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166
American Journal of Lifestyle Medicine
Mar • Apr 2010
The Infl uence of Education and
Exercise on Neck Pain
William J. Hanney, PT, DPT, ATC, CSCS,
Morey J. Kolber, PT, PhD, OCS, Cert MDT, CSCS,
Judi Schack-Dugre’, PT, DPT, MBA,
Rodney Negrete, PT, CSCS,
and Patrick Pabian, PT, DPT, OCS, CSCS
DOI: 10.1177/1559827609351134. Manuscript received February 4, 2009; revised April 7, 2009; accepted April 8, 2009. From the Department of Health Professions,
University of Central Florida, Orlando (WJH, JS-D, PP); Department of Physical Therapy, Nova Southeastern University, Ft Lauderdale, Florida (MJK); and Florida Hospital
Celebration Health, Celebration, Florida (RN). Address correspondence to William J. Hanney, PT, DPT, ATC, CSCS, University of Central Florida, Department of Health
Professions, 4000 Central Florida Blvd, HPA—1 Room 262, Orlando, FL 32816-2205; e-mail: whanney@mail.ucf.edu.
For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2010 The Author(s)
Abstract: Neck pain is a significant
contributor to worldwide disability and
poses a considerable financial bur-
den to its stakeholders. The prognosis
for chronic neck pain is generally poor,
and the associated disability seems to
be more persistent than low back pain.
It has been suggested that the goals of
a rehabilitation program are to max-
imize return to function, limit pro-
gression of degenerative changes, and
prevent further injury. The variety of
treatment options can make it difficult
for clinicians to agree on the most effec-
tive treatment intervention. This article
reviews noninvasive treatment consid-
erations for patients with neck pain.
Exercise-based interventions, includ-
ing aerobic conditioning, stretch-
ing, and strengthening, are addressed.
Moreover, concepts related to education
are covered, including the effects of
posture and ergonomic counseling.
Keywords: neck pain; disability; reha-
bilitation; treatment
N
eck pain is a significant contribu-
tor to worldwide disability.
1-3
Up to
70% of the population will expe-
rience an episode of neck pain at some
point in their lives,
1
and 15% of the popu-
lation will experience chronic neck pain.
4
Neck pain also poses a significant finan-
cial burden to its stakeholders, including
expenses related to the diagnostic process,
treatment costs, sick leave from work, and
premature retirement pensions.
5
The prog-
nosis for chronic neck pain is generally
poor, and the associated disability incurred
due to chronic neck pain seems to be
more persistent than low back pain.
6
It has been suggested that the goals
of a rehabilitation program are to max-
evidence to support various methods of
direct neck stretching and strengthening
for chronic neck disorders.
8
Although
supportive literature is limited, expert
experience suggests that addressing
impairments related to postural and
ergonomic conditions is of benefit.
9
The
variety of treatment options can make
it difficult for clinicians to agree on the
most effective treatment intervention.
This article reviews noninvasive treat-
ment considerations for patients with
The interactions of pain, reduced activity
level, and emotion/stress all play a role
in the chronic pain process.
imize return to function, limit pro-
gression of degenerative changes,
and prevent further injury.
7
A sys-
tematic review illustrates multimodal
approaches to treating neck pain.
8
These approaches suggest that the
inclusion of stretching and strengthen-
ing exercises for subacute and chronic
mechanical neck disorders results in a
favorable response.
8
Another system-
atic review also demonstrated moderate
neck pain. Exercise-based interventions,
including aerobic conditioning, stretch-
ing, and strengthening, are addressed.
Moreover, concepts related to educa-
tion are covered, including the effects
of posture and ergonomic counseling.
This review of the literature also intends
to familiarize the reader with com-
mon impairments associated with each
of these interventions and the reported
effects of treatment.
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American Journal of Lifestyle Medicinevol. 4 • no. 2
167
Postural and Ergonomic
Education
It has been proposed that ergonomic
and postural education is an integral part
of treating those patients with neck pain
likely to benefit from an exercise and
conditioning regimen.
