Effects of deep cervical flexor training on impaired physiological functions associated with chronic neck pain: a systematic review

Johannes Blomgren, Erika Strandell, Gwendolen Jull, Irene Vikman, Ulrik Röijezon, Johannes Blomgren, Erika Strandell, Gwendolen Jull, Irene Vikman, Ulrik Röijezon

Abstract

Background: Neck pain is a major health issue with high rates of recurrence. It presents with a variety of altered sensorimotor functions. Exercise is a cornerstone of rehabilitation and many training methods are used. Exercise is evaluated in most randomized controlled trials on its pain relieving effects. No review has assessed the effect of exercise on the altered physiological functions or determined if there are differential effects of particular training methods. This review investigated the effects of deep cervical flexor (DCF) training, a training method commonly used for patients with neck pain, and compared it to other training methods or no training on outcomes of cervical neuromuscular function, muscle size, kinematics and kinetics.

Methods: Web of Science, Scopus, CINAHL, PubMed were searched from inception until January 2018. Twelve randomized controlled trials were included that compared DCF training as sole intervention to other training or no interventions in persons with neck pain. The Cochrane Risk of Bias tool was used to assess the method quality. All outcome measures were analysed descriptively and meta-analyses were performed for measures evaluated in three or more studies.

Results: DCF training was compared to cervical endurance, strength, proprioception and mobility training, muscle stretching, and no intervention control groups. Physiological outcome measures included neuromuscular co-ordination (craniocervical flexion test), functional tasks, muscle fatigability, muscle size, kinematics (joint position sense, posture and range of motion) and kinetics (strength, endurance and contraction accuracy). Strong evidence was found for effectiveness of DCF training on neuromuscular coordination, but it had no or small effects on strength and endurance at higher loads. DCF training improved head and cervical posture, while evidence was limited or contradictory for other measures.

Conclusions: DCF training can successfully address impaired neuromuscular coordination, but not cervical flexor strength and endurance at higher contraction intensities. A multimodal training regime is proposed when the aim is to specifically address various impaired physiological functions associated with neck pain.

Keywords: Deep cervical flexor training; Neck pain; Physiological outcome measures; Strength training; Systematic review.

Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests. Acknowledgement was made in the manuscript that one author (GJ) contributed to 8 of 12 studies included in the review.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flowchart for selection of the studies.1Reasons for exclusion: important information on how assessments of outcome variables and/or interventions were performed was missing; questionable validity of outcome measure
Fig. 2
Fig. 2
Risk of bias of included studies
Fig. 3
Fig. 3
Forest plot of meta-analysis comparing DCF training with strength-endurance training (Jull et al. 2009 [21] and Ghaderi et al. 2017 [39]) and no intervention (Beer et al. 2012 [38]) on the effects of RMS EMG of sternocleidomastoid (SCM) during the craniocervical flexion test (CCFT). The mean and standard deviation (SD) are the values from the post intervention measures. Raw data was supplied from Beer et al. 2012 [38] while all other data was extracted from the original studies. Average of the EMG data from the left and right SCM was used for data analysis
Fig. 4
Fig. 4
Forest plot of meta-analysis comparing DCF training with strength-endurance training on the effects of cervical muscle strength. The mean and standard deviation (SD) are changes in values between baseline and post intervention measures. Data from Falla et al. 2006 [29] was used to impute the SD values for O’Leary et al. 2007 [36] and for O’Leary et al. 2012 [37] as described by Cochrane handbook chapter 16.1.3.2
Fig. 5
Fig. 5
Forest plot of meta-analysis comparing DCF training with strength-endurance training on the effects of cervical muscle endurance. The mean and standard deviation (SD) are the values from the post intervention measures. All values were extracted from the original studies

