ARTICLE IN PRESS

Manual Therapy 12 (2007) 34–39

www.elsevier.com/locate/math

Original article

Cranio-cervical flexor muscle impairment at maximal, moderate, and

low loads is a feature of neck pain
Shaun O’Leary!, Gwendolen Jull, Mehwa Kim, Bill Vicenzino
Division of Physiotherapy, The University of Queensland, St Lucia Queensland 4072, Australia
Received 20 May 2005; received in revised form 19 December 2005; accepted 13 February 2006

Abstract

Impairment of the cranio-cervical flexor (CCF) muscles is a feature of painful cervical spine disorders. The aim of this study was
to investigate if CCF muscle impairment is present over a range of contraction intensities (maximal, moderate, low) in neck pain
sufferers compared to individuals with no history of neck pain. Isometric CCF muscle strength (isometric maximal voluntary
contraction (MVC)), and endurance at moderate (50% of MVC), and low (20% of MVC) loads was compared in 46 participants
with neck pain (Neck Disability Index (NDI): mean7SD; 22.875.2) and 47 control participants (NDI: 2.672.6). Compared to the
control group, the neck pain group had a significant deficit (15.9%, P ¼ 0:037) in their MVC peak torque recordings, as well as a
significantly reduced capacity to sustain isometric CCF muscle contractions to task failure at 20% of MVC (35% deficit, P ¼ 0:03)
and 50% of MVC (27% deficit, P ¼ 0:002). Neck pain participants also demonstrated poorer accuracy in maintaining their MVC20
contraction at the nominated isometric CCF torque amplitude (P ¼ 0:02), compared to control participants. It would appear that
impairment in isometric CCF muscle performance exists over a range of contraction intensities in neck pain sufferers, which may
benefit from specific therapeutic intervention.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Cranio-cervical flexor muscles; Neck pain; Dynamometry

1. Introduction anterior muscles) to the head, affords them functional

Cranio-cervical flexor (CCF) muscle impairment is a
feature of painful cervical spine disorders (Watson and
Trott, 1993; Falla et al., 2004a, b; Jull et al., 2004b), and
their rehabilitation is effective in reducing the symptoms
of cervicogenic headache (Jull et al., 2002). In accor-
dance, specific assessment and rehabilitation of their
performance is an accepted practice in the clinical
management of neck pain and cervicogenic headache
(Jull et al., 2002, 2004a). Specific assessment of these
muscles is warranted because, compared to other
cervical flexor muscles, the attachment of the CCF
muscles (primarily the longus capitis and rectus capitis
!Corresponding author. Tel.: +61 7 3365 4587;
fax: +61 7 3365 2775.
E-mail address: s.oleary@shrs.uq.edu.au (S. O’Leary).
autonomy in orientation and stability of the specialized
upper cervical motion segments (Vasavada et al., 1998;
Moore and Dalley, 1999; Kettler et al., 2002). Theore-
tically, deficits in the contractile capacity of the CCF
muscles would destabilize the cranio-cervical region with
a tendency for it to extend and as such, poor
performance of these muscles has been implicated in
abnormal head on neck posture (Janda, 1988; Jull, 1988;
Watson and Trott, 1993; Grimmer and Trott, 1998).
While tests of isometric cervical flexor muscle
performance using various dynamometry methods have
been widely described (Jordan et al., 1999; Peolsson
et al., 2001; Chiu and Lo, 2002; Garces et al., 2002; Seng
et al., 2002; Gabriel et al., 2004; Ylinen et al., 2004),
specific measurements of isometric CCF muscle perfor-
mance are less common (Watson and Trott, 1993; Jull
et al., 2004a; O’Leary et al., 2005b). Watson and Trott