9,10
Rempel et al
11
demonstrated decreased neck and shoul-
der pain in sewing machine operators
when improved postural support was
provided. It was also found that provid-
ing ergonomic training and altering work-
stations reduced neck/shoulder pain for
those working on computers in a call
center.
12
Others do not support these
interventions. Grooten et al
13
report
that ergonomic interventions seem
to be ineffective for decreasing neck/
shoulder pain-related disability.
13
Systematic reviews are also not favor-
able for postural and ergonomic instruc-
tion. One literature review reported that
these types of educational interventions
have not been shown to be beneficial in
reducing pain associated with mechan-
ical neck disorders.
14
Some suggest that
poor results of given trials on ergonomics
may be due to single rather than multi-
modal programs.
15
Many studies involving
posture and ergonomic instruction do not
include other interventions. Therefore,
interventions such as ergonomic or pos-
tural instruction alone may not demon-
strate significant effectiveness because
of limitations in the external validity of
study design. These interventions in con-
junction with others, however, may be
valuable. Also, studies involving pos-
ture and ergonomic instruction gener-
ally include a heterogeneous sample.
Homogeneous subgroups may demon-
strate greater success.
Postural and Ergonomic
Impairments
It has been suggested that prolonged
postural malalignment may contribute to
dysfunction.
16
Alterations in skeletal align-
ment during interactions with the envi-
ronment may contribute to imbalances
between muscular agonists and antago-
nists, facilitating abnormal musculoskele-
tal changes.
17-19
These muscle imbalances
may lead to chronic strain, resulting in
pain and dysfunction.
19
An understanding
of how postural and ergonomic impair-
ments contribute to neck pain is nec-
essary to understand the mechanism
by which these dysfunctions persist.
By understanding the mechanical dys-
function within these patients, one can
understand the common impairments
associated with neck pain.
There are a variety of postural devi-
ations.
16
Postural dysfunction is often
referred to in the context of a forward
head position (FHP). One type of FHP is
demonstrated with the head resting well
in front of the vertical gravity line.
20-22
A second type of FHP occurs when the
chin leads and the head is angled slightly
upward, tilted caudally, while still being
within or slightly anterior to the verti-
cal gravity line.
23
Posture has been recog-
nized as a possible contributor to head
and neck pain.
11,24
Neck pain associated
with posture is generally due to static
loading positions.
25
This head position is
thought to increase the load on cervical
structures, which results in pain.
26,27
Poor
posture may also increase compressive
loading of the cervical spine, which is a
result of weight transfer from the upper
extremity through cervicoscapular muscle
attachments.
28
Griegel-Morris et al
29
reported
that those with severe postural abnor-
malities had a significantly increased
incidence of cervical, interscapular, and
headache pain.
29
Braun
20
demonstrated
that symptomatic women demonstrated
more rounded shoulders.
Although postural deviations can lead
to static loading positions, there may
also be influences on muscular func-
tion. The endurance capacity of the short
neck flexors is contributory to mainte-
nance of head posture.
30
It was found
that forward head posture is associated
with weak neck flexor muscles.
29
Also,
patients with neck pain demonstrated a
decreased ability to maintain an upright
posture when cognitively distracted.
31
Cagnie et al
32
found neck pain associated
with prolonged forward head posture, sit-
ting for an extended period of time, and
making repetitive cervical movements.
Some have found that suboccipital exten-
sion specifically may contribute to cervi-
cogenic headaches.
33
Rocabado
34
revealed
that habitual poor posture in a suboccip-
ital extended position can be a source of
posterior headaches. Also, smaller cran-
iovertebral angles are associated with a
high incidence of neck pain.
35
Many factors contribute to pain in the
upper quarter. Many of the contribu-
tors may be postural in nature, but there
is also a significant influence on how
individuals interact with their environ-
ment. Numerous ergonomic factors may
be a potential source of dysfunction and
pain. Marcus et al
36
reported that an opti-
mal desk height, armrests, and relaxed
neck postures are prognostic factors for
neck/shoulder symptoms and disorders.
