Are we measuring the right outcomes?

Steffen Klittmann

Exercises for patients with neck pain

  • Do craniocervical flexion exercises help reduce pain?
  • Do they help to improve muscle function?
  • Do other exercises help as well, better or worse?
  • Does it matter which exercises we give to patients with neck pain?

Here I discuss these questions with the help of a CAP - a Critically appraised paper.


Have fun reading,




Efficacy of Deep Cervical Flexor Muscle Training on Neck Pain, Functional Disability, and Muscle Endurance in School Teachers: A Clinical Trial

Iqbal, Z.A., Alghadir, A.H., Anwer, S., 2021.Efficacy of Deep Cervical Flexor Muscle Training on Neck Pain, Functional Disability, and Muscle Endurance in School Teachers: A Clinical Trial. Biomed Res Int 2021, 7190808. https://doi.org/10.1155/2021/7190808



Research question

The purpose of this study was to investigate the effects of deep neck flexor training using pressure biofeedback on neck pain, muscle endurance of deep neck flexors, and functional disability in teachers with neck pain.

Physiotherapy background

Neck pain is one of the most common occupational diseases and the nature of the workplace is a risk factor for the development of neck pain (Iqbal and Alghadir 2015). These include pre-bent head posture (Keyserling et al 1992) and work-related psychosocial aspects (Etlayeb et al 2009), such as demands, work situation and lack of support from colleagues (Dellve et al 2003, van der Heuvel et al 2005).

Reports suggest that at least 69% of high school teachers suffer from neck pain (Chiu and Lam 2007). Teachers' daily tasks involve spending a lot of time in a forward-leaning head posture (Korkmaz et al 2011), which puts them at risk of developing neck pain. Complementary contributing factors are high workload, lower peer support, and high levels of anxiety (Darwish and Al-Zuhair 2013, Iqbal et al 2013).

Modern media has increased the number of hours a teacher must spend at a computer (Iqbal et al 2013). This in turn has been linked to neck pain (Ijmker et al 2006). Static posture for prolonged periods of time causes neck pain, which leads to muscle tension in the neck region (Ariëns et al 2001).

The deep cervical flexors have an important postural function in supporting neck lordosis (Mayoux-Benhamou et al 1994). Reduced activation and low endurance function leads to muscle insufficiency of these muscles, which is considered a cause of neck pain (Cagnie et al 2008, Falla et al 2004, Silverman et al 1991). Furthermore, weakening of the deep neck flexors can affect head and neck posture (Fernandez-de-las-Peñas et al 2007, Nezamuddin et al 2013, Subbarayalu 2016, 2017).

Craniocervical flexion exercises activate the deep neck flexors in isolation (Conley et al 1995, Hünting and Grandjean 1981). Iqbal et al (2013), and Jull et al (2002) have advocated a specific exercise protocol involving static contraction at submaximal levels to improve their function.

Study Design

Randomized controlled trial

Inclusion Criteria

  • Patients with chronic neck pain
  • Numeric Pain Scale (NRS) > 5 points
  • Mild - moderate impairment due to neck pain (NDI)
  • Poor result on the craniocervical flexion test (CCFT)


Exclusion criteria

  • Neurological signs or symptoms
  • Spinal surgery in the past
  • Ongoing treatment for neck pain



Subjects were randomly assigned to the experimental group or control group. Training and measurements were performed by a trained therapist who was blinded to treatment assignment. Subjects were not blinded to treatment group assignment and were instructed not to receive any other treatment during the study period.

Control group

Conventional exercises for neck pain (Hünting and Grandjean 1981, Jull et al 2002) consisting of stretching exercises for the following muscles: Sternocleidomastoid muscle, upper trapezius muscle, levator scapulae muscle, suboccipitalis muscle, pectoral muscles. Supplementary nonspecific strengthening exercises of the neck flexors: each session included an exercise with 10 repetitions, each held for 10 seconds, with a break of 2 minutes between sets. Sessions were performed 4 days per week for 6 weeks (42 days), and each session lasted no longer than 20 minutes.