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2006.02.010
 ARTICLE IN PRESS
S. O’Leary et al. / Manual Therapy 12 (2007) 34–39
(1993) using an isometric dynamometry method showed
deficits in CCF muscle maximal strength and endurance
in cervicogenic headache sufferers compared to control
participants. Deficits in low load CCF muscle perfor-
mance have also been shown in neck pain sufferers
compared to control participants when performing the
cranio-cervical flexion test (Jull et al., 2004b). The
cranio-cervical flexion test method utilizes a pneumatic
pressure sensor placed behind the upper cervical spine to
monitor the capacity of the CCF muscles to flatten the
cervical lordosis. Larger pressure shortfalls (Jull et al.,
1999, 2004b; Jull, 2000), and altered coordination of the
CCF muscles within the cervical flexor synergy, char-
acterized by reduced activity of primary CCF muscles
(longus capitis) that coincided with elevated activity of
superficial muscles that are not primary CCF muscles
(sternocleidomatoid, anterior scalenes) (Falla et al.,
2004b), have been demonstrated in participants with
neck pain when compared to control participants. Such
findings of CCF muscle impairment at low load have
underpinned strategies for their rehabilitation (Jull
et al., 2002, 2004a).
The purpose of this study was to investigate isometric
CCF muscle performance at maximal (maximal volun-
tary contraction—MVC), moderate (50% of MVC), and
low (20% of MVC) contraction intensities in neck pain
sufferers compared to control participants using a
cranio-cervical flexion dynamometry method (O’Leary
et al., 2005b). The aim of these isometric tests was to
challenge the CCF muscles over a spectrum of contrac-
tion intensities as would be required for cranio-cervical
postural function. The hypothesis was that participants
with neck pain would demonstrate poorer performance
over the spectrum of contraction intensities (maximal,
moderate, low) compared to control participants with
no history of neck pain.
2. Methods
2.1. Participants
Ninety-three female volunteers participated in this
study including 46 participants with a history of neck
pain (age 37.0710.1 years, weight 64.0710.6 kg, height
166.276.7 cm), and 47 control participants with no
history of neck pain (age 27.877.7 years, weight
62.679.3 kg, height 167.576.1 cm). Groups were simi-
lar in their height and weight characteristics but there
was a significant difference in age (Po0:0001) with the
neck pain group being older. Females only were
included in this comparative cohort study so as to
eliminate a potential confounding factor of gender to
strength measures (Jordan et al., 1999; Kumar et al.,
2001; Portero and Genries, 2003).
35
All participants were recruited via electronic and
written advertising within the university and general
community. Participants with neck pain were included if
they reported neck pain of greater than 3 months
duration of either a traumatic or non-traumatic origin,
scored greater than 10/100 on the Neck Disability Index
(NDI) (NDI 22.875.2) (Vernon, 1996), and demon-
strated positive findings on a physical examination of
the cervical spine such as altered joint motion, and
painful reactivity to palpation (Jull, 1994). Control
participants were included if they reported no history of
neck pain for which they had sought treatment, scored
less than 10 on the NDI (NDI 2.672.6), and had no
positive findings on a physical examination of the
cervical spine.
Participants in either group were excluded if they had
specifically trained their neck or shoulder girdle muscles
in the preceding 6 months, had neck pain from non-
musculoskeletal causes, neurological signs, or any
medical disorder contraindicating physical exercise.
After receiving verbal and written information each
participant signed a consent form. This study was
ethically approved by the University’s Medical Research
Ethics Committee and was in accordance with the
declaration of Helsinki.
2.2. Instrumentation and measurement procedure
CCF muscle performance was measured in supine
using a cranio-cervical flexion dynamometer (Fig. 1)
that has been shown to have good test–retest measure-
ment reliability (ICC 0.7–0.92) (O’Leary, 2005). The
dynamometer measures isometric CCF muscle torque
about the axis of rotation (AOR) of the C0/1 motion
segment that lies in close proximity to the anterior
mastoid process (Harms-Ringdahl et al., 1986; White
and Panjabi, 1990; vanMameran et al., 1992). Due the
occlusion of the anterior mastoid process from direct
vision by the ear, the axis of the dynamometer was
aligned to the concha of the ear as this best approxi-
mated the anterior mastoid process (O’Leary et al.,
2005b).
The CCF effort was resisted at the under-surface of
the mandible by the dynamometer resistance arm
producing a torque at the dynamometer axis that was
measured in Newton meters (N m). Any tendency for the