Shikdar and Al-Kindi
37
reported that ergo-
nomic deficiencies are common in office
computer workstation design. Also, those
individuals who use notebook computers
tend to have a more flexed static posture
when compared to desktop computer
users, who generally have a more upright
posture and perform more neck move-
ments.
38
Wong et al
39
demonstrated that
certain ergonomic changes such as alter-
ations in chair back inclination influence
cervical repositioning errors in the sag-
ittal plan. Others found that ergonomic
changes decrease electromyographic
(EMG) activity of the upper trapezius and
pain in the shoulder and neck.
40
These
examples illustrate how the environment
influences performance of specific tasks.
The duration of static work postures also
influences symptoms. Kamwendo et al
41
reported that working with office machines
5 or more hours per day is associated with
a significantly increased risk for neck pain.
Mechanistic considerations of the environ-
ment also influence neck pain. Persons
who routinely use hand-transmitted vibra-
tion devices such as power tools are more
likely to complain of hand/wrist and neck
pain.
42
Also, men who report daily vibra-
tion exposure with a duration more than 1
hour have an increased risk of neck pain.
43
Alipour et al
44
found that risk indicators
for men include duration of employment,
high visual demands, repetitive work, sit-
ting position at work, awkward working
position, no regular exercise, monotonous
work, lack of encouraging organizational
culture, and anxiety concerning change.
Additional risk factors for women include
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American Journal of Lifestyle Medicine Mar • Apr 2010
repetitive work, sitting position at work,
and no support if there is work-related
problems.
44
It can be determined that a
wide variety of ergonomic factors can influ-
ence neck pain. The results of an investi-
gation by Krause et al
45
support the belief
that there is a causal role of physical work-
load and the development of back and
neck pain.
Effects of Postural and
Ergonomic Training
The effects of postural and ergonomic
interventions have generally been mixed.
Although many possible interventions
could be classified as postural and ergo-
nomic instruction, this review focuses on
the key components of patient education,
postural instruction, work environment,
and physical workload.
Patient/client education in one form or
another is a ubiquitous component of
treatment used by many physical ther-
apists. Research generally supports this
type of intervention, particularly as it
relates to neck pain. Brison et al
46
demon-
strated that postural education decreases
the severity of symptoms in patients
with whiplash-related disorders. A ran-
domized controlled trial showed that
a comprehensive ergonomic program
including education is significantly asso-
ciated with reduced discomfort scores in
the neck/shoulder.
47
Furthermore, Rempel
et al
12
demonstrated that providing ergo-
nomic training and altering workstations
reduce neck/shoulder pain for individu-
als working on computers in a call cen-
ter. Consistent with these and most other
studies, patient education is only one
component of a comprehensive treatment
regime. Therefore, it is difficult to differ-
entiate education as an independent vari-
able and its direct influence on neck pain.
Postural instruction can also have a
positive influence on neck pain. It has
been demonstrated that skilled pos-
tural instruction and facilitation results
in greater activation of the deep cervi-
cal flexor group and lumbar multifidus.
31
This suggests that training for proper pos-
ture is a dynamic process. Furthermore,
outcomes are enhanced when more than
verbal instruction is provided. These find-
ings are supported by a review that sug-
gests that ergonomic changes can be
made, which demonstrate a positive
influence on posture and pain.
48
Readjusting the workspace can also
help influence neck pain. Rempel et al
11
demonstrated that improved postural
support decreased neck and shoulder
pain in sewing machine operators. Also,
a randomized controlled trial showed that
a comprehensive ergonomics program
including workstation changes was signif-
icantly associated with reduced discom-
fort scores in the neck/shoulder.
47
Lintula
et al
49
demonstrated that using two arm
supports instead of one decreased upper
trapezius activity and subjective discom-
fort. Interestingly, a significant reduc-
tion in shoulder and neck pain was also
reported after new lighting systems were
installed, workplaces were adjusted, and
optometric corrections were performed.