References

    1. Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the global burden of disease study 2015. Lancet. 2016;388:1545–1602. doi: 10.1016/S0140-6736(16)31678-6.
    1. Haldeman S, Carroll L, Cassidy JD. Findings from the bone and joint decade 2000 to 2010 task force on neck pain and its associated disorders. J Occup Environ Med. 2010;52:424–427. doi: 10.1097/JOM.0b013e3181d44f3b.
    1. Edmondston S, Björnsdottir G, Pálsson T, Solgård H, Ussing K, Allison G. Endurance and fatigue characteristics of the neck flexor and extensor muscles during isometric tests in patients with postural neck pain. Man Ther. 2011;16:332–338. doi: 10.1016/j.math.2010.12.005.
    1. Muceli S, Farina D, Kirkesola G, Katch F, Falla D. Reduced force steadiness in women with neck pain and the effect of short term vibration. J Electromyogr Kinesiol. 2011;21:283–290. doi: 10.1016/j.jelekin.2010.11.011.
    1. O'Leary S, Jull G, Kim M, Vicenzino B. Cranio-cervical flexor muscle impairment at maximal, moderate, and low loads is a feature of neck pain. Man Ther. 2007;12:34–39. doi: 10.1016/j.math.2006.02.010.
    1. Prushansky T, Gepstein R, Gordon C, Dvir Z. Cervical muscles weakness in chronic whiplash patients. Clin Biomech. 2005;20:794–798. doi: 10.1016/j.clinbiomech.2005.05.003.
    1. Falla D, Jull G, Hodges PW. Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain. Exp Brain Res. 2004;157:43–48. doi: 10.1007/s00221-003-1814-9.
    1. 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;29:2108–2114. doi: 10.1097/01.brs.0000141170.89317.0e.
    1. Johnston V, Jull G, Darnell R, Jimmieson NL, Souvlis T. Alterations in cervical muscle activity in functional and stressful tasks in female office workers with neck pain. Eur J Appl Physiol. 2008;103:253–264. doi: 10.1007/s00421-008-0696-8.
    1. Lindstrom R, Schomacher J, Farina D, Rechter L, Falla D. Association between neck muscle coactivation, pain, and strength in women with neck pain. Man Ther. 2011;16:80–86. doi: 10.1016/j.math.2010.07.006.
    1. Schomacher J, Farina D, Lindstroem R, Falla D. Chronic trauma-induced neck pain impairs the neural control of the deep semispinalis cervicis muscle. Clin Neurophysiol. 2012;123:1403–1408. doi: 10.1016/j.clinph.2011.11.033.
    1. Elliott JM, Courtney DM, Rademaker A, Pinto D, Sterling MM, Parrish TB. The rapid and progressive degeneration of the cervical multifidus in whiplash: an mri study of fatty infiltration. Spine. 2015;40:E694–E700. doi: 10.1097/BRS.0000000000000891.
    1. De Pauw R, Coppieters I, Kregel J, De Meulemeester K, Danneels L, Cagnie B. Does muscle morphology change in chronic neck pain patients? - a systematic review. Man Ther. 2016;22:42–49. doi: 10.1016/j.math.2015.11.006.
    1. Bexander CSM, Hodges PW. Cervico-ocular coordination during neck rotation is distorted in people with whiplash-associated disorders. Exp Brain Res. 2012;217:67–77. doi: 10.1007/s00221-011-2973-8.
    1. Cagnie B, Dolphens M, Peeters I, Achten E, Cambier D, Danneels L. Use of muscle functional magnetic resonance imaging to compare cervical flexor activity between patients with whiplash-associated disorders and people who are healthy. Phys Ther. 2010;90:1157–1164. doi: 10.2522/ptj.20090351.
    1. Winters JM, Peles JD. Multiple muscle systems: Biomechanics and movement organization. New York: Springer New York; 1990. Neck muscle activity and 3-d head kinematics during quasi-static and dynamic tracking movements; pp. 461–480.
    1. Panjabi MM, Cholewicki J, Nibu K, Grauer J, Babat LB, Dvorak J. Critical load of the human cervical spine: an in vitro experimental study. Clin Biomech. 1998;13:11–17. doi: 10.1016/S0268-0033(97)00057-0.
    1. Jull G, Falla D. Does increased superficial neck flexor activity in the craniocervical flexion test reflect reduced deep flexor activity in people with neck pain? Man Ther. 2016;25:43–47. doi: 10.1016/j.math.2016.05.336.
    1. Gross AR, Paquin JP, Dupont G, Blanchette S, Lalonde P, Cristie T, et al. Exercises for mechanical neck disorders: a cochrane review update. Man Ther. 2016;24:25–45. doi: 10.1016/j.math.2016.04.005.
    1. Jull GA, O'Leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. J Manip Physiol Ther. 2008;31:525–533. doi: 10.1016/j.jmpt.2008.08.003.
