An Expert’s Approach to Neck Extensor Exercise Prescription

We know exercise is a key component of managing neck pain, but it can often be challenging to implement effectively, especially when patients are dealing with persistent symptoms.

Patient engagement is essential to a successful outcome, so as physios we need to make sure we’re prescribing the right exercises, tailored to each individual’s needs and goals, that challenge them appropriately without increasing pain.

Altered neuromuscular function can contribute to persistent symptoms, so understanding the underlying changes in neck muscle function and tailoring exercise prescription accordingly can help improve outcomes. In this blog, we explore how expert physio Dr Deborah Falla clinically reasons through prescribing neck extension exercises to restore normal muscle coordination and improve patient recovery.

Want a deep dive into neuromuscular rehabilitation for neck pain? Watch Dr Deborah Falla’s full Masterclass here.

Muscle function changes in neck pain

People with chronic neck pain often show altered muscle coordination patterns that differ significantly from healthy individuals.

For example, research shows that the sternocleidomastoid (SCM), which is usually inactive during neck extension, becomes active, while the splenius capitis shows increased activity during neck flexion. This results in excessive co-contraction and a loss of the normal directional specificity in muscle activation.

Additionally, the deep neck flexors often demonstrate reduced activation, frequently compensated for by overactivity of superficial muscles like the SCM. This altered recruitment can disrupt smooth, efficient neck movements and may contribute to ongoing symptoms.

Studies suggest that these changes don’t simply improve on their own when pain lessens, which suggests that if we want to improve neuromuscular control, then targeted exercise is required. Without it, dysfunctional muscle patterns may persist and contribute to recurrent neck pain episodes.

What the evidence says about exercise for neck pain

Exercise is well supported as an effective intervention for relieving neck pain and preventing recurrence.

Various types of exercises have been used successfully, but interestingly, there is currently no strong evidence showing superiority of one form over another, which begs the question: do we really need to prescribe chin tucks for a patient’s neck to get better?

Deborah points out 3 points to consider in relation to this question:

1 – The same exercise will not necessarily have the same effect in different neck pain presentations or severities.

2 – Pain and disability (often outcomes used in research) are important but not the only outcomes to measure. Neuromuscular function and recurrence risk are also important, and less frequently assessed in research evaluating exercise effects.

3 – While providing patients pain relief is important, specificity of exercise to address neuromuscular deficits is also important to restore normal muscle coordination and reduce recurrence.

In short, while not every patient needs highly specific neck exercises, a thorough assessment of muscle coordination helps identify who may benefit most from targeted neuromuscular training. This ensures your treatment is tailored to the individual’s unique impairments, addressing the root causes of their pain rather than just the symptoms. By pinpointing these dysfunctions early, you can design more effective rehab programs that improve muscle control, reduce pain, and lower the risk of future flare-ups.

How an expert prescribes exercises for neck pain

The first step in effective management is a detailed assessment to identify deficits and guide treatment. We’ll use Deborah’s approach to assessing neck extensor function and prescribing the relevant exercises as an example.

During assessment, she uses active neck flexion in four-point kneeling to evaluate neck extensor coordination and endurance. This position challenges the extensor muscles in a controlled way, revealing dysfunctional activation patterns that may be occurring in the patient’s everyday life. See Deborah describe how she assesses neck extensor muscle coordination in this clip from her Masterclass:

Following assessment, her exercise prescription closely mirrors what she observes. Exercises are specifically chosen to address the impairments identified, helping to retrain normal muscle function. See her explain her exercise prescription in this video from her Masterclass:

This targeted, assessment-driven approach provides clarity in exercise selection and allows ongoing reassessment to monitor progress and adjust treatment.

Exercise progression follows familiar principles, gradually increasing challenge by varying load, posture, endurance, and speed. Importantly, progression aims to bring patients back into functional positions relevant to their daily lives, such as sitting and standing, ensuring transfer to real-world activities.

This cyclical process of assess–prescribe–reassess keeps rehabilitation focused and responsive to the patient’s impairments.

Wrapping up

There’s no doubt that neck pain management can be challenging, but exercise prescription for the neck doesn’t need to be complicated.

By assessing muscle coordination and prescribing a few focused, progressive exercises, you can help patients regain control and lower the chance of their pain coming back.

Want to know more? Deborah’s Masterclass distils comprehensive research and complex concepts into a straightforward, practical approach you can start using right away, watch it here!