50
This illustrates the diverse type of inter-
ventions available for consideration
when adjusting the workspace environ-
ment. Although there are many different
ways by which one’s workspace could be
adjusted, each individual situation must
be thoroughly analyzed and changes
must be individually specific.
Adaptations of the actual physical work-
load may be necessary. Interventions
such as biofeedback demonstrated favor-
able outcomes in female computer work-
ers reporting neck-shoulder pain.
51
Another
study demonstrated that taking regular
breaks revealed a decrease in the upper
trapezius activity and subjective discom-
fort.
52
Altering positions can also influence
pain levels. Keir et al
53
showed that alter-
nating positions and tasks with use of a
computer mouse may avoid excessive pres-
sure within the carpal tunnel. Kamwendo
et al
54
reported small correlations between
perceived fatigue, pain, and well-being
with the number of transitions from sit-
ting to standing and time spent typing. This
suggests factors that contribute to neck
pain can be somewhat individual. Another
study found that frequent breaks did
improve symptoms. van den Heuvel et al
52
found that computer software prompting
computer users to take regular breaks con-
tributes to perceived recovery from neck
or upper limb complaints. Others demon-
strated reduced EMG activity when operat-
ing an ergonomic microscope workstation
versus a standard microscope.
55
Aerobic Conditioning
and Physical Activity
Conditioning and physical activity are
components of a fitness program and
described as the ability to perform phys-
ical work.
56
This type of training gener-
ally includes repetitive dynamic activities
that incorporate large muscle groups.
56,57
Examples may consist of walking,
cycling, swimming, or upper body
ergometry. Physical activity has been
shown to reduce the risk of premature
mortality, improve functional capacity,
and help older adults maintain indepen-
dence.
58
Furthermore, aerobic condi-
tioning and physical activity have been
proposed to benefit certain patients with
neck pain.
9
Studies also suggest influ-
ences of exercise on maintenance of
proper posture. An exercise program that
targeted craniocervical flexor (deep neck
flexor) muscles in patients with neck
pain demonstrated an improved ability to
maintain a neutral cervical posture during
prolonged sitting.
59
Impairments Related to
Lack of Aerobic Conditioning
and Physical Activity
Many factors contribute to impairments
associated with conditioning and physical
activity. Fitness levels can be described
as ranging from poor to superior based
on energy expenditure during physical
work.
60
Cardiovascular fitness and fear of
injury or movement have been identified
as impairments that have been related to
a lack of conditioning.
61
There are few studies that correlate neck
pain with fitness level. There is, however,
considerable information available regard-
ing the role that low back pain has on fit-
ness. Common physical characteristics
are shared by patients with neck and low
back pain.
62
An individual’s fitness level
seems to be influenced by the presence of
low back pain.
63
Patients who experience
low back pain typically have a decreased
level of physical activity.
63
Raven et al
64
found a decrease in max O
2
uptake in
patients with low back pain. Factors that
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169
influence oxygen consumption include
age, gender, heredity, inactivity, and dis-
ease.
56
Smeets et al
65
found that patients
with chronic low back pain seem to have
a reduced aerobic fitness level compared
with the normal population. Furthermore,
neck pain specifically has been associated
with cardiovascular disorders.
2
Injury can often cause increased lev-
els of concern or fear about movement.
These concerns in excess can contrib-
ute to higher levels of disability. Verbunt
et al
66
found that fear of injury is more
strongly associated with perceived dis-
ability than with aerobic fitness. Also,
patients with low physical activity had
significantly higher scores in fear avoid-
ance beliefs and pain catastrophizing.
67
Therefore, some feel that a perceived
decline in physical activity is important to
assess when evaluating low back disabil-
ity.
68
Ultimately, fear avoidance behaviors
may lead to a decrease in activity, per-
petuating increased disability in patients
with low back or neck pain.