    1. Jull GA, Falla D, Vicenzino B, Hodges PW. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Man Ther. 2009;14:696–701. doi: 10.1016/j.math.2009.05.004.
    1. Chiu TTW, Law EYH, Chiu THF. Performance of the craniocervical flexion test in subjects with and without chronic neck pain. J Orthop Sports Phys Ther. 2005;35:567–571. doi: 10.2519/jospt.2005.35.9.567.
    1. Cochrane handbook for systematic reviews of interventions version 5.1.0. [].
    1. Izquierdo TG, Pecos-Martin D, Girbes EL, Plaza-Manzano G, Caldentey RR, Melus RM, et al. Comparison of cranio-cervical flexion training versus cervical proprioception training in patients with chronic neck pain: a randomized controlled clinical trial. J Rehabil Med. 2016;48:48–55. doi: 10.2340/16501977-2034.
    1. Yang DJ, Kang DH. Comparison of muscular fatigue and tone of neck according to craniocervical flexion exercise and suboccipital relaxation in cervicogenic headache patients. J Phys Ther Sci. 2017;29:869–873. doi: 10.1589/jpts.29.869.
    1. Deepa A, Dabholkar TY, Yardi S. Comparison of the efficacy of Maitland thoracic mobilization and deep neck flexor endurance training versus only deep neck flexor endurance training in patients with mechanical neck pain. Indian J Physiother Occup Ther. 2014;8:77–82. doi: 10.5958/0973-5674.2014.00360.8.
    1. Gupta BD, Aggarwal S, Gupta B, Gupta M, Gupta N. Effect of deep cervical flexor training vs. conventional isometric training on forward head posture, pain, neck disability index in dentists suffering from chronic neck pain. J Clin Diagn Res. 2013;7:2261–2264.
    1. Kim JY, Kwag KI. Clinical effects of deep cervical flexor muscle activation in patients with chronic neck pain. J Phys Ther Sci. 2016;28:269–273. doi: 10.1589/jpts.28.269.
    1. Falla D, Jull G, Hodges P, Vicenzino B. An endurance-strength training regime is effective in reducing myoelectric manifestations of cervical flexor muscle fatigue in females with chronic neck pain. Clin Neurophysiol. 2006;117:828–837. doi: 10.1016/j.clinph.2005.12.025.
    1. Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain. Phys Ther. 2007;87:408–417. doi: 10.2522/ptj.20060009.
    1. Falla D, Jull G, Hodges P. Training the cervical muscles with prescribed motor tasks does not change muscle activation during a functional activity. Man Ther. 2008;13:507–512. doi: 10.1016/j.math.2007.07.001.
    1. Borisut S, Vongsirinavarat M, Vachalathiti R, Sakulsriprasert P. Effects of strength and endurance training of superficial and deep neck muscles on muscle activities and pain levels of females with chronic neck pain. J Phys Ther Sci. 2013;25:1157–1162. doi: 10.1589/jpts.25.1157.
    1. Lee MH, Park SJ, Kim JS. Effects of neck exercise on high-school students’ neck-shoulder posture. J Phys Ther Sci. 2013;25:571–574. doi: 10.1589/jpts.25.571.
    1. Javanshir K, Amiri M, Bandpei MAM, De las Penas CF, Rezasoltani A. The effect of different exercise programs on cervical flexor muscles dimensions in patients with chronic neck pain. J Back Musculoskelet Rehabil. 2015;28:833–840. doi: 10.3233/BMR-150593.
    1. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. J Orthop Res. 2007;25:404–412. doi: 10.1002/jor.20220.
    1. O'Leary S, Jull G, Kim M, Vicenzino B. Specificity in retraining craniocervical flexor muscle performance. J Orthop Sports Phys Ther. 2007;37:3–9. doi: 10.2519/jospt.2007.2237.
    1. O'Leary S, Jull G, Kim M, Uthaikhup S, Vicenzino B. Training mode-dependent changes in motor performance in neck pain. Arch Phys Med Rehabil. 2012;93:1225–1233. doi: 10.1016/j.apmr.2012.02.018.
    1. Beer A, Treleaven J, Jull G. Can a functional postural exercise improve performance in the cranio-cervical flexion test? - a preliminary study. Man Ther. 2012;17:219–224. doi: 10.1016/j.math.2011.12.005.
    1. Ghaderi F, Jafarabadi MA, Javanshir K. The clinical and emg assessment of the effects of stabilization exercise on nonspecific chronic neck pain: a randomized controlled trial. J Back Musculoskelet Rehabil. 2017;30:211–219. doi: 10.3233/BMR-160735.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa