The Most Overlooked Cause of Neck Problems
Original blog: October 21, 2021
Problem: Deep Neck Flexor Weakness
The pervasive glow of screens and the demands of modern life are natural triggers for poor posture and painful neck dysfunction. Chiropractors often focus on the bony aspects of neck pain; however, experts suggest that approximately 80% of functional neck stability comes from the cervical muscles. (1)
While the proper function of all cervical muscles is necessary, multiple reviews have concluded that weakness of the deep neck flexors is profoundly connected to neck pain and headaches. (2-6)
The deep neck flexors include four muscles behind the trachea on the front of the cervical spine. The group consists of the longus colli, longus capitis, rectus capitis, and longus cervicis. Due to their proximity to the spine and short length, the deep cervical flexor muscles are primary stabilizers of the cervical spine.
This blog highlights the importance of these muscles. In less than 3 minutes, you’ll learn the specific recipe for identifying and resolving deep cervical flexor problems, including:
A simple cervical deep neck flexor test
The best exercises for deep neck flexors
Assessment: Cervical Deep Neck Flexor Endurance Test
The Deep neck flexor endurance test is a maneuver for assessing the suspect muscles. This chiropractic assessment starts with the patient in a supine, hook-lying position. The patient performs chin retraction and then actively lifts their head an inch off of the table. The clinician places their flat hand on the table below the patient’s occiput. If the patient’s head begins to lower or their anterior neck skin folds separate, they are reminded to “tuck your chin and hold your head up.”
The deep neck flexor endurance test is timed until the patient’s head touches the clinician’s hand. The deep neck flexor endurance test norms for men is about 40 seconds and 30 seconds for women. Those with neck pain average closer to 20 seconds. Low endurance suggests weakness of the deep neck flexor muscles with a predisposition to over-utilize the SCM, platysma, and hyoid- resulting in an upper crossed posture and neck pain. (7,8)
Treatment: Deep Neck Flexor Exercises
Strengthening the deep neck flexors can help improve neck posture, pain, and function. The Deep neck flexor strengthening exercise helps enhance neck stability. This exercise essentially asks the patient to practice the assessment described above.
While lying supine, the patient performs a "chin tuck" by retracting their head to create a double chin. The patient then lifts their head, bringing their chin toward their chest without lifting their shoulders- as though they are looking at their toes. The patient holds this position for 3-4 seconds, then lowers their head and repeats as directed for three sets of ten repetitions daily.
Outcomes: Exercise & Manual Therapy
Multiple recent studies have concluded that deep neck flexor exercises improve posture, reduce pain, and lower disability. (9-14) Several studies have concluded that deep cervical flexor endurance training is more potent than conventional manual therapy (PT) for patients with neck pain and headaches. (11,12)
“Compared with manual therapy, deep cervical flexor muscle strength training showed a greater reduction in pain intensity [in 80 cervicogenic headache patients]. (12)”
*Note: Manual therapy included oscillatory mobilization performed by a licensed physical therapist.
Outcomes: Exercise & Manipulation
One recent trial of chronic neck pain patients compared the utility of deep neck flexor strengthening vs. manual therapy (upper thoracic manipulation and upper cervical mobilization) and concluded:
“There are no differences between groups in short and medium terms. Manual therapy achieves a faster reduction in pain perception than therapeutic exercise. Therapeutic exercise reduces disability faster than manual therapy. (14)”
The authors concluded that manipulation provides faster pain relief when used in isolation, while exercises targeting the deep flexor muscles of the neck enhance function more expediently.
Fortunately, evidence-based chiropractors are not limited to a single tool. Effectively managing spinal problems requires a comprehensive strategy that typically includes manipulation combined with the most appropriate chiropractic exercise protocol.
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1. Panjabi MM, Cholewicki J, Nibu K, Grauer J, Babat LB, Dvorak J. Critical load of the human cervical spine: an in vitro experimental study. Clinical biomechanics. 1998 Jan 1;13(1):11-7. Link
2. Amiri-Arimi S, Bandpei MA, Rezasoltani A, Javanshir K, Biglarian A. Asymmetry of Cervical Multifidus and Longus Colli Muscles Size in Participants With and Without Cervical Radicular Pain. Journal of Manipulative and Physiological Therapeutics. 2020 Mar 1;43(3):206-11. Link
3. Page P., Frank C.C., Lardner R., Assessment and treatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics.
4. Falla DL, Jull GA, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine. 2004 Oct 1;29(19):2108-14. Link
5. Abaspour O, Akbari M. Relationship between echogenicity of deep cervical muscles and pain laterality in subjects suffering from cervicogenic headache. CRANIO®. 2021 Jan 7:1-8. Link
6. O’Leary S, Hoogma C, Solberg ØM, Sundberg S, Pedler A, Van Wyk L. Comparative Strength and Endurance Parameters of the Craniocervical and Cervicothoracic Extensors and Flexors in Females With and Without Idiopathic Neck Pain. Journal of applied biomechanics. 2019 Jun 1;35(3):209-15. Link
7. 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 1;3(2):105-10. Link
8. Harris KD, Heer DM, Roy TC, Santos DM, Whitman JM, Wainner RS. Reliability of a measurement of neck flexor muscle endurance. Physical therapy. 2005 Dec 1;85(12):1349-55. Link
9. Alghadir AH, Iqbal ZA. Effect of Deep Cervical Flexor Muscle Training Using Pressure Biofeedback on Pain and Forward Head Posture in School Teachers with Neck Pain: An Observational Study. BioMed Research International. 2021 May 22;2021. Link
10. 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. Journal of pain research. 2019 Mar 7:915-25. Link
11. Gumuscu BH, Kisa EP, Kaya BK, Muammer R. Comparison of three different exercise trainings in patients with chronic neck pain: a randomized controlled study. The Korean journal of pain. 2023 Apr 1;36(2):242-52. Link
12. Hasan S, Bharti N, Alghadir AH, Iqbal A, Shahzad N, Ibrahim AR. The Efficacy of Manual Therapy and Pressure Biofeedback-Guided Deep Cervical Flexor Muscle Strength Training on Pain and Functional Limitations in Individuals with Cervicogenic Headaches: A Randomized Comparative Study. Pain Research and Management. 2023 Aug 14;2023. Link
13. Tsiringakis G, Dimitriadis Z, Triantafylloy E, McLean S. Motor control training of deep neck flexors with pressure biofeedback improves pain and disability in patients with neck pain: a systematic review and meta-analysis. Musculoskeletal Science and Practice. 2020 Dec 1;50:102220. Link
14. Bernal-Utrera C, Gonzalez-Gerez JJ, Anarte-Lazo E, Rodriguez-Blanco C. Manual therapy versus therapeutic exercise in non-specific chronic neck pain: a randomized controlled trial. Trials. 2020 Dec;21(1):1-0. Link