62
Effects of an Aerobic
Conditioning and Physical
Activity Program
A conditioning program can have pro-
found physiological effects. Although
there is limited research regarding the
influence of aerobic exercise on neck
pain, much support exists for the influ-
ence on low back pain. The interactions
of pain, reduced activity level, and
emotion/stress all play a role in the
chronic pain process.
69
Unfortunately, individuals with chronic
pain often present with depressed mood
states.
70
Several factors related to pain can
be influenced by exercise. Participating
in some type of exercise program seems
to have beneficial effects. Low to moder-
ate aerobic exercise improves mood states
and work status in patients with low back
pain.
71
Shepanski et al
72
found that individ-
uals participating in habitual exercises dem-
onstrated higher mood disturbance scores
compared to nonexercisers. Furthermore,
a narrative review illustrated strong sup-
port of acute mood benefits after exercise.
73
Although participation in an exercise pro-
gram seems to influence pain, other fac-
tors from an exercise program may also
have a positive effect. Some have stud-
ied the influence of exercise intensity on
mood. Thayer
74
found that short periods
of exercise at higher intensities offer mood
benefits. Moderate-intensity physical activ-
ity generally seems to positively influence
mood.
75
Yeung
73
concluded that extremely
high or very low training intensities do
not appear to optimally improve mood.
Markoff et al
76
found that long periods
of exercise at lower intensities also pro-
vide benefit. It seems that the intensity and
duration are closely associated with influ-
encing mood state. Regardless of the level
of intensity or duration, the effects of
exercise-induced mood enhancement can
last up to 24 hours.
77,78
Exercise can alter one’s perception of
pain.
79
Janal et al
80
reported a reduction
in nociception after exercise. Another
investigation found decreased pain per-
ceptions after a 1-mile run.
81
One inves-
tigation reported the pain threshold to
be significantly higher along with signif-
icantly lower pain ratings immediately
after exercise.
82
One review illustrated
acute reduction of pain after aerobic
exercise.
69
Some authors have suggested
that a certain level of exercise intensity
is required to increase pain tolerance.
Intensities as low as 50% maximal aerobic
capacity were not enough to show sta-
tistically significant changes in pain per-
ception.
83
Kemppainen et al
84
suggested
that intensities exceeding 70% max aero-
bic capacity are required to increase pain
thresholds. Another study also indicated
that higher levels of intensity are required
to alter pain tolerance. Hoffman et al
83
found that exercise for 30 minutes at 75%
maximal aerobic capacity was enough to
demonstrate exercise-induced analgesia
to a pressure pain stimulus. Furthermore,
individuals who exercise regularly have
higher pain tolerances than sedentary
nonexercisers.
85
Although levels of exercise intensity
required to alter pain tolerance may vary,
some researchers have studied how long
pain tolerance is altered after activity. Some
have found that exercise-induced analge-
sia is present for at least 30 minutes after
a bout of exercise.
84,86
Others have found
that exercise-induced analgesia is present
for as long as 50 minutes after exercise.
87
The effects of exercise-induced analgesia
in patients with low back pain have been
investigated. Hoffman et al
88
found that
those with chronic low back pain and
minimum to moderate disability dem-
onstrated exercise-induced analgesia to
pressure pain testing for over 30 minutes
after 20 minutes of aerobic exercise at
70% peak oxygen update. The effects of
aerobic exercise on mood and pain per-
ception are well documented in a popu-
lation with low back pain. However, to
our knowledge, these effects have not
been studied in patients with neck pain.
There are many benefits to implement-
ing a program of aerobic conditioning
and physical activity. Conditioning activ-
ities improve performance and allow the
same amount of work to be performed
at a lower physiological cost.
56,60
Regular
exercise has demonstrated health benefits
for various psychological conditions.
89,90
Furthermore, aerobic work improves
vigor while decreasing fatigue, tension,
and depression.
