Neck Flexor Endurance Test

Context

The neck flexor endurance test is commonly used to determine the presence of weakness in the neck flexors in the context of cervical pain.

It has been demonstrated that alterations in muscle function are widespread in cervical pain, particularly at the level of the neck extensors, as presented in our video on the Cervical Extensor Endurance Test. Increased fatigability and endurance deficits in the neck flexors have also been reported (Johnston et al., 2008; Jull et al., 2021).

The neck flexor muscles, particularly the deep flexors, such as the longus capitis, longus colli, and the anterior and lateral rectus capitis, are thought to assist in stabilizing the cervical spine during significant neck movements (Domenech et al., 2011).

Individuals with cervical pain also seem to exhibit changes in the activity of the cervical flexor muscles, particularly in their coordination abilities (Johnston et al., 2008), as well as delayed activation of the deep flexors during arm use. These factors may contribute to cervical spine dysfunction (Domenech et al., 2011).

During the initial assessment, it is generally not relevant to directly evaluate the strength and endurance of the cervical muscles. These assessments are more commonly performed during the progression of ongoing rehabilitation, particularly when the patient is able to control the cranio-cervical region in a head lift assessment.

Although many use a dynamometer to evaluate the strength and endurance of the neck flexors (O'Leary et al., 2005, 2007), the Head Lift Test is commonly used in clinical practice.

Video of the Test

Execution

To perform the test, the patient lies on their back with their knees bent and hands resting on their abdomen. The therapist then asks the patient to retract their chin into a chin tuck position and lift their head approximately 2.5 cm above the table. The therapist can place their hand on the table just below the patient's occiput to feel if the patient lowers their head. The stopwatch starts when the patient is in position to measure their ability to maintain a cranio-cervical flexion while performing an active head lift (Juul et al., 2013). Verbal feedback such as “Retract your chin” or “Keep your head up” can be given if the patient starts losing the chin position or if their head touches the examiner’s hand (Edmondston et al., 2008; Childs et al., 2008; Domenech et al., 2011).

The test ends if the patient loses the chin position or if their head touches the therapist's hand for more than one second (Edmondston et al., 2008; Childs et al., 2008).

It is important to note that the SCM (sternocleidomastoid) is the most important neck flexor, and head lift against gravity is the test for all neck flexor muscles.

In their 2005 study, Harris et al. found an average score of 38.95 seconds in healthy subjects, while the cervical pain group had an average score of 24.1 seconds.

Clinical Value

Edmondston et al. reported in their 2008 study that a minimum change of 17.8 seconds represents a significant change for this test.

According to studies, the intra-rater reliability of this test ranges from substantial to almost perfect (ICC from 0.71 to 0.96), and its inter-rater reliability ranges from moderate to almost perfect (ICC from 0.54 to 1.0) (Juul et al., 2013; Oliveira et al., 2018).

In clinical practice, patients with neck pain may be unable to perform this test in the supine position due to pain or insufficient muscle strength (Juul et al., 2013; Jull et al., 2021). Therefore, it can be useful to assess neck flexor endurance in various positions where the effects of gravity and head weight are reduced, such as in several seated angles (Jull et al., 2021).