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Introduction

Neck flexor endurance can be reduced with different types of neck pain and after some types of neck and head injuries . Reduced times have been correlated with reductions in function and increases in pain experienced. This is not necessarily related to age, lifestyle factors or for how long you may have had neck pain (1,2). It is also not always clear why individuals develop endurance issues after the onset of neck pain (3). Sometimes it can be due to viewing your situation as worse than it actually is; also known as catastrophizing (1,4).

That being said, testing neck endurance has been shown to be meaningful and useful in neck and shoulder pain populations (5). Secondly, having this information forms the basis for home exercise prescription and we know that strengthening and endurance exercises for the neck effectively improve function and reduce neck pain (6).

This article will introduce the concepts of endurance and how it may related to persistent neck pain and or function.

What is endurance?

As defined by the National Strength and Conditioning Association of America (NSCA), it is the “time limit of a person’s ability to maintain an isometric force or a power level involving combinations of concentric and/or eccentric muscular contractions” (7). Basically, how big is your battery? Can it last as long as you would like it to!

What about strength?

As per the NSCA, strength is defined as “ the maximal force a muscle or muscle group can generate at a specified velocity” (7). While strength is entirely relevant during musculoskeletal rehab, it is typically more appropriate to first begin with building one’s work capacity (aka endurance), and skill development. It takes skill and a good foundation to display strength! I will discuss this concept more generally in another article J.

Back to endurance!

Normative values

Normative data is defined as “data from a reference population that establishes a baseline distribution for a score or measurement, and against which the score or measurement can be compared” (8). Basically, we need values that we can check your endurance scores against. While these won’t be exact, as everyone will be perform different, it gives us a range of, yea ok that’s sort of how long we’d expect most people to last. The trick is that, if in doubt, double check who the normative values were gained from. Does that match you? If say, it was done on 18-22 year old University female students and you are a 40 year old male, then that information may not match you. Generally most studies have covered most types of groups though! At least for the neck.

How to test your neck endurance

So! How do we find out about the endurance of your neck muscles? Neck flexor and extensor endurance tests have been researched well and shown to be reliable in various age groups in those with and without neck pain (2,5,9–11,13). Recently, sideways, or lateral, endurance tests have been researched, showing excellent reliability in age groups 20-40 years (2). Generally across all studies males tend to last a bit longer than females. Interestingly, side to side differences were found in the lateral endurance. This is also seen when doing side plank endurance tests.

Ok, so how do we test these actions? Check out the videos below for each test type!

Neck flexor endurance

Neck extensor endurance

Neck lateral flexor endurance

How to train your neck endurance

There are whole text books and careers dedicated to this topic. So..let’s keep it simple. Just as strength is specific, so is endurance training (14). Even if we aren’t certain on the mechanisms behind how this happens (increased sodium-potassium concentrations, buffering capacity, increased capillarization etc), we need to endure whatever we are doing. Doing this will build tolerance over time (14)!

In rehab it is useful to focus on task-specificity. How long does someone need to last to do the thing they want to do. A rock climber will need very different endurance of their neck muscles than a fisherman! Granted, most fisherman are probably looking to the God’s, asking where the fish are at ;).

Dad jokes aside, individuals will perform better in endurance if they train for endurance. How much and how often though? Generally you will improve endurance if you train with higher reps and light loads at a given weight. A moderate (6-15) to light (15-30) rep count is your goal here. Basically a weight that you can lift within that rep range. If you can’t get to 6 it’s too heavy, if you can get past 30 it’s too light!

What weight to choose? Or time? We need a max test to reference. This is where your endurance test results come in. light loads are roughly 40% of your 1 rep max. Moderate loads are roughly 60% of your 1 rep max. So simply, take your test result and choose a weight or time that is between 40-60%. If you scored 120 seconds, then you would perform 3 sets of 48-72 seconds.

If you do anything lighter than this i.e. can do 30+ reps, then you will not create a large enough mechanical stimulus for change. It is generally the last few reps, as you fatigue, that catalyze the change you are looking for.

How often. Research indicates 2-3 times a week is optimal (15). Ensuring you have adequate rest between sessions. Every alternate day is a good rule of thumb for this type of training. As a side note, if you are going through a personally stressful period, lean towards doing less, as stress can impair muscle recovery between sessions.

Takeaways:

· Do the endurance test. How long did you last? Compare it to the values in Table 1. E.g. 120 seconds

· Take 40-60% of your endurance test time. E.g. 48-72 seconds

· Do 3x sets 48-72 seconds

· Do this 2-3x/week depending on how stressful life is at the moment!