79
A multifactorial con-
ditioning program that included aerobic
conditioning was effective in reducing
the number of sick days for some work-
ers with chronic back pain.
91
Also, phys-
ical conditioning programs that included
a cognitive behavioral approach demon-
strated a reduction in the number of sick
days in patients with chronic back pain.
92
Lundblad et al
93
used general condition-
ing in addition to interventions focused
on proper movement for female work-
ers with neck and shoulder symptoms
who demonstrated decreased complaints
on neck and shoulder disability. Takala
et al
94
demonstrated improvement using
general conditioning with group gym-
nastics at the workplace to help with
neck pain. Although little research has
been performed on the effects of con-
ditioning on neck pain, this has been
studied extensively for low back pain.
Chatzitheodorou et al
95
found that high-
intensity aerobic exercise alleviated pain,
disability, and psychological strain in
people with chronic low back pain.
Some studies suggest that it is not nec-
essary to perform regimented condi-
tioning activities at a specific intensity.
Hildebrandt et al
96
found simply increas-
ing leisure-time physical activity may
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American Journal of Lifestyle Medicine Mar • Apr 2010
decrease musculoskeletal pain, particu-
larly in sedentary workers. Bernaards
et al
97
demonstrated that a change in life-
style and inclusion of physical activ-
ity decreased neck pain. Other lifestyle
modifications that complement a general
increase in physical activity have been
demonstrated to be effective. Mattila
et al
98
found that lifestyle interventions
to control hypertension had a favorable
effect on perceived disability of neck
pain. Also, people with an active lifestyle,
including participation in sporting events
during leisure time, reported fewer symp-
toms related to neck and upper limb
symptoms.
99
Myofascial Stretching
Myofascial stretching has been recom-
mended for patients with neck pain who
are likely to benefit from a program of
conditioning and exercise tolerance.
9,28
Stretching can be used for a variety of
purposes. DeVries
100,101
recommended
stretching as a method to reduce mus-
cle soreness following activity. Stretching
has also been recommended to prevent
injury.
102,103
Some authors have raised
questions regarding the effectiveness of
stretching in the prevention of injury.
104
Muscle Length Impairments
Implicated in Patients
With Neck Pain
Length-associated changes in mus-
cle are a problem commonly treated by
physical therapists.
105
Dysfunction can be
caused by immobilization, muscle imbal-
ance, postural malalignment, or a com-
bination of these mechanisms.
105
Muscles
affected by improper alignment can
lead to specific alterations, which influ-
ence overall posture.
16
Gossman et al
105
described muscle length impairments
as having stretch weakness or tightness.
Stretch weakness is the effect on muscles
in an elongated position beyond neu-
tral that inhibits the ability of the muscles
to contract.
105
Shortness or tightness is
described as a decrease in muscle length
with limited movement in the direction
of elongation.
105
Both of these conditions
are of particular concern with regard to
development of a rehabilitation program.
In the context of myofascial stretching,
adaptive shortening becomes a particular
concern. A muscle fixed in a shortened
position can cause a decrease of up to
40% in the number of sarcomeres.
106
Also,
the amount of passive and active tension
created by a shortened muscle is less
than that compared to controls.
106,107
This
tension produced by shortened muscle
can lead to misinterpretations of muscle
strength testing when evaluating patients.
Shortened muscles might test strong
because of testing in their optimal short-
ened position.
105
In contrast, shortened
muscles that are tight may also be weak-
ened. This weakness limits their ability to
produce force and ultimately provide sta-
bility and mobility.
Muscle is extremely prone to struc-
tural change with either lengthening or
shortening.
105
Clinically, specific mus-
cles are often stretched in a rehabilitation
program. McDonnell et al
28
published a
case report that included select muscle
lengthening, including that of the pecto-
ralis minor, pectoralis major, and poste-
rior cervical muscles, to improve posture
and decrease cervicogenic complaints.
Another study chose to perform stretches
for the upper trapezius, scalenes, and
posterior cervical musculature.
