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Neck Pain: Exercise and Training Considerations

Hanney, William J DPT, ATC, CSCS1,2; Zbaraschuk, Karis S PT2; Yi, Cathy J MPT2; Klausner, Sheila H MS, PT, CSCS2; Wawrzyniak, Loretta PT, ATC2

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Strength and Conditioning Journal: June 2011 - Volume 33 - Issue 3 - p 104-110
doi: 10.1519/SSC.0b013e3182226c45
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Neck pain (NP) is common in the general population (24). The 6-month prevalence of low-grade NP has been reported to be almost 40% (9). Among those with NP, 37% report persistent problems and 23% report recurrent episodes (11). Compared with the general population, athletes are not at an increased risk for NP; however, the use of free weights has been identified as a risk factor for developing cervical disorders (45). It is likely that strength and conditioning professionals, athletic trainers, and physical therapists will train someone with ongoing or recurrent complaints of NP.

The neck is remarkably mobile and acts as a crossroad for the trunk, upper extremities, and head. Fluent movement and orientation of the head and neck are required to position senses to our surroundings. For these mechanisms to work, considerable muscular and sensory control is necessary. Considering the prevalence of NP and influence of the neck during functional tasks, accommodations must be made for training and/or treatment. Therefore, the purpose of this article was to provide information on how exercise and training programs may be adapted for those with NP.


There are many diverse mechanisms for NP. Each type of injury will present differently; thus, adaptations to training must be based on these presentations. The following will review some of the more common types of neck injuries and discuss how training may be impacted or adapted. Detailed training accommodations for each condition would require a specific diagnostic examination and are beyond the scope of the article. Therefore, this information is presented as a general overview, and medical consultation should always be considered when working with any individual describing NP.


Whiplash is a common disorder after trauma that is often associated with motor vehicle accidents or falls (12,54). This injury occurs when the head is forcefully and rapidly moved in one direction and then in the opposite direction (5). It often results in damage to the underlying soft tissue and may be very painful. The client will often present with severe pain, which reduces in time. Symptoms may be bilateral or unilateral; however, varying levels of soreness may be present with different movements. Education for reassurance, advice regarding posture, return to regular activities, exercises, and pain relief methods seem to have had a beneficial influence on decreasing associated disability (3).


There are many different forms of headaches. Migraines are particularly severe headaches, which can be caused by a variety of conditions (52). These patients are generally photosensitive and reactive to loud noises (16). Another common type of headache is cervicogenic or tension type (52). These headaches stem from the neck and surrounding musculature. The symptoms are generally unilateral, and neck movement usually precedes the headache (33). Also, symptoms start at the base of the skull and terminate over 1 eye (32). Movement of the neck can exacerbate the symptoms and should be avoided if possible, particularly activities that require active cervical extension or rotation.


A sprain is generally defined as an injury to the ligamentous structures, whereas a strain involves the musculotendinous unit (48,55). It is often difficult to separate the 2 cervical conditions; therefore, they are often referred to together. Muscular and ligamentous injuries can occur because of a variety of reasons and are often associated with overexertion or a traumatic blow (56). Caution must be taken because individuals can often have long-term discomfort secondary to cervical sprains (13). Ultimately, muscular and ligamentous injuries must be given an opportunity to recover. This may include rest, gentle stretching, and return to a graduated strengthening program (18,44,58).


Radiculopathy describes pain or numbness, which extends from the neck down into the arm(s) (27). It is a general term that may implicate herniated discs, bone spurs, or other compromises of the neurovascular structures in the neck. Movement, such as rotation, can exacerbate symptoms in those with radicular symptoms (60). Of particular concern are the location of the symptoms and how those symptoms respond to movement. Movement of the neck, which causes symptoms to extend down further into the arm, is a phenomenon called “peripheralization” (26). Movement of the neck, which causes symptoms to recede toward midline, is referred to as “centralization” (26). Those clients who are able to centralize their symptoms generally have a better prognosis (17). Any symptoms extending into the arm should be evaluated by a medical professional, and care should be taken to avoid painful movements.


A herniated disc in the neck is less frequent when compared with that in the lower back (38,59). A herniation is caused by a disruption of the fibers, which make up the outer portion of the disc. It often presents as pain in the neck, with symptoms extending down into the arm. Disc herniations in the cervical spine can be caused by traumatic injuries or degenerative changes (10). This injury is often associated with rotational activities; however, any excessive movement or loading can be irritating and should be avoided (43).


A group of nerves called the brachial plexus emanates from the neck, extends down under the clavicle and through the axillary region (38). Stingers or burners generally occur when a forceful side bending of the neck occurs away with a concurrent downward motion of the shoulder girdle on the injured side (38). This injury often occurs during a tackle in sports, such as football or rugby, and generally present with a strong burning or numbing sensation in the neck and down the arm (38). These symptoms generally reduce with time; however, an individual may note weakness and altered sensation in the upper extremity, which is exacerbated with arm or neck movement. Exercise should be adapted to accommodate these symptoms and should be performed in a nonprovocative manner.


Osteoarthritis is a general term that is commonly associated with degenerative changes in a joint. Although it is often related to aging, degenerative changes in the cervical spine have been reported as early as the third and fourth decades of life (51). Osteoarthritis appears to have a genetic link and has been associated with previous traumatic events (61). It is progressive in nature and often associated with morning stiffness, which loosens up throughout the day. Generally, the pain is localized in the neck and extreme movements increase pain. Exercises that compress the joint surfaces may exacerbate symptoms, and extreme cervical rotation or extension should be avoided.


Concussion occurs after a significant injury to the head and is generally caused by trauma, which leads to bruising of the brain (2). Unfortunately, there are often no outward signs of concussion (39). Also, because this occurs due to trauma to the head, an individual can often complain of NP as well. Initial complaints may be a sensation of unsteadiness, which would be expected after a blow to the head (42). NP, however, can be of greater concern because of the high number of pain-generating receptors in the neck. Be aware of NP after a traumatic injury that potentially may reveal symptoms related to a concussion. Appropriate medical care should be sought if additional symptoms, such as nausea, vomiting, or headaches, occur.



Research has demonstrated that the use of sleeping support can be beneficial in decreasing NP. A study by Persson and Moritz (47) compared the use of neck support pillows in patients with NP. It was discovered that 65% found that the use of a supportive pillow improved sleep quality. Also, 64% said that the use of a supportive pillow decreased NP. There are many over-the-counter options for supportive pillows. The pillows should be soft and comfortable and offer a degree of support for the neck. A simple recommendation is to use a standard pillow with a small bath towel rolled lengthwise. Once an appropriate and comfortable towel roll size has been determined, it may be placed on the inside of a pillowcase at the bottom. This will provide cervical support regardless of the position of sleep and is a cost-effective way to provide additional support (Figure 1).

Figure 1
Figure 1:
Towel roll placed in pillowcase for neck support.


There are a variety of postural differences with no clear definition of “proper posture” (37). Postural dysfunction is often referred to in the context of a forward head and shoulder position and has been recognized as a possible contributor to head and NP (46,50). Poor head posture is thought to increase the load on cervical structures that results in pain (19,31). Individuals with severe postural abnormalities have a significantly increased incidence of pain (28). For individuals who spend an extended period sitting, NP is common. This is exaggerated by the fact that many individuals sit in a poor position with the head deviated forward. A study by Falla et al. (22) demonstrated that those with NP have a harder time maintaining upright posture compared with those without NP. Those who sit in a more upright postural position demonstrate higher recruitment of the deep neck flexors (DNFs) and lumbar multifidus, which are essential spinal stabilizers (23). To facilitate proper sitting posture, give instructions in 3 steps. Step 1, ask your client to slowly roll his or her pelvis forward to create a normal lumbar lordosis. Step 2, lift the sternum, so the shoulders fall back into a neutral position. Step 3, retract the neck as if making a double chin and relax to a resting comfortable position (Figure 2). This final position should be maintained during static sitting activities or during seated exercise.

Figure 2
Figure 2:
Steps in seated postural correction.


It has been proposed that workspace adaptation is an integral part of managing clients with NP because workspace deficiencies are common (6,8,53). One study found that ergonomic instruction and alteration of workstation space significantly reduced neck and shoulder pain, which was maintained at 1 year (49). Ergonomic instructions can involve a variety of interventions, which may include taking frequent breaks (57), alterations in lighting (1), changes in forearm and hand support while sitting (1,25,41), and recommendations with regard to the use of a computer mouse (36,41). There are many ergonomic interventions that may be performed. Ultimately, the intention is to influence either the individual or the surrounding workspace to decrease caustic forces.


Eyewear can also contribute to NP. An incorrect eyewear prescription can cause an individual to strain his or her vision to see clearly, which may create tension in upper trapezius muscles (4). Proper eyeglass or contact prescription allows for a more relaxed position and decreased tension (40). Another consideration is the need to see close or near. Those individuals who have difficulty seeing both close and near may use bifocals. This is helpful because the bottom portion of the eyeglass will help to see close, whereas the top portion will help to see far away. Be aware that individuals wearing bifocals while sitting in front of a computer may excessively extend their neck to adequately view the monitor through the lower portion of the bifocal lens. This may exacerbate cervical pain.


For those with NP, it is critical to warm up appropriately before beginning exercises to prepare the surrounding tissues for activity. All warm-up activities should be performed in a slow and controlled manner, being careful to avoid any movement, which exacerbates symptoms.


Many people present with a forward head and shoulder posture. This places the neck in a position of lower cervical flexion and upper cervical extension. To combat this habitual posture, retraction may help to reinforce the proper postural position.

