As manual therapists, our major goal of treatment is to provide a pain modulating effect for our neck pain patients.  This is usually done through either mobilization/manipulation, soft tissue releases, modalities, repeated movements in a direction of preference, etc.  I have historically not performed any type of exercise (other than repeated movements) for the deep cervical flexors until the pain has been more under control.  However, I do on occasion implement upper deep cervical spine flexor endurance training (longus colli, longus capitis) initially if I find this to be a significant impairment.  You can review back to a past article here (actually my first blog post on my site!) in Aug 2009 here to get further information on this topic.

I have done this through my own cause and effect patterns and assess/re-assess model over the years but finally came across a research article by O’Leary and colleagues in the Journal of Pain here to put evidence into my clinical thinking.  This study looked at the difference in immediate pain relief locally and systemic effects in another location by randomizing into either a cranio-cervical flexion coordination (CCF) exercise group, control group or cervical flexion (CF) endurance group.  The looked at systematic nervous system function, pain pressure threshold (PPT), thermal pain threshold at the local and distal site, as well as recorded the visual analog scale at rest and with cervical movement.  The main positive finding from this study was:

Immediately after 1 session of exercise, there was a

reasonably sized increase of 21% (P < .001, d 0.88) and 7.3% (P .03, d 0.47) in PPT locally at the

neck for the CCF exercise and the CF exercise, respectively.

Here is the graph for the findings:

O'Leary 2007
O’Leary 2007


In short, this study showed that pain pressure threshold of the involved segments (as initially examined from a clinician…in this case 85% at C2-3), decreased significantly mainly in the cranio-cervical flexion coordination exercise group.  One of the cause-effect from a manual treatment is assessing this pain-pressure threshold too, but just after a passive approach instead of an active approach. There was an immediate hypoalgesic effect of exercise, similar to what we can get from manual therapy.  It is a very effective way to improving carry-over from your treatment (as in prescribing it for home) to continue to get pain-relieving results.

Stay tuned for 2nd post on how I get the upper cervical deep flexors to activate.


One comment

  1. Awesome post Harrison. I’ve been working with a lot of patients with pretty severe cervical pain. I’m glad to see that these exercises can provide some short term as well as long term relief.

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