1303
Decreased Isometric Neck Strength in Women With Chronic
Neck Pain and the Repeatability of Neck Strength
Measurements
Jari Ylinen, MD, Petri Salo, PT, Matti Nykänen, MD, Hannu Kautiainen, BA, Arja Häkkinen, PhD
ABSTRACT. Ylinen J, Salo P, Nykänen M, Kautiainen H,
Häkkinen A. Decreased isometric neck strength in women with
chronic neck pain and the repeatibility of neck strength
measurements. Arch Phys Med Rehabil 2004;85:1303-8.
Objectives: To evaluate neck flexion, extension, and, espe-
cially, rotation strength in women with chronic neck pain
compared with healthy controls and to evaluate the repeatabil-
ity of peak isometric neck strength measurements in patients
with neck pain.
Design: Cross-sectional.
Settings: Rehabilitation center and physical and rehabilita-
tion medicine department at a Finnish hospital.
Participants: Twenty-one women with chronic neck pain
and healthy controls matched for sex, age, anthropometric
measures, and occupation.
Interventions: Not applicable.
Main Outcome Measures: Peak isometric strength of the
cervical muscles was tested in rotation, flexion, and extension.
Results: Significantly lower flexion (29%), extension (29%),
and rotation forces (23%) were produced by the chronic neck
pain group compared with controls. When the repeated test
results were compared pairwise against their mean, consider-
able variation was observed in the measures on the individual
level. Intratester repeatability of the neck muscle strength mea-
surements was good in all the 4 directions tested in the chronic
neck pain group (intraclass correlation coefficient range, .74 –
.94). The coefficient of repeatability was 15N, both in flexion
and extension, and 1.8Nm in rotation. On the group level,
improvement up to 10% due to repeated testing was observed.
Conclusions: The group with neck pain had lower neck
muscle strength in all the directions tested than the control
group. This factor should be considered when planning reha-
bilitation programs. Strength tests may be useful in monitoring
training progress in clinical settings, but training programs
should be planned so that the improvement in results is well
above biologic variation, measurement error, and learning ef-
fect because of repeated testing.
Key Words: Muscles; Neck; Rehabilitation; Torque.
© 2004 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
From the Department of Physical and Rehabilitation Medicine, Jyväskylä Central
Hospital, Jyväskylä (Ylinen, Salo, Häkkinen); Punkaharju Rehabilitation Center,
Punkaharju (Nykänen); and Rheumatism Foundation Hospital, Heinola (Kautiainen),
Finland.
Supported in part by the Finnish Social Insurance Institution and Jyväskylä Central
Hospital.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Jari Ylinen, MD, Jyväskylä Central Hospital, Dept of Physical
and Rehabilitation Medicine, Keskussairaalantie 19, 40620 Jyväskylä, Finland,
e-mail: jari.ylinen@ksshp.fi.
0003-9993/04/8508-8685$30.00/0
doi:10.1016/j.apmr.2003.09.018
C HRONIC NECK PAIN IS a common musculoskeletal
disorder in the working-age population in modern indus-
trialized countries.1-3 It has considerable economic impact
through sick leave and the increased use of primary health care
services, medication, specialist care, laboratory tests, diagnos-
tic imaging, and therapeutic interventions.4,5
Muscle function is an important factor in understanding neck
pain. Chronic neck pain is thought to be more common among
women, because their muscle strength is lower than that of
men.6 The sustained muscle contraction required to hold the
head in various positions and the fatigue because of muscular
weakness are suspected of being causative factors in chronic
neck pain.7,8 Gogia and Sabbahi9 found greater neck muscle
fatigue in patients with chronic neck pain than in healthy
controls in the electromyographic analysis. Several studies
have found weakness in the cervical flexor and extensor mus-
cles in patients with chronic neck pain compared with healthy
controls,10-14 but we did not find anyone to report weakness in
the rotator muscles.
The reliability of isometric neck strength measurements has
been found to be good both in healthy subjects and in patients
with chronic neck pain.11-24 However, the statistical methods
used in earlier studies do not make visible the possible varia-
tion in the results between repeated tests in individual cases
because of biologic variation and measurement error.
The main aim of our study was to evaluate whether patients
with chronic neck pain had lower neck strength—in particular,
isometric rotation strength—than healthy controls. A second-
ary objective was to evaluate, by using appropriate statistical
methods, the repeatability of isometric neck strength tests in
women with chronic neck pain.
