EFFECTS OF DEEP CERVICAL FLEXOR TRAINING ON PRESSURE

PAIN THRESHOLDS OVER MYOFASCIAL TRIGGER POINTS IN

PATIENTS WITH CHRONIC NECK PAIN
Enrique Lluch, PT, a Maria Dolores Arguisuelas, PT, b Pablo S. Coloma, PT, b Francisco Palma, PT, b
Alejandro Rey, PT, b and Deborah Falla, PT, PhD c

ABSTRACT

Objective: The purpose of this study was to assess the effects of a low-load training program for the deep cervical
flexors (DCFs) on pain, disability, and pressure pain threshold (PPT) over cervical myofascial trigger points (MTrPs)
in patients with chronic neck pain.
Methods: Thirty patients with chronic idiopathic neck pain participated in a 6-week program of specific training for
the DCF, which consisted of active craniocervical flexion performed twice per day (10-20 minutes) for the duration of
the trial. Perceived pain and disability (Neck Disability Index, 0-50) and PPT over MTrPs of the upper trapezius,
levator scapulae, and splenius capitis muscles were measured at the beginning and end of the training period.
Results: After completion of training, there was a significant reduction in Neck Disability Index values (before, 18.2 ±
12.1; after, 13.5 ± 10.6; P b .01). However, no significant changes in PPT were observed over the MTrPs.
Conclusion: Patients performing DCF training for 6 weeks demonstrated reductions in pain and disability but did not
show changes in pressure pain sensitivity over MTrPs in the splenius capitis, levator scapulae, or upper trapezius
muscles. (J Manipulative Physiol Ther 2013;36:604-611)
Key Indexing Terms: Neck Pain; Exercise; Neck Muscles; Trigger Points

t is estimated that 67% of the population will experience social impact 5; hence, appropriate management of neck pain

I neck pain at some point in their life, 1 with a higher

prevalence in women (22%) than in men (16%). 2 The
estimated annual prevalence of neck pain ranges between
30% and 50% of the adult population. 3 Neck pain tends to
become chronic and recurrent; thus, it is not uncommon that
an individual experiences periods of remission and exacer-
bation of symptoms after a first episode of neck pain. 4 These
epidemiological data translate into a significant economic and
a
PhD student, Department of Physiotherapy, University of
Valencia, Valencia, Spain.
b
Lecturer/Researcher, Department of Physiotherapy, Universi-
ty CEU Cardenal Herrera, Valencia, Spain.
c
Professor, Pain Clinic, Center for Anesthesiology, Emergency
and Intensive Care Medicine, University Hospital Göttingen,
Göttingen, Germany.
Submit requests for reprints to: Deborah Falla, PT, PhD,
Professor, Pain Clinic, Center for Anesthesiology, Emergency and
Intensive Care Medicine University Hospital Göttingen, Robert-
Koch-Str. 40 37075, Göttingen, Germany
(e-mail: deborah.falla@bccn.uni-goettingen.de).
Paper submitted October 22, 2012; in revised form August 6,
2013; accepted August 8, 2013.
