With many neck pain disorders, a common culprit is poor motor control of the deep neck musculature. One of our special tests can be used to teach muscle recruitment of the cervical spine: the Craniocervical Flexion Test. Teaching the patient an upper cervical head nod is crucial to preventing overuse of the superficial neck flexors. Protrusion of the head is seen with superficial muscle use. Once the head nod is mastered, flexion of the lower cervical spine in supine can be utilized (while maintaining head nod). To improve control of the deep neck extensors, use eccentric exercises for the lower cervical spine while maintaining the upper cervical spine in neutral (try performing in quadruped or prone on elbows). Of course, theraband can be used as well to improve motor control for a muscle group. An important consideration is to keep the intensity low, so as to take advantage of the pain-mediating effects. Higher levels of contraction may aggravate the patient's symptoms initially.
When considering cervical muscle strength and endurance, remember to use exercises that are low load for endurance and high load for strength. The choice of focus between endurance and strength can be influenced by the sport of the patient (football - stength, swimming - endurance). With any cervical patient, we must also consider the shoulder and thoracic spine due to their proximity. Poor endurance/strength/motor control of the scapular musculature can lead to poor posturing and influence the positioning of the cervical spine, eventually producing pain. Therefore, it is important to focus part of the treatment on these muscles. Interestingly, this review found some studies that stated there was no difference between having the patient perform 1 set to exhaustion compared to performing 1 or 2 sets of 8-12 reps. Another study found no difference between 1 and 5 sets of repetitions. The American College of Sports Medicine supports the claim that 1 set of an exercise can be performed to exhaustion.
Repositioning Acuity, Oculomotor Control, or Postural Stability
As with any other joint, proprioception and kinesthesia can be impaired with pathology, but is more likely with traumatic pain. One method of treating this involves placing a light on the patient's head. A target is placed on the wall. The therapist passively places the patient's head in a specific position and the patient notes the position. The therapist then moves the patient's head around in various positions (with the eyes closed) and asks the patient to reposition his/her head to the starting position. The patient must rely on the mechanoreceptors to return to the starting position. Check out Table 2 for oculomotor control exercises and Table 3 for postural stability exercises in the review. All the exercises can be progressed by altering the stability of the surface the patient is standing on. It is especially important to adapt the exercises to being sport-specific to train the athlete for the forces their cervical spine will endure, when competing and practicing.