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Introduction

Neck pain and disability is the third cause of disability worldwide across all age groups (1).

Like most chronic pain, it is multifaceted (2). Unless there is an obvious cause, such as an acute injury like a strain from movements, collisions in sports or car crashes, your neck pain and disability may be related to many things. Research indicates these could be factors such as endurance, flexibility, depression, anxiety, pain catastrophizing and social determinants, to name a few (2–4). While structural issues can also contribute, they do not always correlate to results found on X-rays, MRIs and CT scans (1).

As always, a good assessment is important! It is relevant to have a health professional help you understand what may be going on, especially if that cause of pain does not relate to a specific injury or cause. As discussed in our lower back workshop. We can filter what may contribute to our pain using the biopsychosocial framework.

The biopsychopsocial framework and pain

Biopsychosocial Framework

Biological
- Tissue (bone, muscle, skin, tendon, cartilage etc) has been hurt. It will follow healing timeframes. Most tissue will heal within 3 months. Symptoms of pain beyond this may be influenced the other factors below.
- If you have had a moderate to severe injury, which led to time off activity, it is important to do rehab. Without this, biological factors may contribute to ongoing symptoms after 3 months.
Psychological
- Thoughts, beliefs.
Social:
- Home, work, family, cultural.
Red flags
- Serious illness – very low percentage.

What is pain?

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Very necessary for survival
Pay attention to it with a fresh injury
Once tissue heals pain should and typically subsides
Chronic pain is pain that persists for longer than 3 months
How do I interpret pain? Use the below filter.

Pain filter (traffic light system) during activity, after or next day:
<3/10 – Green light – carry on with your activity
4-6/10 – Orange light – caution, change load, volume, speed, weight etc.
7+ - Red light – stop what you are doing and try again next week.

How do you feel pain?

• Pain is like a bad cake recipe. There are a bunch of ingredients. Sometimes an ingredient gets miscalculated, or the oven temperature isn’t right etc.

• Pain is the cake! The biopsychosocial components are the ingredients.

• Consider the homunculus man. This is the physical area in our brain where painful stimuli (nociception) comes to your brain. Our brain then filters the information and decides how threatening it is. The result/output is pain. The ‘bad cake’. Other ingredients can affect how we filter the information. These are the biopsychosocial components.

How do we change upper cervical flexion?

Starting with a flexor endurance test is a good choice. This will give you insight into the working capacity of the flexor muscles. If the test score is below the threshold then including the relevant exercises is reasnoble. Here is an article I put together that outlines endurance tests for the flexors, extensors and side flexors along with how to prescribe based on your test results.

Once you have established some flexor work, look to bring in some movement based exercises too. Here are a few from my YouTube channel. They are listed in order of easiest to hardest.

How do we change upper thoracic flexibility?

A regular restriction that I see in clinic is difficulty extending the upper back when looking upwards. Typically, I will see this with patients who have had trauma around the head, neck or shoulder. As with any musculoskeletal injury, this makes sense. When you injure an area, that region goes through a protective phase of bracing. As healing progresses, and the unpleasant sensations one experiences begin to lessen, we can encourage return to pre-injury ranges. So why does the upper back seem to consistently come up as a restricted area? There are a few potential reasons.

One may avoid unpleasant movements past regular healing timeframes. That is even after an area has healed, they may continue to avoid certain movements. Over time, one may lose that skill. Others may not return to the activity that led to the injury in the first place. We regularly see this in ACL injuries, where many don’t return to pre-injury levels. This might be a choice, or due to changing circumstances.

What would encourage the upper back to extend when looking up? Well, activities that require looking up! While upper cervical exercises are regularly taught and prescribed when rehabbing this area, it is also important to target the lower cervical flexors. The longus colli muscle attachments reach into the thoracic spine at the front (5)! If the lower longus colli are unable to lengthen, the upper back will struggle to fully extend.

So far, this particular exercise arrangement looks to be the most consistent, that I have found, for learning how to move here. Please share if you have alternatives!

Other benefits of this exercise include the cuing potential. External cuing is straight forward in that you can encourage visual cues and ensure these end up pushing the range a ‘bit more’ each session. External cuing is consistently better for learning or improving motor skills (6).

How to improve mid to lower cervical and thoracic extension:

This a medium to advanced level exercise which aims to strengthen the cervical and thoracic extensor muscles. It is the beginnings of building strength for a neck bridge. A neck bridge is an advanced neck and thoracic extension exercise which you see used in wrestling and grappling sports as a means to improve strength! While most won’t need to progress to a full neck bridge, the regression covered in this video is an excellent way to learn how to create tension from your head to your mid thoracic spine. This skill is useful for creating power when pushing and pulling with your arms. Additionally, it takes minimal equipment and home exercise programs that include strengthening exercises have been shown to be effective in reducing pain and disability in specific and non-specific neck pain populations (3). So it will apply to most people and is fairly straightforward to implement.

Personally, I find this movement extremely useful as a teaching tool. You get instant feedback from the ground, along with straightforward progression or regression options. I find patients learn faster with this movement over resistance exercises with bands or a cable machine. Not to say those exercises aren’t helpful. I just find this particular exercise as a better entry point for learning.

How do we work on upper cervical extension?

As per the head and cervical flexors, it is good to start with an endurance test. You can find this information here. Once established, look to improve your strength and comfort through the capable range of this region.

What about sideways or lateral neck strength?

As per previous recommendations above, test your lateral neck endurance as part of a comprehensive program. See here for instructions.

Lastly! Rotational strength.

Flexion based.

Extension based.

Conclusion

As always, stick to regular strengthen and conditioning principles, while blending the degree of irritability. If your neck is grumpy, less is more. Most start with 1x5 reps a couple times a week and progress weekly until they can do upwards of 3x10-15. Keep your symptoms <4/10 during and after performing the exercise.

References:

1. Fejer R, Kyvik KO, Hartvigsen J. The prevalence of neck pain in the world population: a systematic critical review of the literature. Eur Spine J. 2006 Jun;15(6):834–48.

2. Walton DM, Balsor B, Etruw E. Exploring the Causes of Neck Pain and Disability as Perceived by Those Who Experience the Condition: A Mixed-Methods Study. ISRN Rehabilitation. 2012 Nov 14;2012:1–7.

3. Zronek M, Sanker H, Newcomb J, Donaldson M. The influence of home exercise programs for patients with non-specific or specific neck pain: a systematic review of the literature. J Man Manip Ther. 2016 May;24(2):62–73.

4. Dimitriadis Z, Kapreli E, Strimpakos N, Oldham J. Do psychological states associate with pain and disability in chronic neck pain patients? Journal of Back and Musculoskeletal Rehabilitation. 2015 Jan 1;28(4):797–802.

5. Marieb EN, Hoehn K. Human Anatomy & Physiology. 9 edition. Boston: Pearson; 2012. 1264 p.

6. Wulf G. Attentional focus and motor learning: a review of 15 years. International Review of Sport and Exercise Psychology. 2013 Sep;6(1):77–104.

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How to train your neck strength