0161-4754/$36.00
Copyright © 2013 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2013.08.004
to prevent the transition to chronicity has been established as
a priority in forums and debates. 6 This trend to chronicity can
be attributed in part to an inadequate recovery of cervical
muscle function after a first episode of neck pain 7 especially
considering that stability of the cervical spine largely depends
on adequate muscle control. 8
Patients with idiopathic and trauma-induced chronic neck
pain show dysfunction of the deep cervical flexors (DCFs)
(longus colli and longus capitis). 9,10 Studies have confirmed
reduced strength and endurance of these muscles, 11,12 reduced
activation during a task of craniocervical flexion, 13 and delayed
activation in response to postural perturbations. 14 Furthermore,
patients with higher reported levels of neck pain were shown to
display the greatest dysfunction of the DCF muscles. 15
Myofascial trigger points (MTrPs) are a clinical entity that
can contribute to neck pain. Indeed, the referred pain elicited
by active MTrPs in the neck and shoulder muscles has been
shown to contribute to symptoms of mechanical neck pain. 16
An MTrP is defined as a hyperirritable focus within a taut band
of skeletal muscle that is painful on compression and that,
when stimulated (usually by compression, percussion, or
needling), can evoke a characteristic pattern of referred pain
and related autonomic phenomena. 17 In addition, the motor
behavior of a muscle with an MTrP may be altered in the form

604
Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 9
of muscular inhibition, increased fatigability, delayed relaxa-
tion after activation, 17 or alteration of its physiological motor
recruitment pattern. 18 A previous study showed that the
presence of latent MTrPs in the scapular rotator muscles
decreases the consistency of the motor activation pattern of this
muscle group while also affecting muscles more distal in the
upper limb chain. Moreover, treatment to remove latent MTrPs
normalized the motor activation pattern. 18 However, no
studies have investigated the effects of motor control training
on MTrPs. Although training of the DCF in patients with neck
pain has been shown to reduce pain and disability and enhance
the activation of the DCF, 19 whether this training can influence
the sensitivity of MTrPs in the superficial muscles of the neck
is unknown. Therefore, the purpose of this study was to eva-
luate the effects of a specific low-load training program for the
DCF on the pressure pain threshold (PPT) of MTrPs located in
selected superficial neck muscles as well as on perceived pain
and disability in patients with chronic neck pain.
METHODS
Participants
Subjects between 18 and 60 years old with chronic
idiopathic neck pain were invited to participate in the study.
Recruitment was performed by notices distributed in different
universities and hospitals. Besides presenting with a history
of neck pain lasting 3 months or more over the last year,
subjects who were included in the study were required to have
a score of 5/50 or higher in the Neck Disability Index (NDI) 20
and have active or latent MTrPs in at least one of the
following muscles: upper trapezius, levator scapulae, or
splenius capitis. The testing sites for PPT were chosen as they
are known clinically to be sensitive in patients with chronic
nonspecific neck pain, 21 have shown increased tenderness to
local mechanical pressure, 22 and have been used in trials to
assess reliability of pressure algometry and outcomes after
treatment. 23 Both active and latent MTrPs were considered
because latent MTrPs have been associated to the develop-
ment of sensory-motor dysfunction and can contribute to
different chronic musculoskeletal pain disorders. 24,25
Subjects were excluded if they had previous cervical spine
surgery, cervical radiculopathy, presence of a severe systemic
disease (ie, diabetes), fibromyalgia, or other widespread
musculoskeletal pain syndromes (ie, chronic fatigue syn-
drome) or had participated in an exercise program for the
neck muscles in the 6 months preceding the study.
Ethical approval for the study was granted by the
Institutional Ethics Committee (University CEU Cardenal
Herrera, Valencia, Spain), and the procedures were
conducted according to the Declaration of Helsinki.
Study Design
This study was a single-group design with repeated
measures. Earlier studies have demonstrated the efficacy of
Lluch et al 605
Effects of Neck Training on Pressure Pain Thresholds
the training intervention applied in the current study in
randomized controlled trials. 19,26,27 The outcome measure-
ments for the study were patient-reported levels of pain and
disability rated on the NDI and PPT over active/latent
MTrPs of the upper trapezius, levator scapulae, and
splenius capitis, bilaterally. All were assessed at baseline
and in the week immediately after the 6-week intervention
period (week 7).
Procedure
Patients were initially examined by a researcher who
assessed compliance with the inclusion and exclusion
criteria. In addition, demographic and anthropometric data
of each patient were recorded. Subjects who met the study
requirements completed the NDI and were then examined
for the presence of active/latent MTrPs in the upper
trapezius, levator scapulae, and splenius capitis muscles,
and PPT was measured at these points. Finally, the
craniocervical flexion test (CCFT) was carried out to
identify the starting level of exercise for each patient.
During week 7, measures of the NDI and PPT of the MTrPs
were repeated.
