Neck Pain: Activation Exercises

In observing patients and studying rehab, I have learned that tight muscles are weak muscles and that stretching is sometimes less effective than muscular activation. There is a delicate balance between joints that move too little and joints that are hypermobile.

What is the basic muscle imbalance pattern in the neck? The scalenes and the SCM become too tight and short; the deep neck flexors get weak. This was one of the first principles I learned from Vladimir Janda's work. Let's take a look at some of the common neck pain patterns we all miss and specific rehab strategies we can employ to help more patients.

Common "Most Missed" Pain Patterns in the Lower Neck

How can we apply this principle to help your neck pain patients? Here are the "Marc's most missed" patterns in the lower neck. In relation to the lower cervical joints, check both the front and the back of the neck. For the anterior cervical, we see a common fixation pattern. I suspect this relates to patients who text or sit at a computer, or just have lousy head / neck posture.

A significant fixation is a lower cervical segment that resists flexion and lateral bending. A simpler term would be an anterior lower cervical. Do you check and adjust the front of the neck? P.S.: This pattern often disappears when the patient is supine; palpate for it with the patient sitting.

I don't care for high-velocity moves for the anterior lower cervicals. I find that combining muscle energy and counterstrain can be very effective. Video: https://m.youtube.com/watch?v=4XZJtFYh0eA&feature=youtu.be.

For the back of the neck, the most missed pattern is one of hypermobility. Mark Comerford of Kinetic Control calls it a neck hinge; a hypermobility while moving into extension, at a specific level in the lower cervical spine. Once you recognize this pattern, you will look at your post-whiplash patients differently forever. This is more common in your thinner patients, especially women with less musculature.

The Neck Hinge: Assessment

With the patient sitting, stand behind them. Use a bilateral contact between the spinous processes with your active hand. I use my thumb and my second finger knuckle. My other hand is on the forehead, applying gentle anterior-to-posterior pressure, stabilizing the head and neck. Gently press posterior to anterior, starting at C3-4, extending the neck over your midline contact.

The mid-cervical spine is usually normal, at least in relation to the hypermobility pattern you are looking for. Normal means you will feel motion, but with some resistance.

Work your way down the posterior neck. The culprit, the area of palpable hypermobility, is usually found at C5-6 or C6-7. This will feel like a hinge, an area that has way too much give. It is usually a sudden change from the joint above, so it's not difficult to spot.

We are so focused and well-trained to look for a lack of motion; you have to switch gears to find hypermobility. Train yourself. Do this hundreds of times and it will become second nature to you. Adjusting the neck will not fix this. Correcting the anterior cervical fixation above or below can be helpful, but the patient has to learn to control this aberrant motion.

Exercise #1: Correct the Neck Hinge

What is the answer? Specific rehab. Use a variation on activation of the deep neck flexors (DNF). Activating the deep neck flexors is good. In my clinical experience, specifically activating them to address the neck hinge, the hypermobile segment, works great.

Step #1: The patient has to understand how to gently activate the DNF first. The DNF universally get weak with any neck problem. I teach this with the patient in a sitting position. This activation is usually done with a couple of fingers underneath the chin, providing mild resistance. You don't want the patient to activate the scalenes and SCM. You can check this with palpation, and train them. Hard for motor morons, but worth it.

Step #2: Once the patient understands this basic activation, the next step is to "retract" the neck while activating the DNF. This is not neck extension. The chin is not going forward – the whole face is coming directly backward. This simple exercise is a great "reset" for any neck problems. The patient will feel more upright after doing this, as if the head is properly on top of the neck.

Step #3: Now apply this principle to the neck hinge problem (hypermobility going into extension). Focus on the specific level in the lower cervical spine. The patient starts with the neck in mild flexion, about 20 degrees. They are going to use both of their hands, at least at first. They place their knuckles under the chin and gently activate the deep neck flexors.

With their other hand directly over the midline, at the neck hinge level, over the spinous process, they continue to activate the DNF. They are going to slowly extend the neck, going from 20 degrees of flexion to upright (zero degrees; no flexion, no extension), while monitoring at the neck hinge level in the back.

The goal: to feel mild, gradual extension at the neck hinge level. It will feel very different than the previous sudden extension at the involved level. (This is not retraction of the neck as we taught in the basic DNF; this is controlled extension.) Video: https://youtu.be/YBOR68uSBn8.

The usual rehab challenge: Can we teach the patient a conscious new motion pattern and have that translate into a difference in their motion in life? The patient should do the above often, a few reps at a time. Once they understand how to activate the DNF, they may be able to do this without resistance under the chin. This exercise can dramatically help stabilize chronic neck problems and help the patient "hold" their adjustments.

Activating the Deep Neck Flexors to Quiet the Scalenes

If you palpate the front of the neck, you probably have noticed that many patients have chronically tight scalenes and fascia, usually more prominent on one side. This goes along with the anterior cervical fixation pattern. For many years, I taught patients to stretch the scalenes, with some success. More recently, I came up with a better way: through unilateral activation.

Assess the tight scalenes and the stuck joints in the front. Make sure the patient can feel this as well; make them aware of the tension and the tender spots. Showing the patient that they can change their own tender, painful places is a great motivator.

Exercise #2: Chin to Collarbone

This exercise is relatively simple, but it has to be done right. The devil is in the details, as it always is with rehab. Here are the four necessary steps:

1. Patient starts with deep neck flexor activation and retraction.
2. Patient maintains the chin tuck and rotates the head to the involved side, about 25 degrees.
3. Patient uses their opposite hand to provide resistance over the forehead. (They have to use the opposite hand; if they use the same-side hand, it will create too much shoulder motion.)
4. Patient slowly moves the head and neck against mild resistance, toward the collarbone, maintaining the chin tuck. This is not isometric; they need to move through the range, starting neutral and tucked, ending after 3 inches of motion.

The patient can repeat by coming back to center and going through all four steps 3-5 times. You can recheck by palpating the front of the neck. If this is the right exercise for this patient, tenderness and rigidity will be improved, often dramatically. Video: https://youtu.be/70zMz2Hp_w8.

There you go: two profound rehab exercises. Both involve activation of the deep neck flexors, but for different purposes and with specific positioning. Teach them to your neck pain patients and see what results you can achieve.