The Effects of Cervical-Spine Exercise Protocol for Neck Pain Pericervical Muscle Endurance and the range of motion in medical Students The Prospective Study Cureus


It is a frequent and debilitating condition that puts significant strain on the health system. There are no practical guidelines developed using a mobile commercially-available, cost-effective device that dramatically reduces chronic and acute neck pain.


Forty-six young adults suffering from or without moderate to mild neck pain, completed a 6-week stretch and strengthen program with a portable cervical stretch along with a strengthening tool. The main outcome was improvements to the pericervical muscles endurance. The secondary outcomes were improvements to the cervical range of movement (ROM) as well as neck length, circumference and the perception of pain, flexibility and strength. The measurements were taken on study days 21, and 42.


An increase of pericervical muscles endurance was evident across all cervical planes of movement, ranging from 84 percent to 105 percent. Cervical ROM increased across all directions of motion, but it was most significant for right-side bending (5.3deg) and right rotation (6.2deg) in right and left turn (7.8deg). The subjective pain assessed using the Numeric Rating Scale (NRS) had statistically significant improvements also (1.33 up to 0.51). A subjective evaluation of the cervical pain, strength and flexibility increased 61.3 percentage, 95.7%, and 97.8 percent, respectively.


A six-week training and stretching program was able to increase the endurance of the pericervical region and its ROM in adolescents. The reduction in cervical pain was observed through NRS and modified pain scales. NRS as well as a modified scales across the majority of participants.


Neck pain can affect a lot of people at one time in their lives, having a prevalence of around 21% and a 12-month frequency of 30 50 and a percentage of 0 percent [1,21 2 3 4 5 6 7 8 9. Patients suffering from chronic neck pain use medical services more often than the general population [33. The risk factors for developing neck pain in the adult population are the genetics of the patient, tobacco exposure or other tobacco products, occupations that require manual labor and over-time work. They also have a high mental load and poor mental health and insufficient leisure time in an adult community [2,4-62, 4 ].

It has been demonstrated that conservative treatment that involves active stretching and strengthening of the pericervical region provides both long- and short-term advantages in relieving the pain in neck and lifting performance [7-9]. A few of these muscles that are pericervical include the levator scapulae and rhomboid. They also include sternocleidomasto semispinalis, trapezius, splenius and multifidus. Manual and pharmacologic provider-directed methods of reducing the risk (i.e. osteopathy, chiropractic, and physical therapies) are extensively reviewed [10-1410-14]. Although these methods are commonly utilized by patients suffering from neck pain, the same readily available methods for self-mitigation to alleviate neck pain that is mild to moderate are not feasible and do not have high-quality evidence [15-19and 15-19. This study is designed to find out if a new commercially accessible device was developed for individuals to utilize ad-hoc in any setting (e.g. their house, workplace, work, etc.) can be effective in improving the endurance of their pericervical muscles and the cervical movement (ROM) and thereby reducing moderate to moderately subjective neck pain. The current study focuses on the treatment of neck pain among medical students since this group is prone to neck pain that is caused by relatively benign conditions.

Materials & Methods


Two hundred and one medical students aged 18 years or older (range from 21 to 31) old and suffering from varying neck pains based on the Numeric Rating Scale (NRS) were enrolled to be included in the study in August of 2019. From the 201 volunteers 50 participants (30 males, 20 females) were randomly chosen for inclusion in the study using random number generation using the aid the software Microsoft Excel in a simple randomization. The subjects were screened by an orthopedic surgeon (BA) during the data collection. Inclusion criteria were moderate to mild cervical pain due to the NRS and subacute, acute or chronic onset pain. The criteria for exclusion were age 18 years at the time this study a lifetime medical history of cervical pathology or surgery, trauma in the past six months, extreme cervical pain and moderate-to-severe pain associated with exercises for ROM as well as radicular pathology, disk pathology, or facet pathology. The radiographs used to determine exclusion criteria were read by a radiologist who had an musculoskeletal subspecialty, and later approved by the chief Investigator (BA). The study was approved by the appropriate institution review board the protocol was 26-064. The subjects signed an informed written consent prior to taking part in the study.

