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12 Articles in Volume 9, Issue #1
Atypical Herpetic Reactivation and Chronic Pediatric Pain
Blending Prescription Pain Treatments with Alternative Medicine
Cervical Disc Disease with Referred Pain to TMJ
Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 1
In My Opinion
Laser Therapy: Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Pain Management in the Elderly
Personality Disorders in Migraineurs
Surgical Implants for Pain Management
Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Trigger Point Ablation and TMJ Syndrome
What a Decade of the Mind Affords the Decade of Pain Control and Research

Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 1

Myofascial stretching, self-mobilization, and muscle strengthening of the deep neck flexors may ameliorate forward head posture, cervicogenic headache, and tension-type headaches.

Nearly fifty percent (50%) of the population is affected by cervical spine pain and/or headaches during their lives.1 Headache is not only one of the most common human ailments,2 but also accounts for the expenditures of billions of health care dollars annually and is a leading cause of lost time from work.3

Cervical dysfunction may be seen in up to seventy percent (70%) of the population suffering from any type of headache.4 This suggests that the cervical spine may be either a causative or contributing factor in the pathogenesis of many headaches.5

The pilot study by Placzek, Pagett, et al. demonstrated and supported the theory that headache may be influenced by cervical muscle strength, and that weakness of the cervical spine musculature may lead to abnormal stress on the upper cervical facets which are related to head and neck pain. It is further speculated that stability, and thus normal function and biomechanics, is dependent on a balance of anterior and posterior cervical muscle balance. Despite advances, the pathogenesis of tension-type headache is not clearly understood. However, cervical musculoskeletal abnormalities have been linked to multiple headache types.6-8

In the study published by Fernandez-De-Las-Penas, Perez-De-Heredia, Molero-Sanchez, and Miangolarra, the authors presented results similar to those previously reported:

1. impairment in deep neck flexor muscles in individuals with cervicogenic headaches, and
2. deficits in the performance of the cranio-cervical flexion test (ie., reduced endurance or holding capacity of the deep neck flexor muscles).

The authors concluded that patients with chronic tension-type headache showed reduced holding capacity of the deep neck flexors. Patients with chronic tension-type headache also exhibited greater forward head posture (FHP) in a standing position than healthy controls.

The dental profession has become increasingly aware of the postural relationships between the head and neck, especially with regard to the diagnosis and treatment of head and neck pain and temporomandibular disorders.10-12

Clinical observation suggests that FHP and weakness of the deep cervical flexor musculature are associated with, and co-exist in, the cervical headache patient.14,15 The study by Watson and Trott confirmed the clinical observation with respect to isometric endurance and isometric strength.16 The study also showed that cervical headache is commonly precipitated or aggravated by sustained neck posturing or neck movements.

Yip, Chiu, and Poon performed a cross-sectional correlation study to investigate the relationship between head posture with pain and disability in patients with neck pain.17 The study showed a significant difference in the Cranio-vertebral (CV) Angle between subjects with and without neck pain. There is a moderate negative correlation between CV Angle and neck disability. Patients with small CV Angle have a greater forward head posture and the greater the forward head posture, the greater the disability.17

Figure 1. PostureJac® exercise and posture-support device.

New Research

Preliminary data collected in the Department of Physical Therapy at the New York Institute of Technology (NYIT) in Old Westbury, New York, indicates that an exercise and posture-support device—such as the PostureJac® invented by one of the authors and illustrated in Figure 1—immediately increased the endurance capacity in the deep neck flexors by over forty percent (40%), whereas the control group showed only a six percent (6%) increase. This has implications for tension-type and cervicogenic headaches; where the endurance capacity of the deep neck flexors has been shown to be deficient.18,19 In addition, poor endurance of the deep neck flexor muscles (rectus capitus anterior, rectus capitus lateralis, longus capitus, and longus colli) may lead to forward head posture which has been linked to not only chronic headaches, but also to:


  • temporomandibular disorders,20

    Exercise and Posture Support Device

    Individuals can perform myofascial stretching, self-mobilization, and muscle strengthening utilizing an exercise and support device such as the PostureJac.

    While such a device works on a biomechanical basis to correct forward head/ rounded shoulders posture, perhaps its most profound effects on form and function operate on a neurological level through sensorimotor learning and improved kinesthetic awareness. Patients are trained to recognize abnormal postures and movement patterns and exchange them for static and dynamic alignment that is balanced, efficient, and in a vertical relationship with gravity.24 In addition to the therapeutic effects of posture correction, it serves as a tool for core strengthening of the local muscles of the lumbopelvic region (ie, transversus abdominis, pelvic floor, multifidi, and diaphragm) as well as the deep neck flexors (ie, rectus capitis anterior, rectus capitis lateralis, longus capitis, and longus colli)

    Two applications of the device—namely, posture correction exercises and deep neck flexor muscle training will be described below.

