I find it appropriate to write my first blog based on a continuation of a guest post, entitled “The Role of Transversus Abdominus in Low Back Pain” in January 2009 on Mike Reinold’s Blog.  If you have not had the opportunity to read it yet, it can be found here.  Please feel free to also read the comments and make another if you choose, as the article resulted in a great deal of feedback.  This seems to be a hot topic in rehabilitation of low back pain. If you haven’t had the chance to visit Mike’s site, it is well worth your time. Including Mike, there are many outstanding practitioners that visit and discuss daily on current concepts in physical therapy at www.mikereinold.com.

colli picDeep Cervical Flexors Exercises for Cervical Spine Stability

I’m not going to beat a dead horse with more information against the use of the term stability in rehabilitation of the neck and back, but if you read the previous article, I am not a big fan.  I feel it is a disservice to ourselves and our patients to claim therapeutic exercises stabilize the spine. We have not proven a valid diagnostic test for instability and research has never shown exercise to directly or indirectly stiffen or stabilize a motion segment, in turn, creating stability locally.

We tend to claim this concept in the low back predominantly but also with neck pain through activation of deep cervical flexors (DCF), mainly the longus colli and longus capitus.  These two muscles are important for the support of cervical lordosis. It has been shown in the literature that individuals with neck pain disorders do have altered neuromuscular control and movement strategies showing increased activity in the superficial flexors (particularly the SCM) and decreased activity in deep flexors.  Strength and endurance training of the DCFs have been a norm for rehabilitation for neck pain.

What is the best way to measure the DCFs clinically?

Before we decide a patient has strength and endurance limitations in DCFs, we need to objectively identify it clinically. Not only can we determine if this is the impairment but also can make long-term goals to really use it practically towards physical therapy practice.

The Cranio-Cervical Flexion Test (CCFT) is a great tool to begin parting this bridge. It has been shown to be a valid test in symptomatics and asymptomatics, as demonstrated using nasopharyngeal EMG application to directly measure the longus colli.

As demonstrated in the literature, there is also a strong linear relationship between EMG amplitude of DCF and increments of CCFT showing more activation as cuff pressure increases.

What is ‘normal’ endurance and strength?

-Jull et all 2000 showed that WAD II patients could control pressure using CCFT at an average of 23 mmHg, while asymptomatics could control it without subsitution at 28mmHg.  Chiu et al 2005 showed the chronic neck pain patients were able to hold pressure using CCFT at 24mmHg, while asymptomatics could hold at 28mmHg.

-Olsen et al studied the chin tuck and lower cervical spine flexion on patients with history of neck pain to determine norms for DCF endurance.  The average time for upper and lower cervical flexion was 25 seconds in males and 20 seconds in females.

Needless to say, normal (asymptomatics) strength is 28-30mmHg @ 10 second holds x 10 reps via CCFT and endurance is 25 seconds male/20 seconds female via upper & lower cervical flexion endurance test.  This can be translated into long term goals.

Will exercise reduce pain and disability in neck pain?

This exact concept was recent studied by Falla et al., 2007 to determine if training the DCF muscles with cranial cervical flexion exercises (longus colli and longus capitus) and also cervical flexor endurance-strength training (all cervical flexors including sternocleidomastoid, anterior scalenes, hyoids) change pain, disability and muscle activity during a functional activity (i.e. sitting and desk writing).

-After 6 wks of training, there was no difference in pain or perceived disability between the groups even though both of them did show a reduction overall.

-After 6 wks, there was no significant change in the activity of SCM via EMG for either group during the functional activity.

This is an interesting study two-fold:

  • First, there was no more reduction in pain between either two groups (DCF only exercise and all cervical flexor exercises).
  • SCM muscle activation did not change functionally by either exercise group.

This makes me re-think the entire theology of only deep cervical flexors involvement with exercise for our patients to get better.  Should we really try to limit SCM involvement?  Or should we concentrate more on manual therapy techniques to diminish pain directly and then globally address cervical flexors?

I do feel we need to incorporate cervical retraction moments into our rehabilitation process for neck pain but rethink the reasoning behind it.  As stated above, lets do away with the stability concept and relay the exercise for postural correction, strength, endurance, motor timing (possibly) or maybe even multilevel impairment, but lets drop stability.

What are your thoughts on treating neck pain patients with concentrate on DCFs?  Do you find it useful and obtain positive outcomes?


Jull GA, Barrett C, Magee R, Ho P 1999 Further clinical clarification of the muscle dysfunction in cervical headache.  Cephalalgia 19: 179–185

Uthaikhup S, Jull G. Performance in the cranio-cervical flexion test is altered in elderly subjects. Manual Therapy. 2009 (1-5).

Hudswell S, von Mengerson M, Lucas N. The cranio-cervical flexion test using pressure biofeedback: A useful measure of cervical dysfunction in the clinical setting? International Journal of Osteopathic Medicine, Volume 8, Issue 3, September 2005, Pages 98-105

Jull GA, O’Leary SP, Falla DL. Clinical Assessment of the Deep Cervical Flexor Muscles: The Craniocervical Flexion Test. Journal of Manipulative and Physiological Therapeutics, Volume 31, Issue 7, September 2008, Pages 525-533

Falla D, Jull G, Hodges P. Training the cervical muscles with prescribed motor tasks does not change muscle activation during a functional activity. Manual Therapy 13 (2008) 507–512

Falla D, O’Leary S, Jull G. Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting. Manual Therapy 12 (2007) 139–143

Hudswell S, von Mengerson M, Lucas N. The cranio-cervical flexion test using pressure biofeedback: A useful measure of cervical dysfunction in the clinical setting?International Journal of Osteopathic Medicine 8 (2005) 98e105

Falla D. Unravelling the complexity of muscle impairment in chronic neck pain. Manual Therapy 9 (2004) 125–133

Falla D., Campbell CD, Fagan AE, et al. Relationship between cranio-cervical flexion range of motion and pressure change during the cranio-cervical flexion test.  Manual Therapy (2003) 8(2), 92–96

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.

Jull GA. Deep cervical flexor muscle dysfunction in whiplash. Journal of Musculoskeletal

Pain. 2000;8:143–54.

Cook C, Brismee J, Fleming R, et al. Identifiers Suggestive of Clinical Cervical Spine Instability: A Delphi Study of Physical Therapists.  Phys Therapy.  September 2005, 895-906.

Olson et al. Reliability of a Clinical Test for Deep Cervical Flexor Endurance. Journal of Manipulative and Physiological Therapeutics.  29, 134-138.

Chiu et al.  Performance of the Craniocervical Flexion Test in Subjects With and Without Chronic Neck Pain. Journal of Sports and Physical Therapy. 2005.  35, 567-571.



  1. I fully agree in that no specific parameters have been put in place to quantify the effects of CCFT for the use of increasing inter-segmental stability in the cervical spine.

    The logic that infers benefit from the protocol is that of maintaining “neck flexor synergy “as described by Janda,1999.

    Any dysfunction between the deep and superficial cervical flexors or extensors would result in abberant muscle forces acting on the cervical spine hence altering the intrinsic biomechanics specific to the cervical spine.This may result in a reduction in stability at a single motion segment or of the entire region.

    The question one must ask is did the dysfunction indeed begin at the DCF level and not rather from some other dysfunctional myogenic or osteogenic origin.

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