Study design

It was a prospective single-arm study in which patients with no known cervical problems were screened for changes in pericervical muscles endurance and the cervical neck ROM and circumference and subjective pain for six weeks, while following the 10-minute daily stretching and strengthening program for the cervical region developed to be utilized over 42 days using NeckX(r) device. NeckX(r) gadget (NeckX(r), LLC, Aspen, CO). NeckX(r) does not constitute a medical instrument instead it is a strength conditioning device, and doesn’t require Food and Drug Administration (FDA) approval for its sale or use. Pericervical endurance for purposes of the research is the term used to describe the pericervical muscle’s capacity to resist fatigue after repetitions of isotonic contraction. Information on the subject’s pericervical muscle endurance, neck circumference, ROM, as well as subjective pain were collected before study start (i.e. the study day zero) in addition to on days of study 21 and 42. The questionnaires for pre-study as well as post-study as well as NRSs for pain reporting were filled out on days of study 0, 21 and 42. Subject information was desensitized, and saved on an encrypted database only accessible by the researchers. The subjects of the study and team members were unaware of prior measurements during post-/inter-study study data gathering and analyses.

Evaluation of clinical needs

The endurance of the cervical muscles was the main outcome test and was measured with an NeckX(r) device during study day 0, 21 and 42. For each exercise that strengthened such as cervical extension, flexion side bent (bilaterally) as well as rotation (bilaterally) subjects performed as many full reps as they could in the time limit of 60 minutes. The subjects were permitted to take a break for 60 minutes before each session. The proper use of devices and the correct form were demonstrated to the participants prior to the use of the protocol , and they were strictly adhered to during each strength test. Participants demonstrated proper form and exercise to the research team prior to beginning an at-home stretching, and strength workout procedure (Figure 1A). This NeckX(r) gadget is displayed in Figure 1B.

Cervical ROM was an additional outcome criterion that was measured with an headset-mounted Halo digital goniometer (Halo Medical Devices, Sydney, Australia) on study days 0, 21 and 42. Subjects were in an upright spine position , and then three repetitions of cervical extension, flexion as well as side bent (bilaterally) as well as rotating (bilaterally) measures were taken and averaged. For each movement, subjects were required to move their heads as much as they could in the same direction three times, without engaging the cervical vertebrae.

Neck circumference and length were the primary outcomes criteria that were recorded on days of study between 0 and 42. For measurements of circumference the subjects sat in neutral spine position . The it could be measured from two locations between the mid-neck and the bottom of neck. The mid-neck circumference was determined by placing the upper edge of the tape measurement under the laryngeal protrusion. It is parallel to the length neck axis. The neck’s circumference at the base was measured by placing the higher edge of the tape measurement below the spinous C7 process, as well as perpendicularly to the length neck’s axis.

The subjective assessment of cervical pain as well as flexibility as well as strength, were used to determine secondary outcomes criteria. They were collected on study days 0, 21 and 42. The pain was evaluated by using two scales: an NRS for pain as well as an altered pain scale which described the neck discomfort as “worse,” “the same,” or “improved.” The cervical strength and flexibility were evaluated with a 10-point analog scale zero = zero change; 10 = significantly improved.

Study protocol

The subjects who participated in the study attended the three events for data collection (Table 1.). The workout program included the exercise for 10 minutes every day for six weeks, which was performed at the subject’s preferred location (e.g. home gym, home, or at school). The exercise consisted of three minute static stretching as well as seven minutes of cervical strengthening exercises that were isotonic. The training was a progressive program that involved more repetitions as well as larger therapy bands as participants continued to follow the six-week program.