Neck Disability Index. The NDI questionnaire is a clinical
tool designed to assess perceived pain and disability in
patients with neck pain. 20,28 It consists of a total of 10 items
each with 6 possible choices. The NDI is a valid, reliable,
and sensitive tool for measuring changes in pain and
disability in patients with neck pain. 28 This study used the
Spanish version of the NDI validated by Andrade et al. 29
Pressure Pain Threshold Measurement and MTrPs. Pressure pain
threshold of active and latent MTrPs of the upper trapezius
(MTrP2 according to Simons et al 17), levator scapulae
(insertional MTrP 17), and splenius capitis 17 was recorded
bilaterally (Fig 1). To ensure repeatability in location, the
distance to the MTrPs from the spinous process of C7 (for
the upper trapezius and levator scapulae MTrPs) and the
mastoid process (for the splenius capitis MTrP) was
measured. Testing sites were also marked and photo-
graphed as this has been shown to improve the reliability of
PPT measurements. 30
The presence of a MTrP was performed using the
following diagnostic criteria described by Simons et al 17:
(1) presence of a palpable taut band in a skeletal muscle, (2)
presence of a hypersensitive tender spot in the taut band, (3)
local twitch response elicited by snapping palpation of the
taut band, and (4) reproduction of the typical referred pain
pattern of the MTrP in response to compression. Myofascial
trigger point was considered latent if these 4 criteria were
satisfied. If the patient additionally recognized the referred
pain as familiar, then the MTrP was considered to be active. 17
Pressure pain threshold was measured with an analog
algometer (Force Dial model FDK 20; Wagner Instruments,
Greenwich, CT) with a surface area at the round tip of 1 cm 2.
The algometer probe tip was applied perpendicularly to the
606 Lluch et al
Effects of Neck Training on Pressure Pain Thresholds
A B
Fig 1. A, Locations for the PPT measurement over levator scapulae, upper trapezius, and splenius capitis MTrPs. B, Pressure pain
threshold assessment of upper trapezius MTrP in sitting. C, Pressure pain threshold assessment of splenius capitis MTrP in prone.
skin at a rate of 1 kg/cm 2 per second. Pressure pain threshold
was measured at each site with a 30-second rest period
between each measurement. A familiarization phase preceded
the formal measurements where participants were instructed
on the procedure and the examiner practiced with them at a
remote site (forearm). Subjects were instructed to indicate the
moment when pressure changed to pain, which correspond to
the definition of the PPT. They were told repeatedly that
recording the first sensation of pain was the aim and not
tolerance to pressure. The same researcher performed the PPT
measurements in all subjects and was blinded to the purpose
of the study. Participants were also not informed of their
scores to prevent subject bias from influencing the results.
The mean of the 3 trials were calculated for each point
and used for further analysis. Pressure algometry is a valid
and reliable method to measure PPT, 31 with studies
showing good repeatability of measurements on the neck
muscles (Intraclass correlation coefficient: 0.78-0.93). 23
Craniocervical Flexion Test. The application of this test
followed the protocol described by Jull et al. 32 Patients
were comfortably positioned in supine, crook lying with the
head and neck in a mid-position and were instructed to
perform a craniocervical action (anatomical action of the
DCFs). The task consisted of 5 incremental movements of
increasing craniocervical flexion range of motion. Perfor-
mance was guided by visual feedback from an air-filled
pressure sensor (Stabilizer; Chattanooga Group, Inc, Austin,
TX), which was placed suboccipitally behind the subject's
neck and inflated to 20 mm Hg. During the test, subjects
were required to perform gentle nodding motions of
craniocervical flexion that progressed in range to increase
the pressure by 5 incremental levels, with each increment
representing 2 mm Hg. Subjects practiced targeting the 5 test
levels (22-30 mm Hg; increments of 2 mm Hg) in 2 practice
trials before performance on the test was graded.
Visual observation and palpation of muscle activity were
used to evaluate any inappropriate or compensatory
Journal of Manipulative and Physiological Therapeutics
November/December 2013
C
movement (ie, retraction) and muscle strategies (ie,
excessive use of the superficial cervical flexors). Once the
examiner had identified the pressure level that the patient
could achieve correctly, the endurance of the DCF was
evaluated by assessing how many repetitions of a 10-second
hold the patient could perform at the level which was
performed successfully. Thus, the score during this second
phase was the pressure level and the number of repetitions
that the patient could hold steady for repeated 10-second
holds, with minimal superficial muscle activity or presence
of any substitution strategies (ie, 5 repetitions of 10 seconds
at 24 mm Hg).