METHODS
Participants
The subjects, women with nonspecific chronic neck pain for
at least 6 months, were recruited through local occupational
health care services in eastern and southern Finland. The other
inclusion criteria were age 25 to 53 years, full-time office
worker, and permanently employed. In most patients with
chronic neck pain, no specific neck pain etiology is generally
revealed by clinical examination, laboratory tests, or medical
imaging techniques. Such patients are commonly defined as
having mechanical neck pain or nonspecific neck pain. The
exclusion criteria in our study were the presence of specific
diseases known to cause chronic neck pain, such as nerve root
compression, a previous cervical operation, peripheral nerve
entrapment, spinal stenosis, known radiologic instability,
anomaly of the cervical spine, spasmodic torticollis, disorder of
the shoulder, fibromyalgia, rheumatoid arthritis, or other in-
flammatory joint diseases, as well as diseases and conditions
preventing physical loading, such as pregnancy, severe depres-
sion, mental illness, a recent major operation, or acute infec-
tion. These states were assessed mainly on the basis of the
patient’s medical history and the clinical examination. All the
Arch Phys Med Rehabil Vol 85, August 2004
1304 NECK STRENGTH IN WOMEN WITH NECK PAIN, Ylinen

Table 1: Demographic and Clinical Data of the Women With The head was centralized by a screw system traveling the same
Chronic Nonspecific Neck Pain and Healthy Controls distance from both sides and tightening the support against the
Neck Pain Group Control Group head. Then the subjects were instructed to turn the head to the
(n⫽21) (n⫽21) right and to the left against the head supports.
Demographic
During the flexion and extension measurements, the subjects
Age (y) 44⫾6 44⫾8
pushed directly forward or backward against the padded strain
Weight (kg) 68⫾10 69⫾13
gauge of the neck strength measurement system. Verbal en-
Height (cm) 166⫾6 165⫾5
couragement was given in a steady loud voice without shout-
BMI (kg/m2) 25⫾3 25⫾4
ing. Changing position took about 2 minutes. Three submaxi-
Clinical
mal warm-up efforts with gradually increasing force were
Grip strength, right (N) 324⫾59 314⫾69
performed in each direction, to acquaint subjects with the
Grip strength, left (N) 294⫾69 294⫾49
testing position and with the neck strength measurement sys-
tem. In the test trials, each subject was told to perform at least
NOTE. Values are mean ⫾ SD. 3 maximal efforts lasting 5 seconds each, at 45-second inter-
Abbreviation: BMI, body mass index. vals. If the third result showed an improvement of more than
5%, additional efforts were performed until the improvement in
strength remained under that. The best result was used in the
final analysis.
participants gave written consent before entering the study. The
local ethics committee approved the study.
The patients who volunteered to participate in the study were
21 middle-aged women (table 1). They filled out a set of
questionnaires assessing their neck pain and level of disability.
Mean neck pain ⫾ standard deviation (SD) was 54⫾22mm on
the visual analog scale.25 The mean Oswestry26 and Vernon27
disability indices were 13⫾8 and 13⫾5, respectively. The
women had been suffering from neck pain for an average of
9⫾6 years.
The healthy controls were recruited from among office
workers (n⫽263) at Jyväskylä Central Hospital via an e-mail
message describing the study. The control group finally con-
sisted of 21 women, none of whom had had any neck pain
during the previous 6 months or any of the other contraindi-
cations listed above. None of the controls had any background
in strength training, and they were only infrequently engaged in
physical exercise. The control subjects were matched with the
patients for occupation (office work), sex (female), age (⫾5y),
weight (⫾5kg), and height (⫾5cm), to eliminate major con-
founding factors (table 1).
Hand-grip strength is commonly used to assess the func-
tional ability of the upper extremities, and it has also been
shown to correlate with overall muscle strength of the body,
sex, age, anthropometric parameters, health, and remaining-life
time in the aged.28,29 Thus, this measure was chosen as a
practical method of comparing the general strength levels of
the subjects with the controls (table 1). Grip strength was
measured by a Jamar dynamometer.30,a The subjects performed
3 maximal efforts at 45-second intervals in a sitting position
with the wrist straight and the elbow at a 90° angle.
Experimental Procedure
The neck strength measurement systemb was used to test the
selected parameters of isometric neck strength with subjects
seated in a standard position, and the methodology followed
the same method used in testing healthy subjects in the reli-
ability study reported earlier (fig 1).24 The measurement system
was calibrated with standard weights (5kg, 10kg, 15kg, 20kg).
Isometric rotation strength was measured first. Torque was not
measured from the head supports but from the shaft of the
apparatus to which the head supports were attached. The rota-
tional axis of the upper cervical column, which runs through Fig 1. Neck strength measurement system consists of 2 parts
the center of the dens,31 was brought into the same line as the having strain gauges of their own. Rotator muscle strength is mea-
shaft of the measurement device. The openings of both ear sured with the part above the head, which is attached on both sides
of the head by 4 pads. Flexor and extensor muscle strength is
canals are located directly above the dens. Thus, the head was measured with the pad, which is now supporting the head, but
positioned by looking at the opening of both ear canals from 2 which is lifted up to the level of the forehead and occiput on these
sights running parallel to the shaft of the measurement device. tests.

Arch Phys Med Rehabil Vol 85, August 2004

 NECK STRENGTH IN WOMEN WITH NECK PAIN, Ylinen
Table 2: Peak Isometric Neck Strength Values in Women With Chronic Neck Pain and Healthy Controls
Neck Pain
Group
Rotation (Nm)
Right 5.8⫾1.2
Left 6.1⫾1.6
Flexion (N) 53.8⫾18.3
Extension (N) 132.1⫾38.5
NOTE. Values are mean ⫾ SD unless otherwise noted.
*Multivariate P value (Hotelling T2): P⬍.001.
†
Univariate, t test.
In the chronic group with neck pain, the strength tests were
repeated at the same time on the following day by the same
tester, to evaluate repeatability. The tests were conducted by 2
physiotherapists, both of whom had considerable experience in
strength testing with the neck strength measurement system.
Statistical Procedures
The results are expressed as means with SDs and with 95%
confidence intervals (CIs). Intraclass correlation coefficients
(ICCs) and coefficients of repeatability were calculated be-
tween 2 repeated trials for each strength parameter tested. An
analysis described by Bland and Altman32 was done in which
differences between 2 strength measurements were plotted
against the corresponding mean for each patient, to show the
variability of the results at the individual level. Statistical
comparisons between the groups were performed using the
2-tailed unpaired t test and the multivariate Hotelling T2 test.33
Hommel adjustments were used to correct levels of signifi-
cance for multiple testing. Correlation coefficients were calcu-
lated by the Pearson method. The normality of variables was
evaluated by the Kolmogorov-Smirnov test with Lilliefors sig-
nificance or by the Shapiro-Wilk test. The ␣ level was set at .05
for all tests. Statistical packages SPSS, version 11.0,c and
STATA, version 8.0,d were used for the analysis.
RESULTS
The distributions of age, anthropometric measures, and grip
strength were similar in both groups (table 1). There was a
significant difference in peak force production between the
patient group and the control group in both the multivariate test
and the univariate t test (table 2). Peak force production in the
patient group was 29% lower in both flexion and extension and
23% lower in rotation than in the healthy control group. The
individual variation in the peak force produced was consider-
able in the patient group and even greater in the control group.
No significant difference emerged in the neck flexion/extension
strength ratio between the patient (.41) and control (.40)
groups.
There was no significant difference in the peak force pro-
duced in rotation to right and left within either of the groups.
Pearson correlation coefficients between the different force
Table 3: Correlation (Pearson) Coefficients With 95% CIs Between Different Parameters of Isometric Neck Strength Within Groups
Neck Pain Group (n⫽21)
Rotation, Rotation,
Right Left
Rotation, left .80 (.56–.92)
Flexion .61 (.24–.82) .57 (.19–.81)
Extension .65 (.31–.85) .62 (.26–.83)
1305
Mean (95% CI) Difference
Control Group Between Groups* P Value†
8.0⫾2.4 2.2 (1.0–3.4) ⬍.001
7.4⫾2.3 1.3 (0.1–2.6) .032
75.7⫾23.5 21.8 (8.7–35.0) .002
187.1⫾39.2 54.9 (30.7–79.1) ⬍.001
parameters within groups were slightly better for the control
group than for the patient group (table 3).