Week 1 Week 2 Week 3 Weeks 4 5, 6, and 7
Therapy color band Yellow Green Blue Blue
The stretching (1 repetition = 10 seconds of stretch passively)
Flexion 2 reps 2 reps 2 reps 2 reps
Extension 2 reps 2 reps 2 reps 2 reps
Side bending 2 . Repeat (right) 2 . Repeat (right) Two reps (right) 2 . Repeat (right)
2 . Repetition (left) Two reps (left) Two reps (left) 2 . Repetition (left)
Neck rotation 2 . Repeat (right) Two reps (right) Two reps (right) 2 . Repeat (right)
Two reps (left) 2 . Repetition (left) Two reps (left) Two reps (left)
Flexion 10 reps in 2 sets 10 reps in 2 sets 10 reps in 2 sets 15 reps in 2 sets
Extension 10 reps in 2 sets 10 reps in 2 sets 10 reps in 2 sets 15 reps in 2 sets
Retraction 10 reps in 2 sets 10 reps in 2 sets 10 reps in 2 sets 15 reps in 2 sets
Side bending 10 reps, two sets (right) 10 reps, two sets (right) 10 reps, two sets (right) 15 reps in two sets (right)
10 reps, two sets (left) 10 reps, two sets (left) 10 reps, two sets (left) 15 reps in two sets (left)
Rotation 10 reps, two sets (right) 10 reps, two sets (right) 10 reps, two sets (right) 15 reps in two sets (right)
10 reps, two sets (left) 10 reps, two sets (left) 10 reps, two sets (left) 15 reps, two sets (left)

Analysis of statistics

Clinical measurements of pericervical muscle endurance and length of cervical range of motion, cervical circumference, and perceived neck pain, strength and flexibility was statistically evaluated. The statistical comparison was conducted between days 1 21, 42, and 0 for each category by with a two-way analysis variance (ANOVA) using multiple comparisons. Then, it was and then followed by a Tukey Kramer significant difference test using the Holm-Sidalk procedure. A beta of 0.05 was applied to all tests. The statistical analysis alpha value of 0.01 was calculated based on the Sidalk correction for Bonferroni inequality. Subjective cervical responses were analysed using chi-squared analyses with an alpha level of 0.05. The analysis was conducted with GraphPad Software, LLC, version Prism 8.


Subject demographics

46 subjects (28 males and 18 females) were enrolled in the study, with the exception of one participant who resigned prior study day 21 due the increased pain in the cervical region that was associated with the study (which was relieved upon the end of the exercise program). Three subjects were excluded from the study after being able to complete 75 percent of the study. The demographics of subjects are provided in Table 2.

Subject Demographics Study Group
The number of subjects 46
The age in years (range) 24 (21-31)
(percentage of total) (percent percent of the total)
Male 28 (61%)
Female 18 (39%)
BMI in kg/m2 (+-SD) 25.8 +- 8.18

Pericervical muscle endurance

All subjects experienced significant increases in their pericervical muscular endurance (p > 0.0001) throughout all cervical motions (Table 3 and Figure 2.). The total improvement in pericervical muscular endurance varied between 84 percent (right-side bent) to 105 percent (extension).

Plane of Motion Study Day 0 (repetitions) Study Day 21 (repetitions) Study Day 42 (repetitions)
Flexion 37.30 +- 14.18 62.87 +- 17.78 74.98 +- 19.11
Extension 35.95 +- 15.00 60.91 +- 17.52 73.52 +- 16.38
Left-side bending 38.14 +- 16.06 60.85 +- 13.12 71.40 +- 13.56
Right-side bending 38.61 +- 16.57 60.52 +- 12.63 71.14 +- 13.52
Left rotation 40.05 +- 15.99 59.22 +- 12.07 73.71 +- 13.19
Right-hand rotation 39.05 +- 15.85 58.65 +- 13.37 75.43 +- 12.67


The range of motion in the cervical region

All subjects showed an increase in ROM (p 0.008) for right-side bent (5.3deg) and right-side rotation (7.8deg) as well as left-side rotation (6.2deg) (Figure 3.). The improvement on left-side bends (4.7deg) and right-side flexion (4.6deg) did not show any significant difference. Table 4 summarizes the ROM information.