The exercise load prescribed to each patient (number of
repetitions and pressure level) was based on their assess-
ment. For example, if the patient correctly performed five
10-second repetitions at 24 mm Hg, then the home training
program started at this level and consisted of five 10-second
repetitions at 24 mm Hg, twice daily. Each patient was given
a pressure biofeedback unit for home training.
Subjects received an exercise diary and were requested
to practice their respective regime twice per day for the
duration of the study, without provoking neck pain and with
attention to correct performance of uniplanar movements.
The subjects were asked not to seek other treatments for
their neck pain during the period of the study while their
usual medication was not altered.
All subjects received personal instruction and supervi-
sion by a physiotherapist twice a week throughout the 6
weeks of the intervention. The physiotherapist regulated the
training load of each patient adjusting it at each weekly
session based on the patient performance on the CCFT.
Data Analysis
Descriptive statistics were used to define the demo-
graphic characteristics of the sample. The dependent
variables analyzed were the NDI and the PPT over the
Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 9
Volunteers
N = 30
No MTrPs present Included
N=4 N = 26
Withdrawal from
Study
N=4
Final Sample
N = 22
Fig 2. Participant flow and retention. MTRP, myofascial trigger
point.
MTrPs recorded at 3 sites. Normality of the variables was
confirmed using the Kolmogorov-Smirnov test.
A 2-way analysis of variance (ANOVA) was performed to
analyze the effect of training on the PPT over the MTrPs with
time (pre, post) and location (right and left, upper trapezius,
levator scapulae, and splenius capitis) as repeated measures.
A 1-way ANOVA was applied to the NDI score with time
(pre, post) as a repeated measure. Significant differences
revealed by ANOVA were followed by post hoc Student-
Newman-Keuls (SNK) pairwise comparisons. Results are
reported as mean and SD in the text and SE in the figures. The
significance was established at a value of P b .05.
RESULTS
A total of 30 patients with chronic neck pain accepted to
participate, of which 22 completed the study (Fig 2). The 22
patients (14 women, 8 men) who formed the final sample
had a mean age of 30.6 ± 10.2 years, weight of 70.0 ± 16.2
kg, and height of 169.7 ± 8.4 cm (Table 1).
A total of 132 muscles were assessed for MTrPs. Eighty-
five presented with active MTrPs; 24, with latent MTrPs;
and 23, with no MTrPs present. Most of the active MTrPs
were located in the right upper trapezius (n = 19), whereas
the right splenius capitis and right levator scapulae were the
most affected by latent MTrPs with a total of 5 in each
muscle. Left levator scapulae was the muscle with the least
number of MTrPs (n = 6) (Table 2).
Lluch et al 607
Effects of Neck Training on Pressure Pain Thresholds
Table 1. Descriptive group data (mean ± SD)
Variable Value
Age (y) 30.6 ± 10.2
Sex (male/female) 8/14
Weight (kg) 70.0 ± 16.2
Height (cm) 169.7 ± 8.4
NDI (0-50) 18.2 ± 12.1
NDI, Neck Disability Index.
n = 22.
The 6-week intervention resulted in significantly lower
values of NDI (pre, 18.2 ± 12.1; post, 13.5 ± 10.6; F = 12.2;
P b .01). However, there was no effect of the training on the
PPT over the upper trapezius muscle, levator scapulae, or
splenius capitis muscles (F = 0.9; P = .35; Fig 3). Of interest,
there was a significant main effect for location (F = 36.6; P b
.00001). Post hoc analysis revealed significantly lower
values of PPT over the splenius capitis MTrPs compared
with both the upper trapezius and levator scapulae muscles
(SNK, P b .001). Furthermore, the PPT recorded over
MTrPs in the upper trapezius was significantly lower than
PPT recorded over the levator scapulae (SNK, P b .001).
DISCUSSION
This is the first study to assess the effects of specific
motor control training for the neck on the pressure pain
sensitivity over cervical MTrPs in patients with neck pain.
Although the intervention led to a significant reduction in
the patient's perceived pain and disability, no effect on
pressure pain sensitivity over MTrPs in the splenius capitis,
levator scapulae, or upper trapezius was observed.