In the control group, 40% of subjects made 4 efforts in
rotation and 12% made a fifth effort, whereas 29% made 4
efforts in flexion and 19% made 4 efforts in extension. In the
patient group, 48% of subjects made 4 efforts in rotation, 14%
made 4 efforts in flexion, and 29% made 4 efforts in extension,
but none had to perform a fifth effort. On the same test
occasion, the second or third attempt in each direction mea-
sured gave the best result in 70% to 80% of subjects in both
groups. The first attempt produced the highest result only in
10% of subjects. The same proportion of subjects attained their
best result on their fourth attempt. Although 20% of the sub-
jects performed 5 attempts in at least 1 direction, only 1 woman
in each group produced her best result on the fifth attempt in 1
direction. The second effort was on average 8%, and the third
effort 10%, better than the first.
Intratester repeatability was analyzed by using the ICC,
which varied from .74 to .98, depending on the directions
tested (table 4). The coefficient of repeatability was 15N in
flexion and extension and 1.8Nm in rotation. The differences in
peak isometric strength between the first and second measure-
ments were plotted against their means; figures 2 and 3 show
the considerable variation between the results of consecutive
tests on the individual level. The results of the second test
occasion were often greater than the results of the first for the
same patient.
There were no major complications, despite the fact that the
subjects were instructed to perform the neck strength tests with
maximal effort within the limits of pain that they were able to
bear.
DISCUSSION
Peak isometric neck strength values were statistically signif-
icantly reduced in the women with chronic neck pain compared
with healthy controls in all the directions tested. Kraut and
Anderson10 found, by manual testing, that neck flexor muscle
strength was significantly lower in a chronic neck pain popu-
lation than in healthy controls. Silverman et al11 and Barton and
Hayes12 showed this with objective measurements. Jordan et
al13,18 further confirmed this finding and found lower neck
Control Group (n⫽21)
Rotation, Rotation,
Flexion Right Left Flexion
.89 (.74–.96)
.68 (.35–.86) .62 (.26–.83)
.51 (.10–.77) .70 (.38–.87) .71 (.40–.87) .62 (.26–.83)
Arch Phys Med Rehabil Vol 85, August 2004
1306 NECK STRENGTH IN WOMEN WITH NECK PAIN, Ylinen
Table 4: Peak Neck Strength Values of Repeated Isometric Tests in Women With Chronic Neck Pain
Measurements
Isometric Testing First Day Second Day
Rotation (Nm)
Right 5.8⫾1.2 6.4⫾1.8
Left 6.1⫾1.6 6.9⫾1.6
Flexion (N) 53.8⫾18.3 59.8⫾17.3
Extension (N) 132.1⫾38.5 136.1⫾38.4
NOTE. Values are mean ⫾ SD unless otherwise indicated.
*Value below which 95% of the difference between 2 replicated measurements should lie.
extensor muscle strength in patients with neck pain compared
with controls. In addition to that, our study found weakness in
the rotator muscles. Recently we found lower neck rotator
muscle strength in patients after cervical disk surgery com-
pared with controls. Our studies have shown that neck pain is
related to muscle weakness in all the directions tested. It
remains unclear whether muscle weakness is the cause or the
result of chronic neck pain. However, it is probably not a
question of general muscle weakness in the patient group,
because there was no difference in the grip strength between
the neck pain and control groups in our study, as was also the
case after cervical disk surgery.34 Further, Ylinen et al35
showed, in their controlled study, that neck muscle training
increased neck strength, which was associated with decrease in
neck pain and disability scores.
Three efforts in each direction were selected for the testing
protocol on the basis of clinical experience from the peak
strength tests. In general, the difference between repeated mea-
surements was not great, but in a few subjects the result on the
second or third attempt was up to twice the value of the first
effort. Rotation proved an exceptionally difficult task for the
production of maximal effort during the first attempt. This may
be because it is the only direction without an antigravity
function, and, in general, people are not accustomed to making
strenuous efforts in neck rotation.
Our results differ from those obtained by Peolsson and
Öberg,22 who reported that the first value was almost always
the highest and the third one the lowest in healthy subjects,
despite having only 1 submaximal pretest trial before the
maximal effort.
Arch Phys Med Rehabil Vol 85, August 2004
Repeatability
Difference Coefficient of
Mean (95% CI) ICC Repeatability*
0.6 (1.0–1.0) .74 (.47–.89) 1.9
0.8 (0.5–1.2) .75 (.49–.89) 1.6
6.0 (2.6–9.3) .86 (.70–.94) 14.8
4.0 (0.5–7.4) .98 (.94–.99) 15.2
Pearson correlation coefficients between the different force
parameters showed a good correlation between rotation to the
right and to the left, which is understandable because the same
function is being tested, albeit in different directions. There
was also a moderate correlation between the other strength
parameters, despite the fact that the muscles involved have
different functions.36 There was no significant difference in the
flexor/extensor strength ratio between the neck pain group and
the control group, indicating that the strength of these antago-
nist muscle groups seems not to be affected differently by neck
pain.