participant to push their head into or lift it off the
supporting surface, thought to be a possible strategy to
enhance CCF muscle torque (O’Leary et al., 2005a), was
monitored with a force platform (Watson and Trott,
1993; O’Leary, 2005). All measurements of CCF muscle
torque were recorded in an anthropometric neutral
cranio-cervical flexion/extension position (Montagu,
1960; Norton and Olds, 1996), with the participant’s
knees and hips positioned in 451 and the arms folded
 ARTICLE IN PRESS
36 S. O’Leary et al. / Manual Therapy 12 (2007) 34–39
Fig. 1. Cranio-cervical flexion dynamometry device for the measure-
ment of isometric cranio-cervical flexor muscle torque about the AOR
of the C0/1 motion segment. The dynamometer axis is aligned to the
participants’ C0/1 AOR (concha of the ear) with the assistance of the
web camera. The dynamometer resistance arm is extended from the
dynamometer axis so that the application pad sat comfortably at the
under-surface of the mandible. When the participant performed a
cranio-cervical flexion effort it resulted in torque at the dynamometer
axis that was recorded in Newton-meters (N m). The head was
supported on a padded platform supported on ball bearings to
minimize friction at the point of head contact and suspended on a
mechanical transducer to monitor changes in dorsal head force on the
supporting surface.
across the chest to minimize the effects of limb leverage
(O’Leary et al., 2005b).
Two custom-written LabView programs (LabView 6i
Virtual Instruments) recorded the CCF muscle torque
data at 20 Hz. The first was for the measurement of
isometric MVC peak torque, and the second for
endurance measurements of sustained torque at 20%
of MVC (MVC20) and 50% of MVC (MVC50). Visual
feedback of CCF muscle torque was provided to
participants on a visual display unit.
Maximal voluntary contraction (MVC) test: Five
MVC trials were performed following a standardized
warm up procedure. A rest period of 1 m was given
between repetitions. Participants were instructed to nod
their head (‘yes’ type action) such that their jaw pushed
down onto the padded bar in an effort to maximally
elevate the visual display graph. Following the MVC
trials, 5 min rest was permitted before performing the
endurance tests.
MVC20 and MVC50 tests: The MVC20 test was
performed first. Participants performed cranio-cervical
flexion onto the application pad of the dynamometer to
elevate the visual display graph to the marker indicating
20% of their MVC effort. Participants were asked to
accurately maintain this level of contraction effort until
they perceived that their muscles were too fatigued to
sustain the contraction any longer. No expectations
were given to participants of any maximal time limit for
the test and they were not informed that the Labview
program was set to default after a 10-min time period.
Participants were warned that while some discomfort
associated with muscle fatigue was to be expected, they
were to discontinue the test if they experienced their
reported neck pain symptoms, or pain in the jaw, head,
or upper limbs. Following completion of the MVC20 test
and 10 min rest, the MVC50 test was performed using
the same procedure as for the MVC20 test with the
exception that the target torque was set at 50% of MVC.
All participants received standardized verbal encour-
agement during the dynamometry tests.
2.3. Data management and statistical analysis
Data were excluded for measurements that repro-
duced participants’ painful neck symptoms, or produced
pain in the head, jaw, or upper limb during the
dynamometry procedure, or if the participant found it
too difficult to control the dual task of CCF and control
of their dorsal head force on the supporting surface.
For the MVC measurements the highest amplitude
torque measurement (N m) of the five MVC trials was
recorded as the MVC peak torque score.
For the MVC20,50 tests, two measures were extracted
from each trial. The time (s) until the participant
terminated the test was recorded as the time to task
failure measure. The second measure, contraction
accuracy, was calculated as the percentage of the
recorded samples that remained within a previously
detailed amplitude margin (73%) either side of the
expected torque task for the duration of the test
(O’Leary, 2005). This calculation was performed offline
using a custom written program (LabView 6i Virtual
Instruments). The first 10 s of data for each test was
discarded as this time was permitted for the participant
to reach and stabilize the contraction.
Group means (7standard deviation) were computed
for both the neck pain and control groups for all
measures (MVC peak torque, MVC20,50 time to task
failure, contraction accuracy). Between group data were
compared using a general linear model univariate
analysis for the MVC peak torque measure (N m), and
a multivariate analysis for the MVC20 and MVC50