108
The
tendency for muscles to develop tight-
ness is generally not random, and typi-
cal muscle imbalance patterns have been
described.
109
The cross-shoulder syn-
drome is a model describing the clinical
presentation of some muscles that have
a tendency to become tight.
109
The mus-
cles in the upper quarter, which gener-
ally become tight more often, are the
pectoralis major, pectoralis minor, upper
trapezius, levator scapulae, sternocleido-
mastoid, and suboccipital muscles.
109
Effects of Myofascial Stretching
There is a mechanical and neurophys-
iological premise for myofascial length-
ening. Although it is not clear which
stretching technique is most beneficial, it
is clear that stretching in any context will
improve muscle length. There are several
considerations when observing a mus-
cle’s response to a given stretch. The rate
of stretch is important when applying a
stretch. Greater peak tension and energy
absorption occur at faster stretch rates,
suggesting increased risk of injury with
increased stretch rate.
110
Noncontractile
structures around muscle also affect a
muscle’s response to stretch and immobi-
lization.
111
Age influences tissue response
to stretch. As a person ages, the rate
of adaptation to stress slows, and max-
imum tensile strength and elastic rate
decrease.
112
Several studies have looked at the
effects of myofascial stretching on cer-
vicogenic pain. Tsauo et al
113
reported a
reduction in neck and shoulder symp-
toms in sedentary workers through
the use of an intensive group exercise
stretching program. A systematic review
by Gross et al
8
found moderate evi-
dence of long-term benefit for improved
function favoring direct neck strength-
ening and stretching for mechanical
neck pain. Although stretching exer-
cises alone have demonstrated an ability
to decrease neck pain,
108
other studies
suggest a combination of strength train-
ing and stretching exercises for chronic
neck pain.
114,115
Although these stud-
ies used a variety of treatment options,
including muscle endurance training,
stretching was a component of treatment
that demonstrated the most significant
improvement
114,115
Muscular Performance
Muscle performance describes the
manner in which muscles function and
includes components of strength, endur-
ance, and motor control. Muscular
strength is defined as the maximal abil-
ity of a muscle to contract and generate
force.
57,116
Muscular endurance is the abil-
ity of a muscle to resist fatigue or its abil-
ity to contract repeatedly over a period of
time.
57,116
Motor control is the ability of a
muscle to perform coordinated contrac-
tions to control specific and purposeful
movements through the range of motion.
56
Each characteristic of muscular perfor-
mance lends itself to proper functioning of
the muscle. Muscular strength, endurance,
and motor control play an integral part in
facilitating movement of the cervical spine.
Rehabilitation programs will often incor-
porate components of each of these
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American Journal of Lifestyle Medicinevol. 4 • no. 2
171
physical characteristics to improve muscu-
lar performance and function.
Muscle Performance
Impairments Implicated
in Neck Pain
If the musculature is not function-
ing properly, this may lead to an inabil-
ity to adequately stabilize, protect, and
functionally move in space. Performance
impairments are commonly found in pha-
sic muscles, which are generally weak
in nature.
109
Specific muscles that tend to
develop weakness and are prone to inhi-
bition in the cervicothoracic region are
the serratus anterior, rhomboids, mid-
dle trapezius, lower trapezius, deep
neck flexors, and posterior rotator cuff
mucles.
109
McDonnell et al
28
published
a case report that addressed muscular
control impairments in the rhomboids,
middle and lower trapezius, and lower
abdominals. Other studies have impli-
cated deep neck flexor muscle weakness
in patients with cervicogenic pain.
117-119
The deep cervical flexors play an impor-
tant supporting role in the functioning of
the cervical region.
120
Jull et al
121
reported
that individuals with cervicogenic head-
aches were more likely to present with
weakness of the deep neck flexors. In
addition, groups reporting monthly and
weekly neck pain were found to have
significantly decreased neck muscular
endurance.
122
The tendency for muscles to develop
weakness is generally not random.
Typical muscle imbalance patterns have
been described.