The measures of peak isometric neck strength proved to be
reproducible in the neck pain group, as shown by the ICCs. The
highest repeatability was found in extension, which is probably
because of the fact that the extensor muscles are the strongest
muscle group in the neck. ICCs were lower in rotation, which
is the only movement not normally requiring countergravita-
tional effort and thus makes lower demands on muscle
strength. The repeatability of peak neck flexor, extensor, and
rotator muscle strength in patients with chronic neck pain
remained only slightly lower than that found in an earlier study
of the neck strength measurement system with healthy subjects
(ICC range, .94 to .98).24 The ICC, which has commonly been
used to evaluate the repeatability of measurements, lacks sen-
sitivity to systematic changes in results such as incremental
improvements because of repeated testing. Therefore, other
statistical tests should also be used.
The coefficients of repeatability already showed a moderate
level of variability in the peak strength test results. When the
differences between the repeated measurements were plotted
Fig 2. The difference in peak
flexion and extension strength
(N) between the first and sec-
ond measurements, plotted
against their mean for each
patient. Dotted lines show
95% limits of agreement.
 NECK STRENGTH IN WOMEN WITH NECK PAIN, Ylinen
Fig 3. The difference of peak
rotation strength (Nm) be-
tween the first and second
measurement, plotted against
their means for each patient.
Dotted lines show 95% limits
of agreement.
against their means, considerable variation and a tendency
toward better results on the second test occasion were found in
all the parameters tested. The reason may be that on the second
test occasion the subjects had already learned the test procedure
and were familiar with the neck strength measurement system
and could thus concentrate better on force production. The
improvement in forces varied between 10% and 13% in rota-
tion and flexion but was only 3% in extension. Thus, extension
strength seems to be more stable than the other forces mea-
sured. This may be partly because of differences in the anat-
omy and function of the muscle groups tested.
We did not find any previous studies of neck strength in-
volving the analysis recommended by Bland and Altman.
However, Rantanen37 used this analysis to evaluate the repeat-
ability of isometric trunk strength measurements and found
wide intrasubject variation, which is in line with the results of
our study. Ylinen et al24,35 showed that repeated neck strength
testing without any strength training improved the results on
average by 3% to 8% on the second test occasion on the same
day in healthy individuals and by 7% to 10% at 12-month
follow-up in women with chronic neck pain. These results
should be borne in mind when assessing improvements in
strength test results in the clinic because a small improvement
may not be the result of effective training but may be because
of biologic variation, measurement error, and a learning effect
due to repeated testing.
Because of the wide range of peak neck strength results in
both the patient and control groups, those with neck pain
cannot be differentiated from healthy persons by strength tests,
even though the patients with chronic neck pain were signifi-
cantly weaker than the healthy controls at the group level. We
have found no studies evaluating low neck strength as a pos-
sible risk factor for neck pain. However, strength testing may
be useful in testing the basic strength level of the individual
patient, setting goals for strength training, and monitoring
progress of training, provided that the training method is ef-
fective enough to improve results well above biologic varia-
tion, measurement error, and test effects, as shown in other
studies.16,35,38-40
Patients with chronic neck pain may have low neck strength
in flexion, extension, and rotation, or in any combination of
these. Knowledge of the different parameters of neck strength
is essential in planning individually tailored neck strength–
training programs. Strength testing may also be useful to mo-
tivate training, but it is of paramount importance that the
1307
training intensity is monitored and its effectiveness followed
up.
CONCLUSIONS
Neck strength in all directions was significantly lower in
patients with neck pain than in controls. Different parameters
of neck strength should be tested separately, to obtain full
information about neck strength. On the same testing occasion,
at least 3 maximal attempts in each direction should be tested
to obtain a true peak strength result. When neck strength testing
is used to follow up the training of individual patients in the
clinic, measurement error, biologic variation, and improvement
in results because of repeated testing should be kept in mind.
However, when the strength training methods used are effec-
tive, the results should be on a considerably higher level, and
therefore we recommend isometric neck strength measure-
ments for clinical settings.
Acknowledgments: We thank Kai Viertola for technical assis-
tance and expertise with the neck strength measurement system.
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