S. O’Leary et al. / Manual Therapy 12 (2007) 34–39
measures of time to task failure (seconds), and contrac-
tion accuracy (% accuracy). All group comparative
analyses included the age as a covariate to account for
any discrepancies due to the significant age difference
between the groups.
3. Results
3.1. MVC test
All 93 participants completed the MVC trials with no
report of neck pain during these measures. The neck
pain group (n ¼ 46) showed significantly less CCF
muscle strength (P ¼ 0:037) than the control group
(n ¼ 47), demonstrating a deficit of 15.9% of peak
torque (Table 1).
3.2. MVC20 test
Between-group comparisons were made between 31
neck pain and 36 control participants for the MVC20
test following the exclusion of data due to the onset of
pain (14 neck pain, 8 control), and inability to control
the dual task of CCF muscle torque and dorsal head
force (1 neck pain, 3 controls). Six of the control and
two of the neck pain participants maintained the
contraction for the 10-min time limit of the test. These
data were retained in the analysis.
The time to task failure measure revealed that the
neck pain group could not sustain the MVC20 contrac-
tion for as long as the control participants (mean
difference ¼ 86.7 s (35% deficit), P ¼ 0:03, Table 1).
The neck pain group were significantly less accurate at
sustaining the MVC20 contraction within the set margin
(P ¼ 0:02), demonstrating a deficit of 10.4% compared
to the control group.
Table 1
Comparison of group (neck pain, control) means7standard deviations
for the isometric maximal voluntary contraction (MVC) peak torque
measurement, and the 20% MVC (MVC20) and 50% MVC (MVC50)
measurements of time to task failure (seconds), and contraction
accuracy (%)
Measurements Neck pain
MVC
Peak torque (N m) 5.371.5!
MVC20
Time to task failure (s) 158.47154.2!
Contraction accuracy (%) 33.1715.7!
MVC50
Time to task failure (s) 48.1723.6!
Contraction accuracy (%) 35.7717.3
! Denotes significant differences between groups (Po0:05).
ARTICLE IN PRESS
37
3.3. MVC50 test
Between-group comparisons were made between 37
neck pain and 43 control participants for the MVC50
test following the exclusion of data due to the onset of
pain (7 neck pain, 1 control) and inability to control the
dual task of CCF torque and dorsal head force (2 neck
pain, 3 controls).
The group with neck pain exhibited a 17.8 s (27%)
deficit in the MVC50 contraction compared to controls
(P ¼ 0:002, Table 1). There were no significant group
differences for the contraction accuracy measure at
MVC50.
4. Discussion
Knowledge of the characteristics of muscle impair-
ment is a prerequisite to the appropriate prescription of
therapeutic exercise when managing painful neck
disorders. The results of this study indicate that neck
pain sufferers have deficits in CCF muscle strength,
endurance at low and moderate intensity contractions,
and contraction precision at low intensity contractions.
Each of these deficits may require specific exercise
strategies to restore as adaptations in the neuro-
muscular system to exercise appear to be related to the
specificity of training (Conley et al., 1997). Changes in
muscle performance appear to be specific to exercise
characteristics such as movement pattern, velocity of
contraction, type of contraction and joint angle (Rasch
and Morehouse, 1957; Sale and MacDougall, 1981;
Kanehisa and Miyashita, 1983; Portero et al., 2001).
Studies are now needed to evaluate training effects and
adaptations of various cervical muscle training proto-
cols in order to better match them to specific impair-
ments.
Deficits in maximal CCF muscle strength in neck pain
sufferers in this study (15.9% deficit) were similar to
those found by Watson and Trott (1993) (14.6% deficit)
in cervicogenic headache sufferers. It could be postu-
lated that when head on neck orientation is challenged
under larger loads, these muscles may be less capable of
controlling cranio-cervical joint orientation and absorb-
ing the forces of load. Poorer ability to exert maximal
Control CCF muscle torque in the presence of musculoskeletal
impairment may be intrinsic to the muscle tissue itself
such as reductions in cross-sectional area (Mayoux
6.371.7
Benhamou et al., 1989), or due to other factors such as
neural drive (Gandevia, 2001), which may also be
245.17198 influenced by factors such as pain tolerance, fear
43.5714.5
avoidance, determination, and competitiveness (Vlaeyen
and Linton, 2000; Mannion et al., 2001).
66731.5 A large (35%) and significant deficit (P ¼ 0:03) in the
37.7714
capacity of the neck pain participants to sustain an
MVC20 contraction until task failure and poorer
 ARTICLE IN PRESS
38 S. O’Leary et al. / Manual Therapy 12 (2007) 34–39
accuracy in sustaining the contraction compared to