Interestingly, lower values of PPT were found over MTrPs
in the splenius capitis muscle. Referred pain originating from
splenius capitis MTrPs could contribute to neck symptoms
perceived by subjects with idiopathic neck pain, headache, or
whiplash-induced neck pain. 33,34 Interestingly, the splenius
capitis muscle was shown to be the second most commonly
affected muscle in a sample of 244 patients with cervical
radiculopathy with a 14.7% and 16.8% prevalence of active
and latent MTrPs, respectively. 35
Interventions aimed at improving activation of the DCF
have been shown previously to be effective in patients with
chronic neck pain for increasing the activation of these
muscles and reducing pain and disability when tested in
randomized controlled tirals. 19,26,27,36 The results of the
current study confirm the positive effect of this training
approach on pain and disability. 19,26,27,36 However, no
significant change was found for the PPT measured over
both active and latent MTrPs. This lack of effect could be
attributed to a number of reasons.
First, the lack of effect may be related to the muscles
selected for investigation. Previous studies investigating the
effect of DCF muscle training have shown a significant
reduction in electromyographic activity of superficial flexor
608 Lluch et al
Effects of Neck Training on Pressure Pain Thresholds
Table 2. Number and distribution of MTrPs between selected
cervical muscles
Upper Upper Levator Levator Splenius Splenius
trapezius trapezius scapulae scapulae capitis capitis
MTrP (right) (left) (right) (left) (right) (left)
Active 19 16 14 12 13 11
Latent 3 4 5 4 5 3
Not 2 3 3 6 4 5
present
MTRP, myofascial trigger point.
muscles, the sternocleidomastoid (SCM), and anterior
scalene (AS) muscles, 19 which have been shown to be
overactive in patients with neck pain. 13 Recently, cervical
mobilization has been shown to modulate neck muscle
function by increasing DCF and reducing superficial
muscle activity. 37 These muscles (ie, SCM and AS) were
not considered as potential locations for MTrPs for the
current study due to the absence of clear references to the
most common location of MTrPs in these muscles, 17
together with a greater difficulty in reliably establishing the
presence of taut bands and MTrPs over them. Thus, it is
unknown whether MTrPs in the SCM or AS, if present,
would respond to the training intervention used in this
study. Furthermore, other locations such as suboccipital
muscles 38 or the semispinalis capitis may have also shown
different results due to the nature of the exercise, which is
focused on the craniocervical region. However, due to their
deep location (ie, palpation is performed through other
muscles) and the lack of demonstrated reliability of MTrPs
localization or PPT measurements over these muscles, they
were not tested in this study.
Secondly, the occurrence of trigger points varies not
only between subjects but also from day to day within
subjects, some being “latent” and some “active,” rendering
systematic studies difficult. 39 It is unknown if this
phenomenon affected the results. Furthermore, the trigger
points may not have been a primary contributor to the
current participants' complaint but rather their presence was
a secondary manifestation of the chronic neck pain state.
Previous studies have also shown no positive effect of
active training on PPT recorded over neck muscles. 40-42
One reason argued to explain this lack of effect is that the
training intensity was too low and intervention time too
short to produce clinically significant changes in muscle
tissue. As stated by Ylinen, 43 to achieve significant
improvements in PPT, high-load and long-term cervical
muscle training is likely required. Accordingly, a clinical
trial showed significant beneficial effects on tolerance to
local mechanical pressure over the neck muscles with long-
term neck strength and resistance training (ie, 12 months). 38
O'Leary et al 44 on the contrary showed immediate effects
on PPT measurements after a single training session with
low-load craniocervical flexion in patients with chronic
neck pain, as compared with a high-load cervical flexion
Journal of Manipulative and Physiological Therapeutics
November/December 2013
Fig 3. Mean ± SE of the PPT detected over MTrPs in the left and
right upper trapezius, levator scapulae, and splenius capitis muscles
preintervention and postintervention. LS, levator scapulae; SC,
splenius capitis; UT, upper trapezius.
exercise. However, in this study, PPT measurement was not
performed over the neck muscles, but rather over the
articular pillars of the most symptomatic cervical segment.