Plane of Motion Study Day 0 (degrees) Study Day 21 (degrees) Study Day 42 (degrees)
Flexion 57.64 +- 10.88 61.55 +- 8.90 62.20 +- 10.07
Extension 73.36 +- 15.17 75.66 +- 16.55 76.74 +- 14.65
Left-side bending 46.24 +- 8.47 50.18 +- 9.43 50.91 +- 8.89
Right-side bending 45.44 +- 9.32 49.40 +- 9.57 50.71 +- 8.84
Left rotation 73.83 +- 8.31 77.93 +- 8.58 80.03 +- 8.60
Right-hand rotation 76.09 +- 8.74 80.25 +- 8.34 83.93 +- 7.61


Neck circumference

Neck circumference was recorded during study days 0 and 42. There was no significant difference in neck circumference either at the upper part of the neck (p = 0.969) or in the middle of the neck (p is 0.515).

Perceptions of subjective satisfaction and satisfaction

Except for one subject who was unable to continue due to increased discomfort prior to the study day 21, none of the subjects noticed an increase in pain , or an improvement in the strength or flexibility that was a result of the study’s methodology.

Pain Day zero, 58.6% of subjects experienced mild to moderate neck discomfort. On the study day 21, 41.3% of the participants reported less neck pain as compared to the baseline (Figure 4, p 0.01). On day 42 of study, 61.3% of subjects experienced less neck pain when compared to the baseline (p less than 0.001). It was noted that the NRS pain scale demonstrated significant improvement (p less than 0.018) between study day zero (mean equal to 1.33) until the study’s day 42 (mean of 0.51).

Force: On the days of study between 21 and 42 76.1 percentage (p > 0.01) respectively 95.7 percent (p less than 0.001) of the subjects experienced subjectively increased neck strength when compared to the baseline (Figure 4.).

Flexibility: Between the study the days of 21 and 42 79.3 percent (p > 0.01) (p 0.01) and 97.8 percent (p > 0.001) of participants were able to report improvements in their flexibility in comparison to baseline (Figure 4.).



The aim of this study was to confirm the effectiveness of a home-based pericervical endurance and stretching program by using a mobile commercially accessible, affordable device that reduces neck pain with the daily 10 minute routine that lasts for six weeks. Studies have previously demonstrated that there is a positive correlation between the improvement in muscle strength in the pericervical region and reduced cervical pain. The study proved the positive relationship between pericervical muscle endurance as well as neck pain. The results confirm the study’s methodology as a successful method to ease neck pain in a short therapeutic time.

Cervical ROM significantly improved in three planes. We speculate that ROM did not increase in all planes examined due to the absence of ROM pathology within the sample and not due to the inadequacy of the protocol.

There was no change significant in neck circumference throughout the course of six weeks, which suggests an increase in pericervical muscles endurance required to alleviate neck pain is possible without significant increase in neck the size.

Although the effectiveness of pericervical muscle rehabilitation programs is not well-studied for the treatment of neck pain that is chronic however, research has been in favor of treating the lumbar region and its associated chronic low back pain by tightening and stretching of lower and lumbar muscles [20-2320-23. Lee et al. [20] found that subjects suffering from chronic low back pain were significantly weaker in strength of the knee and trunk extensors when compared with gender- and age-matched controls. A 12-week program of physical rehabilitation on the knee extensor and trunk muscles for those suffering from long-term back pain has shown to significantly improve their strength. back pain has been shown to dramatically increase the strength of knee and trunk extension while reducing pain and disability [21,2222. Nelson et al. [23treatment of 46 patients who were deemed eligible for cervical or lumbar surgery using 10 weeks of strengthening treatment and only three went to undergo the procedure previously approved. Concerning the cervical spine it is unclear if concise or practical protocol has been published that utilize the portable, readily available affordable device that dramatically reduces chronic and acute neck discomfort.