Experimental group

The same conventional exercises for neck pain as in the control group. However, pressure biofeedback training for the deep cervical flexors was added according to the protocol of Jull et al (2002): Subjects lay supine with their legs braced. The pressure biofeedback device was placed below the occiput and inflated to a baseline pressure of 20 mmHg. Subjects were instructed to nod their heads to gradually reach 5 pressure levels. This included 3 sets per session of 10 repetitions each with 2 minutes rest between sets. Exercise was performed 5 days per week for 6 weeks (42 days).


NRS – Pain intensity in the neck using a numerical scale (range: 0-10).

CCFT – endurance of deep cervical flexors using pressure biofeedback unit (PBU / Stabilizer).

  • Initial value: 20 mmHg
  • Progression: in increments of 2 from 20 to 30 mmHg.
  • Goal: Hold pressure for 10 seconds without activating superficial flexors, retracting head or elevating head at a minimum of 26 mmHg.


NDI – Functional impairment due to neck pain (Range: 0-50).

Pain, muscle endurance, and impairment due to neck pain were measured before the start of treatment, after 2 weeks, and after 6 weeks.


Sixty-five teachers aged 25-45 years with more than five years of teaching experience were invited to participate in this study. After considering the inclusion and exclusion criteria, 50 subjects (25 males, 25 females) were included in the study. The experimental group included 12 men and 13 women, and the control group included 13 men and 12 women. The average working time of the subjects was 8 hours per day. At the start of the study, there were no significant differences in age, pain, muscle endurance, and impairment level between the groups (p >0.05).



  • Experimental group
    • At baseline: 5.2 +- 0.99
    • After 2 weeks: 4.56 +- 0.85 (p <0.05)
    • After 6 weeks: 3.2 +- 0.78 (p <0.05 - improvement of 2 points)


  • Control group
    • At baseline: 5.4 +- 0.56
    • After 2 weeks: 5 +- 0.64 (p <0.05)
    • After 6 weeks: 4.5 +- 0.55 (p <0.05 - improvement of 0.9 points)


  • At 2 and 6 weeks, there were statistically significant group differences (p <0.05).

Muscle endurance

  • Experimental group
    • At baseline: 23.6 +- 0.1
    • After 2 weeks: 26.9 +- 1.3 (p <0.05)
    • After 6 weeks: 28.8 +- 1 (p <0.05 - improvement of 5.2 mmHg)


  • Control group
    • At baseline: 24.1 +- 1
    • After 2 weeks: 25.9 +- 1.2 (p <0.05)
    • After 6 weeks: 27 +- 1 (p <0.05 - improvement of 2.9 mmHg).


  • There were statistically significant group differences at 2 and 6 weeks (p <0.05).

Neck pain impairment

  • Experimental group
    • At baseline: 15.2 +- 5.6
    • After 2 weeks: 11.6 +- 4.9 (p <0.05)
    • After 6 weeks: 8.45 +- 4.3 (p <0.05 - improvement of 6.7 points)


  • Control group
    • At baseline: 13.5 +- 3.8
    • After 2 weeks: 12 +- 3.7 (p <0.05)
    • After 6 weeks: 10.7 +- 3.9 (p <0.05 - improvement of 2.8 points)


  • There were statistically significant group differences at 2 and 6 weeks (p <0.05).


The results of this study show that the supplemental use of pressure biofeedback is statistically significant in reducing pain and functional impairment, as well as increasing muscle endurance in teachers with neck pain, compared to conventional exercises performed alone.

Reduced impairment from neck pain is associated with pain relief (Iqbal et al 2013). Improvements in cervical muscle endurance and strength via biofeedback training are associated with a reduction in neck pain (Jull et al 2004). Training of deep neck flexors is more effective for neck pain than nonspecific training of other neck muscles (Wing Chiu et al 2005).

Work-related prolonged use of technical equipment among teachers often results in poor neck posture that is unconsciously maintained for long periods of time, leading to inadequate muscle performance in various activities (Hakala et al 2006). Complementary ergonomic factors, stress, and low collegial support may influence the development of pain (Chiu and Lam 2007). There are no prevention or intervention strategies to control neck pain in teachers.

Future studies with a larger sample and longer follow-up period are warranted to thoroughly investigate the effects of deep neck flexor training with pressure biofeedback on neck pain duration, cervical spine range of motion, and posture.


This study was a great read and the authors got to the heart of the findings. It is clear and concise and makes it easy for the reader to understand how it went.

