// Injury & Rehab: the cervical spine

Poor positioning of the neck during intensive exercises is the most common cause of neck injury in the gym. If your client is experiencing neck pain, a series of rehabilitative and strengthening exercises may be called for, says Merrin Martin.

Cervical spine: anatomy overview

The cervical spine allows us to move our head in all directions. The atlas and axis vertebrae at the very top of the cervical spine provide us with a large range of rotation due to their unique shape and facet joint orientation. The cervical spine vertebrae house and protect the vertebro-basilar arteries which supply blood to the brain. The small discs provide a small amount of shock absorption, when compared with lumbar discs.

The position or posture of the cervical spine is directly influenced by the lumbar spine and thoracic spine postures. For example, if there is a large thoracic kyphosis (curvature of the upper back), the cervical spine will go further into extension or lordosis to enable the eyes to become level and to look straight ahead. This results in an increased cervical lordosis or ‘poke neck’ posture.

Similar to the lumbar spine, the cervical spine uses deep musculature to ensure inter-segmental spinal control – the control of one vertebrae in relation to another. These muscles are known as longus colli and longus capitus or the ‘deep neck flexors’ (DNFs). They sit anteriorly to the spine and are involved in providing stability and flexion of the neck. Their role is to reduce the shearing forces across the facet joints and discs, and to help support the curve of the cervical spine, thereby reducing injuries.

Weak deep neck flexor muscles are evidenced by a small head lag when lifting the head off the floor during sit ups, or when the head drops down into a poke neck posture when in a plank position. Keep a watchful eye on your client’s neck posture when performing these exercises.

Common causes of neck injury

The most common cause of neck injury in the gym is poor positioning of the neck while doing intensive exercises, which increases pressure on the spine.

Examples of increased pressure on the cervical spine include pushing a heavy weight with the arms above the head; bench press with unsupported head position or extending the back of the head into the bench too far while pressing; and putting a heavy bar across the back of the shoulder with the head in a poke neck position while performing squats. It is extremely common for clients to seek treatment on their neck as a consequence of completing a heavy upper body workout. I also see clients for treatment following their participation in exercise classes that incorporate a lot of abdominal work in supine position with unsupported neck flexion.

Common complaints from neck problems include pins and needles in the arms or hands, a headache which will not go away with gentle pain medication, or ‘wry neck’ (inability to turn the head to look over the shoulder). Underlying these complaints are injuries such as strained or torn muscles, facet joint sprains/pain, nerve impingements or bulging cervical discs – and in some cases, a combination of all of these. If your client has hurt their neck during a workout, you should refer them on for a diagnosis.

What can the health professional do?

A personal trainer specialising in rehabilitation can perform exercises to help strengthen the DNF muscles. The idea is to teach the client to relax their sternocleidomastoid (SCM) at rest and throughout the initial ‘nod’ of cervical flexion movement. It is quite tricky, and to be successful in rehabilitating the neck you require knowledge of injuries, breathing techniques, relaxation techniques and massage releases to aid in reducing SCM tension.

Progressing the exercises from this beginner exercise to isometric and full range cervical flexion takes time and patience. Once the client has learnt how to maintain a good cervical posture and to activate their DNF muscles, the personal trainer is able to isometrically load the neck in neutral spine positions without changing the position of the cervical spine.

Start your client with isometric or static neck exercises to help stabilise the cervical spine in neutral position. These include all directions of movement. It is important to keep the neck still while providing resistance with your hand (photo 1). Variations include lateral flexion, flexion and extension (standing or supine lying), and rotations to the left and right.

Stretching the neck
  • All exercises and stretches for the neck should be done without any pain or aggravation.
  • Neck stretches should be held for a short period of time (five seconds only), as there is a tendency for long stretches to aggravate symptoms.
  • Always ask your client where they are feeling the stretch, as a lot of people will experience it on the opposite side of the head than is desired.
  • Never perform neck stretches with the hand anchored down (pulling the shoulder girdle into depression), as this increases the stretch on the upper body nerves and can easily aggravate them.
  • Never put pressure on the head or pull hard with the hand to perform a stretch. It is easy to shift the facet joints and cause a possible wry neck or headache as a result.

Postural retraining for the upper body and shoulder girdle muscles is key to reducing the load on the head and neck. Exercises should initially include isometric scapula stabilisation exercises (scapula ‘setting’) (photo 2). This can be progressed from an isometric squeeze exercise, to incorporate the scapula position into a seated row, and slowly progress the exercise to take the arms above the head with good scapula position, such as with a lat pulldown.

In addition, encouraging weight bearing though the arms will encourage serratus anterior activation. Serratus anterior is essential for scapula stability and allows efficient activation of the rotator cuff muscles. In turn, the serratus anterior will support and help position the cervical spine in a good postural position. Cervical spine posture is also reliant upon good core/ trunk stability, so be sure to include core training without loading the head or neck in your client’s training sessions. Examples of this include the 4-point position, half plank position and side plank position on knees (photo 3).

Remember that a neck stretch should slightly reduce the muscle spasm in a specific muscle; the stretch shouldn’t be held for a prolonged period of time to improve muscle length. Important muscles to include in a program include:

  • Levator scapulae
  • Upper trapezius
  • Pec major and minor
  • Neck extensors (sub occipitals)
  • Rhomboid
  • Scalenes.

In summary, correct cervical posture, strength in the deep neck stabilising muscles and good support from the scapula stabilisers and core muscles are essential to a healthy functioning neck.

Merrin Martin, BSc (Physio)
Based in Sydney's Neutral Bay, Merrin is the director of Active Anatomy which provides quality accredited education to qualified health professionals in the area of research-based assessment and corrective exercise. Merrin's affiliation with the Australian Institute of Fitness and Australian Fitness Network has seen her present, lecture and develop face-to-face, online and distance education courses. For more information visit www.activeanatomy.com