    Posture Correction Exercises

    The ‘Release.’ This introductory exercise involves the process of releasing excess tension in the upper half of the body. The upper trapezius and sternocleidomastoid muscles are known to generate excessive and unnecessary tension,25 the result being a tendency towards forward head/rounded shoulders posture. Most likely this tension is driven emotionally through the limbic system,26 but other postural influences certainly play a role.27 Ideally, the head-neck-shoulder region should remain relaxed and fluid. However, because of habitual tensing in these muscles, the head-neck may intermittently “freeze.” The goal of this release maneuver is to recognize when “freezing” occurs and to restore the head-neck region to its fluid and relaxed state. Following is a series of steps in accomplishing the desired result:

    a. In the sitting or standing position, the patient is advised to become aware of muscle tightness in the shoulders, head, neck, face, and chest. Using a mirror for visual feedback may enhance the awareness of tightness by observing poor postural alignment, including elevation of the shoulders.
    b. Once aware of this excess tension, the patient is encouraged to release it by “letting go” and to enhance this release of tension by lightly pushing the handles down towards the floor (see Figure 2).
    c. As the shoulders drop, the patient should imagine the top of the head (towards the proverbial “bald spot”) floating up to the ceiling as if being “pulled” by a rope attached to a helium balloon.
    d. Breathing slowly in through the nose, followed by a long exhalation out through pursed lips—while gently pushing the handles down—enhances the release.
    e. This can be done from 1 to 5 minutes, several times per day. Over time, the patient will become more aware of unnecessary tension in the upper body and may suffer less from myofascial trigger points, tension-type headaches, etc. In addition, the patient will ultimately feel taller and less compressed.
    f. If at any time the patient experiences pain, dizziness, numbness, etc., the exercise should be stopped.

    The ‘Rocket.’ The goal of this exercise is stretching and strengthening by causing an upward rise of the central column of the thorax and is accomplished as follows:

    a. In the standing or seated position (ideally in a chair without armrests so as to avoid interference), the patient pretends to be a rocket that is “blasting off.” As the PostureJac handles are pushed down with moderate pressure, the patient’s torso is propelled upward against gravity like a rocket until “lift-off” is experienced (see Figure 3a). In fact, the rocket engine is an excellent example of Newton’s Third Law of Motion, which is crucial in grasping the mechanism by which the device improves body posture (ie, action and reaction). If the rocket illustration fails to communicate a sense of upward rise of one’s body posture, perhaps the image of a fountain, rising from the base of the spine and working its way through the vertebral column to the top of the head, may be preferred.
    b. Initially, the joints of the thorax may not allow the unhindered upward rise of the central column of the thorax (ie, spine and sternum). However, with time and practice this upward rise will free up and become second nature.
    c. To enhance this feeling of “lift-off” the patient can rise up on his/her toes, as the spine is lengthening, provided that the requisite balance is present (see Figure 3b).
    d. As a stretching exercise, the ‘Rocket’ is performed 3 times, held for up to 30 seconds, and repeated up to 6 times per day. As a strengthening exercise, it is performed 10 times, held for 5 – 10 seconds, and performed 3 times per day.
    e. If at any time the patient experiences pain, dizziness, numbness, etc., the exercise should be stopped.

    Deep Neck Flexor Muscle Training

    The ‘JacRetract.’ This 2-stage exercise works very well with McKenzie’s neck retraction exercises.28 The key to successful head-neck retraction is trunk stability. Without it, the movement is only partially effective in restoring extension to the lower cervical spine. The stages are as follows:

    Stage 1
    a. In the sitting or standing position, the patient engages the handles in a downward direction until there is moderate pressure against the shoulders.
    b. In the chin-tucked position (chin to hyoid, eyes looking straight ahead, head rotation around ear axis), the patient retracts the head-neck backward for 3 seconds (see Figure 4a).
    c. Repeat this movement 10 times.
    d. If at any time the patient experiences pain, dizziness, numbness, etc., the exercise should be stopped.
    Stage 2
    a. At the end of Stage 1, the patient is instructed to turn slowly to the right then slowly to the left, 10 times, maintaining the head-neck retraction throughout (see Figure 4b).
    b. If at any time the patient experiences pain, dizziness, numbness, etc., the exercise should be stopped.

    The ‘HeadFlex.’ By stabilizing the scapulothoracic region and lower cervical spine, one can dramatically improve function of the deep neck flexors (ie, strength and endurance). In addition, the reconditioning of this deep and local core system enables the superficial neck flexors (eg. sternocleidomastoid and scalenes) to relax, which contributes to posture correction of the head-neck region. Prior to commencing the ‘HeadFlex’ exercise, the therapist should first address flexion limitation in the upper cervical spine (eg. inhibitive occipital distraction technique and occipital extensor stretching). Otherwise, the deep neck flexors will be unable to achieve their full strength and endurance potential.29-31 The procedure is as follows:

    a. The supine-lying patient begins by engaging both handles down towards the feet.

    b. When moderate pressure is felt under the shoulder straps, the patient performs a chin-tuck and raises the back of the head less than an inch off the surface (Figure 4). It is important that the motion be confined to the upper neck as much as possible. This ensures that the superficial neck flexors are kept from substituting for the deep neck flexors.

    c. The goal is for the patient to maintain this position for at least 10 seconds without shaking, raising, or lowering the head. As strength and endurance show signs of improving, the amount of downward pressure applied to the handles can be lessened. This exercise can be performed up to 3 times per day.

    d. If at any time the patient experiences pain, dizziness, numbness, etc., the exercise should be stopped.


    The literature points to a strong relationship between cervicogenic headache, forward head posture, and weakness/poor endurance of the deep neck flexors.18,32 In addition, the research literature establishes a similar correlation between FHP/deficient deep neck flexors and tension-type headache.19,33-35 To assist head, neck, and facial pain sufferers in addressing poor postural alignment (eg., forward head posture) and weakness/poor endurance of the deep neck flexors, a device was developed by one of the authors. Recent unpublished data suggest that it holds promise as a tool for improving strength and endurance of the deep neck flexors and anecdotal evidence indicates its effectiveness in improving body posture.

    • shoulder impingement,21
    • fibromyalgia,22
    • chronic neck/back pain, and
    • osteoporotic deformity in the upper thoracic region.23
    Last updated on: November 1, 2012
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