The authors kept the inclusion criteria simple, thus the study gains clarity. It should be emphasized that they were careful to include only patients who had poor performance on CCFT. On the other hand, they leave open what poor means. The performance of the study participants at baseline ranged from 23.6 mmHg to 24.2 mmHg. Thus, all subjects have room for improvement. In everyday clinical practice, the same procedure would be followed - that is, only those patients would be allowed to exercise who had previously shown poor performance in the test.

Craniocervical flexion exercises are used in patients with movement control disorders, among others (Blanpied et al 2017, Falla et al 2003, 2008, Jull et al 2008). These tend to present with ischemic pain behavior and large neck pain, which is increasing over the day (Hengeveld et al 2014, Westerhuis and Wiesner 2014). Although these criteria were not explicitly mentioned, they could be given by the subject selection of young teachers. Unfortunately, the authors did not include other outcomes, such as active mobility of the cervical spine, quality of active movements, and PPIMVMs (passive physiological intervertebral movements) and PAIVMs (passive accessory intervertebral movements). Typically, patients with neuromuscular dysfunction have few movement limitations and tend to be at the hypermobile end of the spectrum of active and passive mobility (Röijezon et al 2010, Sarig Bahat et al 2015, Sjölander et al 2008). Complementary to the deep neck flexors, other muscle groups are often involved, such as the inferior and superior trapezius muscles or the serratus anterior muscle (Falla and Farina 2005, Jull et al 2018).

In the interventions, the authors describe a conventional exercise program in the control group; unfortunately, the exact exercises are left open in this regard, but they do describe stretching exercises for different muscles and nonspecific strengthening exercises for the neck flexors. Which strengthening exercises were used for this purpose is not mentioned.

For outcomes, a longer follow-up would have been desirable. After 6 weeks, the intervention group was better than the control group with respect to all parameters. Jull et al (2009) showed that patients with neck pain who exercised the deep neck flexors for 6 weeks showed a normal activation pattern, as in healthy individuals. In addition, Jull and Falla (2016) found that CCFT normalized within 10 weeks using motor relearning training, but compensations increased again after 6 months.

Both groups were comparable with each other at the beginning and the results of the study were presented in an understandable way. Group differences can thus be clearly compared.

The authors of the study discuss that for neck pain, training the deep neck muscles is more effective than non-specific strengthening of other neck muscles (Wing Chiu et al 2005). This is consistent with the findings of various other authors (Jull et al 2002, Ylinen et al 2010). In contrast, Garziono et al (2022) concluded in a systematic review with meta-analysis that there is moderate to very low evidence that deep neck flexor exercises do not relieve neck pain more effectively than other types of active exercises. However, if the goal is to improve activation, endurance, and strength of the deep neck flexors, then exercises for the deep neck flexors are highly effective and superior to other exercises. This was demonstrated by Amiri Amiri et al (2017) in a systematic review.

Thus, in terms of pain reduction, it does not matter what type of exercises are used. On the other hand, if the goal is to improve neuromuscular patterns-in terms of improving recruitment and endurance performance of the deep neck flexors-exercise selection plays an important role. Evidence clearly shows that a motor pattern is modifiable by low-load exercise (Falla et al 2006, 2007, 2013, Jull et al 2009, O'Leary et al 2012).

Last, the study authors concluded that there were no prevention or intervention strategies to control neck pain in teachers. This conclusion can be expanded as there are currently few prevention strategies for neck pain in general and no scientifically reviewed exercise program to maintain function (Jull et al 2018). However, regular exercise and consideration of contributing factors appear to play an important role because neck pain is recurrent (Haldemann et al 2010) and recovery from an acute episode is often incomplete (Hush et al 2011, Leaver et al 2013). Thus, subclinical pathologies and the effect of arthrogenic muscle inhibition on muscle function after a period of rehabilitation should be considered (Callaghan et al 2014, Hurley and Newham 1993, Lee et al 2004).


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Steffen Klittmann, PT, OMPT-DVMT®, IMTA Teacher



#ccft #craniocervical #craniocervicalflexiontest #outcome #neckpain #deepcervicalflexors #teachers #nms #imta #maitland #musculoskeletal #pain #manualtherapy

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