controls was observed. Poorer contraction accuracy
when sustaining a contraction may reflect other muscle
fatigue manifestations such as muscle tremor (Gandevia,
2001). These findings are consistent with the deficits
found at low load in studies utilizing the cranio-cervical
flexion test (Jull et al., 1999, 2004b; Jull, 2000; Falla et
al., 2004b). It is feasible that poorer performance by
neck pain sufferers during the MVC20 test may be
explained by altered coordination of the CCF muscles
previously demonstrated during the cranio-cervical
flexion test (Falla et al., 2004b), however this needs to
be investigated.
A significant deficit (27%, P ¼ 0:002) was also
found for the neck pain group in their capacity to
sustain the MVC50 test to task failure. This is the first
study to demonstrate CCF muscle impairment at
moderate loads. The results of the MVC20 and
MVC50 measures suggest that when the head on
neck postural orientation is challenged under prolonged
or repetitive circumstances in a neck pain sufferer, the
CCF muscles may fatigue prematurely and not be
capable of controlling cranio-cervical orientation poten-
tially exposing cervical spine tissues to abnormal
mechanical load.
It is acknowledged that the MVC20,50 measures of
time to task failure are affected by factors other than the
intrinsic fatigue of the CCF muscle group and would
include multiple neural contributions (Hunter et al.,
2004), supraspinal influences (Gandevia 2001), and
factors such as pain tolerance, boredom, determination,
competitiveness and fear-avoidance (Vlaeyen and Lin-
ton, 2000; Mannion et al., 2001). Surprisingly a far
greater proportion of data were excluded due to the
onset of pain during the low load MVC20 test (30% of
symptomatic participants, and 17% of control partici-
pants) than during the moderate load MVC50 test (15%
of symptomatic participants, and 2% of control
participants), or during the maximal load MVC test
(no exclusions). These findings may reflect the far
greater duration for which the gentler MVC20 contrac-
tions were sustained. Perhaps pain sensitive neck
structures adversely respond to gentler sustained me-
chanical load more so than loads that are more
substantial in magnitude, but are of shorter duration.
Interestingly, a relatively high proportion of control
participants (17%) also ceased the MVC20 test due to
the onset of pain, these findings perhaps reflecting the
difficulty participants have in distinguishing pain
resulting from exercise-induced fatigue, to that per-
ceived to be a signal of potential injury. Some
participants also discontinued their test due to the onset
of jaw and head pain from the sustained pressure to the
mandible from the dynamometry procedure, this may
account for some of the control participant exclusions.
Irrespective, the high proportion of data excluded from
the MVC20 test due to pain, jeopardizes the tests clinical
usefulness as measure of muscle fatigue.
For all measurements (MVC, MVC20, MVC50), age
was entered as a covariate in statistical analysis to
account for the neck pain group being older (9.2 years)
than the control group. With regard to the MVC
measures, isometric cervical spine strength has been
shown to decrease with age (Jordan et al., 1999; Garces
et al., 2002), however perhaps not significantly so until
the seventh decade (Jordan et al., 1999; Ylinen et al.,
2004). Barber (1994), using the same isometric dyna-
mometry method for the CCF muscles as Watson and
Trott (1993), demonstrated no significant effects of age
on CCF muscle strength in women over a 20–65 years
age range. In our study, age did not have a significant
effect on the MVC peak torque measures (P ¼ 0:14) or
for any of the MVC20 measures (P40:36). However, age
was a significant factor for the MVC50 measure of time
to task failure (P ¼ 0:04), but did not alter between-
group differences in this measure.
It should be noted that the neck pain participants
used in this study were of a mild neck pain severity
according to the NDI score (Vernon, 1996). Participants
had an average NDI of 22.8 points out of a possible 100.
We chose to use participants with only mild symptoms
to optimally scrutinize the presence of CCF muscle
impairment in neck pain. We could reasonably expect
that participant populations with greater NDI scores
would show larger differences in measurements.
5. Conclusion
This study found deficits in isometric CCF muscle
performance across a spectrum of contraction intensities
in persons with neck pain. These findings suggest that
rehabilitative exercise of the CCF muscles in neck pain
sufferers may need to incorporate various intensities,
durations, and precision of CCF muscle contraction
efforts.
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