Future research should consider assessing the effects of
prolonged low-load DCF training (ie, 12 months) on PPT
over muscle tissue. This would establish whether the effects
on the PPT obtained with this type of exercise and duration
of training are similar to those already shown with long-
term strength and resistance training. Six weeks of training
was used in this study because this time frame usually
permits patients to reach and maintain the 5 levels of
pressure on the CCFT, although this period is variable. 45
Furthermore, 6 weeks of training has been previously
shown to be sufficient to induce a significant decrease in
perceived pain and disability in patients with neck pain. 19,45
The results of this study showed that specific DCF
training was not sufficient to produce a change in the
sensitivity of MTrPs of the superficial extensor muscles.
These observations suggest that specific MTrP techniques
may need to be included in a multimodal management
approach if sensitivity of MTrPs is considered to be a
contributing factor to a patient's disorder. However, because
of the design of this study (1 group), no firm conclusions can
be extracted for the time being. Future studies should further
analyze the therapeutic benefit obtained with isolated and
combined applications of treatment strategies aimed at
MTrPs and motor control deficits in the cervical region to
further guide clinicians. As noted by several authors, the
combination of exercise and manual therapy is the most
effective conservative treatment for subacute and chronic
neck pain. 46,47 Specific DCF training has already proven its
effectiveness, both in isolation and as a component of a
multimodal intervention. 19,27 Similarly, techniques such as
dry needling 48 or ischemic compression 49 of MTrPs have
shown moderate evidence for neck pain, being more
effective when combined with exercise. 50
Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 9
Limitations
Pressure pain threshold has been used as an index to
discriminate tenderness of musculoskeletal structures in
different disorders. However, the specific tissues contributing
to the change in threshold cannot be identified, as pressure
algometry cannot be considered a diagnostic tool for differen-
tiating soft tissue pathology from other conditions. 23 Moreover,
pressure algometry does not determine the pain processing
mechanisms underlying sensory changes in pain perception. 51
The absence of a control group raises the possibility that the
positive results for pain and disability obtained in this study
may not be due to the exercise program. However, previous
randomized controlled trials have consistently confirmed the
efficacy of the training approach used in this study. 19,26,27,36
The small sample size, the inclusion of only idiopathic neck
pain, and the fact that mostly women were examined imply
that the results of this study may not be generalized.
During the CCFT, performance was determined visually,
and therefore, the assessment depended largely on subjec-
tive criteria and the clinical experience of the examiner.
However, the same examiner evaluated all patients both
pretraining and posttraining. As only DCF training was
performed in this study, the findings cannot be extrapolated
to more comprehensive exercise programs where training of
other muscle groups is also incorporated.
CONCLUSION
Patients performing DCF training for 6 weeks demon-
strated reductions in pain and disability but did not show
changes in pressure pain sensitivity over MTrPs in the
splenius capitis, levator scapulae, or upper trapezius muscles.
Practical Applications
• Patients with chronic neck pain participated
in a 6-week low-load training program for the
DCF muscles.
• The results show that specific training of the
deep cervical muscles is not sufficient to
produce a change in the sensitivity of MTrPs
of the superficial extensor muscles in patients
with chronic neck pain.
• This finding suggests the need for multimod-
al treatment combining specific MTrP treat-
ment techniques together with specific
training regimes in the management of
patients with chronic neck pain.
• Future studies should further analyze the
therapeutic benefit obtained with isolated and
combined applications of treatment strategies
aimed at MTrPs and motor control deficits in
the cervical region to further guide clinicians.
Lluch et al 609
Effects of Neck Training on Pressure Pain Thresholds
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
EL, MDA, PSC, FP, AR, DF.
Design (planned the methods to generate the results):
EL, MDA, PSC, FP, AR, DF.
Supervision (provided oversight, responsible for orga-
nization and implementation, writing of the manuscript):
EL, MDA, PSC, FP, AR, DF.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data):
EL, MDA, PSC, FP, AR, DF.
Analysis/interpretation (responsible for statistical analy-
sis, evaluation, and presentation of the results): EL,
MDA, PSC, FP, AR, DF.
Literature search (performed the literature search): EL,
MDA, PSC, FP, AR, DF.
Writing (responsible for writing a substantive part of the
manuscript): EL, MDA, PSC, FP, AR, DF.
Critical review (revised manuscript for intellectual
content, this does not relate to spelling and grammar
checking): EL, MDA, PSC, FP, AR, DF.
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