109
The cross-shoulder
syndrome is a model that has been used
to describe the clinical presentation of
some muscles predisposed to weakness
and inhibition. The syndrome is charac-
terized by weakness of the deep neck
flexors, lower trapezius, middle trapezius,
serratus anterior, and posterior rotator
cuff muscles. In FHP, the serratus ante-
rior muscles are weakened. This weak-
ness results in a protracted position of
the shoulder complex, leading to gle-
nohumoral malalignment. The plane of
the glenoid becomes vertical, and main-
tenance of the humeral head in the fossa
may lengthen the posterior rotator cuff
muscles. This static lengthening leads to
additional weakness and instability of the
shoulder complex.
Effects of Muscular
Strength and Endurance
Training on Neck Pain
As discussed, there are many com-
ponents contributing to neck pain.
Additional contributors are the ability to
stabilize segmentally, perform controlled
movement, and be able to absorb out-
side forces.
123,124
If the musculature is
unable to perform these tasks adequately,
then complaints of neck pain may ensue.
Many studies support various methods
of direct neck strengthening and stretch-
ing exercises for chronic mechanical neck
disorders.
93,118,125,126
In a recent review of
the literature, Gross et al
8
found moderate
evidence in support of various methods
of direct neck strengthening and stretch-
ing exercises for chronic neck pain.
There seems to be little consistency
with regard to the specific development
and implementation of training programs.
Although there is much variation in the
training programs, there does seem to
be some trends. Many studies used mus-
cle performance exercises as one compo-
nent of treatment. The positive outcomes
therefore may not be exclusively due
to training of the musculature. It seems,
however, that addressing muscle perfor-
mance is a critical component of treating
some patients with cervicogenic pain.
Conclusion
In conclusion, there are numerous con-
servative options for the treatment and
management of neck pain. Development
and implementation of these treatment
regimes also vary greatly and are often
dependent on who a patient sees rather
than their presentation. Etiological con-
siderations and presentation of the con-
dition are additional factors that must
be reviewed and considered before any
course of action is initiated when work-
ing with individuals with neck pain. It
has been demonstrated that not only
personal physical condition but psy-
chological and emotional states can
influence pain and pain perception.
Musculoskeletal and postural adaptations
also can affect the presence and severity
of neck pain.
The use of verbal instruction or edu-
cation alone is not sufficient as a treat-
ment intervention for cervicogenic pain.
Individuals learn and understand in dif-
ferent ways. This review of the literature
suggests that a combination of interven-
tions is best used to maximize outcomes
when an individual is in need of conser-
vative intervention to manage or reduce
cervical pain. Influences from education
and exercise on pain have been estab-
lished within this review. Conservative
treatment and its influences as discussed
here may not be the most appropriate
course of treatment for all individuals
suffering from neck pain. Where this is
not the case, invasive procedures would
need to be investigated.
The economic impact of the individual
as well as society was touched on briefly
but cannot be taken lightly. Its effects can
be far reaching when addressing cervi-
cal pain disability. With an epidemic-like
proportion of the population reporting
neck pain, understanding the influences
of education and exercise becomes para-
mount not only for an individual’s qual-
ity of life but for minimizing the financial
fallout of a society.
Summary of Findings
Based on the above stated findings,
the clinician must consider the follow-
ing. Education for neck pain is an impor-
tant component of overall treatment.
Although many educational modalities
can be used such as verbal communica-
tion, video, or booklets, the key is repe-
tition of the information given. Patients
who hear the same information in dif-
ferent forms are more likely to make
adaptive changes. Consider verbally
instructing the patient and reinforcing this
information with a booklet. Also, assum-
ing medical red flags have been cleared,
the practitioner should recommend an
active lifestyle within tolerance. Guided
exercise is also important for nonspecific
neck pain. Clinicians should consider a
course of supervised clinical exercises
that is reinforced to be performed
independently.
AJLM
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American Journal of Lifestyle Medicine Mar • Apr 2010
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