Imagine the head bisected and divided into upper and lower halves at the point of the upper lip. Ask the client to place his or her index and middle fingers on the upper portion of the lip as a guide to move the head back into a retracted position. Think about keeping the head in the same horizontal plane. A verbal cue of making a “double chin” sometimes helps. Move back into full retraction in a pain-free range. Repeat this 15-20 times (Figure 3).

Figure 3
Figure 3:
Cervical retraction exercises.


Shoulder rolls help to engage the cervicothoracic muscles and prepare them for activity. While in proper sitting posture with hands comfortably resting on the thighs, ask the client to slowly move his or her shoulders in large circles, first in the forward direction and then backward. The range should be large but comfortable and should not increase symptoms. The purpose is to improve the contractility of these muscles and increase blood flow to the region. Therefore, higher repetitions should be performed with little or no resistance. Consider asking clients with NP to perform shoulder rolls for at least 1 minute forward and 1 minute backward.


With the client seated in an upright posture, ask the patient to slowly bring his or her head to the side toward 1 ear, slowly roll and flex his or her neck forward, then roll toward the opposite ear, and then return to neutral. Avoid hyperextending the cervical spine. This places undue pressure on joint structures and may compromise deep vascular structures of the neck. Neck rolls should always be performed in a nonprovoking range of motion.


The DNF muscle group is a commonly reported impairment associated with NP (29,34,35). Additionally, NP has been associated with altered patterns of muscle activity characterized by reduced DNF muscle activation and increased activity of the superficial cervical flexor muscles (such as the anterior scalenes and sternocleidomastoids) (21,34). Programs may be designed to improve muscle performance of the DNF group and outcomes among the population afflicted with NP. Begin training sessions by performing light chin tucking with head lift maneuvers to activate the DNF. This is performed by tucking the chin and lifting the head while maintaining the chin tuck. Place the hands behind the head for support. Hold each repetition for 10 seconds and repeat 6-8 times (Figure 4).

Figure 4
Figure 4:
Chin tucking exercise.


Stretching has been recommended as a method to reduce muscle soreness (7,14,15,20) and as a treatment of NP. Muscles, including the upper trapezius, levator scapulae, pectoralis major, and pectoralis minor, have a tendency to become tight in those with NP (30). Gentle stretching of these muscles may assist in avoiding injury, preparing the muscles for activity, and supporting proper upright posture. A gentle stretch held for 30 seconds repeated twice on each side is generally sufficient.



All exercises should be performed in a relaxed position and in proper posture. Slightly tuck the chin and place the tongue on the roof of the mouth. Also, the mouth should be closed; however, there should be slight space between the teeth. This will help to facilitate this relaxed posture.


Caution should be taken when placing a client in extreme positions, which is particularly the case with excessive rotation or extension. This tends to compress the joints in the neck, which can exacerbate symptoms. Also, this position places some of the deep vascular structures in a compromised position that can lead to dizziness or, in more severe cases, stroke. Attempt to keep the cervical spine in a neutral position. For example, when prone, place a towel roll under the forehead. This will prevent the face from being compressed and allow the neck to maintain a neutral position (Figure 5).

Figure 5
Figure 5:
Prone neck positioning.


The cervical spine has a normal lordosis or curvature. When performing exercises in a supine position, it is important to maintain this curvature and prevent exaggerated stress placed through the cervical spine. Also, be sure the client does not press excessively into the bench by extending the neck back during lifts.


Heavy lifts should be avoided; however, functional movements, such as the squat or deadlift, may be beneficial, provided they are performed with proper form and guidance. The lifter should avoid extreme cervical extension during these movements. Keeping the visual field approximately 3-5 ft in front of the participant will help keep the cervical spine from excessively extending.


Heavy overhead lifting requires the use of large muscles, such as the upper trapezius, which has attachment to the cervical spine. The upper trapezius tends to compensate when the lower scapular stabilizers are not functioning adequately. Avoid heavy overhead lifting if you are working with a client who is recovering from a neck injury or has NP. Recommend performing lighter overhead lifts and paying particular attention to proper form. Observe for excessive recruitment of the upper trapezius, and make sure the lower trapezius is activated. When performing any overhead lifting, the client is in an upright position and shoulder blades retracted.


Chest press or incline press exercises are to be performed with caution. The lifter may push or extend his or her head into the bench as a compensatory movement. This position of cervical extension can place considerable force through the neck and increase pain. It is recommended that clients use lighter weight and adhere to strict form.


Front rows or lateral rows may be problematic for the lifter with NP as well. These type of exercises cause increased recruitment of the upper trapezius muscle and scalenes. The increased muscle tension on the cervical muscles may aggravate the lifter's NP. Lighter weight should be considered, and strict adherence to form is necessary.


In conclusion, NP is a prevalent condition in the general population. It is likely that strength and conditioning professionals, athletic trainers, and physical therapists will work with a client possessing current or previous reports of NP. To properly train these individuals, one must have an understanding of basic conditions associated with NP. Finally, simple strategies, including posture, exercise position, and training adaptations, can be implemented, which may help to avoid exacerbating or causing NP.


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neck pain; exercise

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