A study done by Ylinen et al. [8] showed similar results as this study in regards to neck pain, cervical ROM and pericervical endurance. Ylinen et al. observed statistically significant improvements of neck pain and ROM and endurance for middle-aged women who did at-home neck stretching exercises and isometric strengthening exercises using Theraband (Hygiene Corp., Akron, OH) three times per week for one year. However, this study observed improvements in the same variables with just 3 to 6 weeks.

Highland et al. [24] evaluated the efficacy of the machine-based (MedX Cervical Extension machine; MedX Corp., Ocala, FL) cervical extension and flexion strengthening program to improve pericervical muscular strength, ROM, and the perception of neck discomfort. The patient population included those with known injuries to the cervical spine, degenerative discs, and herniated disc disorders (n > 90). Participants participated in 12 workouts at the gym over eight weeks. The authors observed significant improvement on strength, flexibility and neck pain throughout the entire cohort as well as across all diagnostic groups. While it is effective, this study’s exercise machine-based regimen could be difficult for the general population.

Hakkinen et al. [25] investigated the effects of stretching and manual therapy on neck pain, cervical strength and ROM during a controlled, randomized study of 125 patients suffering from chronic neck pain, which was diagnosed with cervical strain. Participants engaged in either the active stretch and massage (five times a week for 4 months) and manual therapies by itself (twice every week for 4 weeks). The authors observed statistically significant improvement in both groups with respect to neck discomfort as well as cervical ROM. However, only minor improvement was observed for both groups in relation to the strength of the pericervical muscles. These results call into questions the long-term neck-pain reduction benefits from stretching as well as manual therapy in cases where pericervical muscle strength is not included.

The improvements observed in pericervical muscle endurance, range of motion, and measured neck pain perception are encouraging as they were recorded using a significantly more compact (three-to-six weeks) exercise program than the previously studied studies. The brief procedure (10 minutes daily, five days each week over 6 weeks) and portable design enabled participants to perform the exercise exercises at their leisure throughout the day , instead of going to a fitness or gym center to carry out their routine. This could have led to a higher level of acceptance. It is also possible that by gradually increasing the intensity of exercises during study day 14 and 21,, ROM increased faster when as compared to the previous methods that required months to see improvement.


The research design was restricted by the size of the sample. While standard random sampling methods were used to select the participants, the research was designed specifically to examine the young graduates within the boundaries of a specific geographical location. The result was a group of students between the age of 21 and 31 and might not accurately reflect healthy normal populations, much less those with diseases. Further studies are needed to verify this method as well as the device’s use in older and sickly populations.

Another limitation of the study was the absence of an uncontrolled group. The data of all subjects on the study’s days 21, 42 and 23 were examined with the baseline data collected on day zero of the study, inclusion of a control group , or an additional study arm that utilized an alternative treatment approach will strengthen the results obtained from this investigation.

The short study and the short time between follow-ups can be criticised. The study didn’t monitor subjects for longer periods to evaluate their continued compliance with the protocols, sustained pericervical muscular endurance and ROM, as well as the lasting improvement or worsening neck pain.


Active ROM as well as durability of the cervical muscles grew in the course of our six-week incremental training program. In addition, the majority of our subjects experienced an improvement in their daily cervical neck pain following the six-week pericervical muscular stretch and endurance. This is why it is the opinion of the authors that this program could delay or even eliminate surgical treatment and be of great benefit to those who suffer from severe neck pain and advanced cervical diseases (e.g. an underlying history of chronic cervical muscles strains, cervical arthrosis of the facet or herniated disc diseases that is accompanied by cervical pain). Further studies must be conducted using this particular group of subjects to verify the efficacy of this simple, low-cost device and the new protocol. It could be a useful alternative for therapists, patients primary health care providers as well as specialists. The authors suggest that this exercise routine could be a beneficial prophylactic exercise program for athletes at high risk. In this regard, future studies will also be focused on athletes who are high-impact (e.g. soccer, football, hockey, lacrosse, etc.) and the capacity of this device to help prevent and treat sports-related neck pain, pericervical injuries or ROM deficiency and even concussion.