· Retest in 6 weeks.

· Do it again for another 6 weeks, for a total of 12 weeks.

Conclusion

Neck endurance can be compromised in people with persistent neck pain. Do the endurance tests to decide if you have this issue. Compare your results to the normative values. If it is less than the normative value, then improving your endurance may help improve your symptoms. Take 40-60% of your test score and perform 3 sets of that number range 2-3 times a week. Re-test your endurance in 6 weeks! Readjust your sets and reps and complete for another 6 weeks for a total program duration of 12 weeks.

Stay inquisitive and do the basics well,

[C]

References

1. Parazza S, Vanti C, O’Reilly C, Villafañe JH, Tricás Moreno JM, Estébanez De Miguel E. The relationship between cervical flexor endurance, cervical extensor endurance, VAS, and disability in subjects with neck pain. Chiropr Man Therap. 2014 Dec;22(1):10.

2. Swanson BT, Bromaghin HM, Bubacy N, Messick A, Tinker L. The lateral neck flexor endurance test: Normative values in the young adult population. Journal of Bodywork and Movement Therapies. 2020 Jul 1;24(3):242–5.

3. Falla D, Rainoldi A, Jull G, Stavrou G, Tsao H. Lack of correlation between sternocleidomastoid and scalene muscle fatigability and duration of symptoms in chronic neck pain patients. Neurophysiologie Clinique/Clinical Neurophysiology. 2004 Oct 1;34(3):159–65.

4. Reddy RS, Meziat-Filho N, Ferreira AS, Tedla JS, Kandakurti PK, Kakaraparthi VN. Comparison of neck extensor muscle endurance and cervical proprioception between asymptomatic individuals and patients with chronic neck pain. Journal of Bodywork and Movement Therapies. 2021 Apr 1;26:180–6.

5. Lemeunier N, Suri-Chilana M, Welsh P, Shearer HM, Nordin M, Wong JJ, et al. Reliability and validity of clinical tests to assess the function of the cervical spine in adults with neck pain and its associated disorders: part 5. A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) collaboration. European Journal of Physiotherapy. 2020 Nov 1;22(6):332–63.

6. Zronek M, Sanker H, Newcomb J, Donaldson M. The influence of home exercise programs for patients with non-specific or specific neck pain: a systematic review of the literature. J Man Manip Ther. 2016 May;24(2):62–73.

7. Knuttgen H, Kraemer W. Terminology and Measurement in Exercise Performance. 1987;

8. Campbell D. Normative Data. In: Volkmar FR, editor. Encyclopedia of Autism Spectrum Disorders [Internet]. New York, NY: Springer; 2013 [cited 2022 Jan 16]. p. 2062–3. Available from: https://doi.org/10.1007/978-1-4419-1698-3_315

9. Edmondston S, Björnsdóttir G, Pálsson T, Solgård H, Ussing K, Allison G. Endurance and fatigue characteristics of the neck flexor and extensor muscles during isometric tests in patients with postural neck pain. Manual Therapy. 2011 Aug 1;16(4):332–8.

10. Jarman NF, Brooks T, James CR, Hooper T, Wilhelm M, Brismée J-M, et al. Deep Neck Flexor Endurance in the Adolescent and Young Adult: Normative Data and Associated Attributes. PM&R. 2017 Oct 1;9(10):969–75.

11. Domenech MA, Sizer PS, Dedrick GS, McGalliard MK, Brismee J-M. The Deep Neck Flexor Endurance Test: Normative Data Scores in Healthy Adults. PM&R. 2011 Feb 1;3(2):105–10.

12. Kanda M, Kitamura T, Sato N. Cervicothoracic spinal alignment and neck flexor muscle endurance in young and older adult females with and without neck and shoulder pain (Katakori in Japanese). Journal of Physical Therapy Science. 2021;33(6):489–94.

13. Edmondston S, Wallumrød ME, Macléid F, Kvamme LS, Joebges S, Brabham GC. Reliability of isometric muscle endurance tests in subjects with postural neck pain. J Manipulative Physiol Ther. 2008 Jun;31(5):348–54.

14. Beardsley C. Strength is Specific: The key to optimal strength training for sports. 1st edition. Strength and Conditioning Research Limited; 2018. 328 p.

15. Beardsley C. Hypertrophy: Muscle fiber growth caused by mechanical tension. 1st edition. Strength and Conditioning Research Limited; 2019. 351 p.

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How to test and train your neck endurance