What physical therapy exercises are recommended for a patient with neck pain?

Physical Therapy Exercises for Neck Pain

For patients with nonspecific neck pain, prescribe a structured program of cervical and scapulothoracic strengthening and stretching exercises performed 2-3 times per week, with specific neck strengthening exercises (targeting deep cervical flexors and extensors) showing superior short- to medium-term pain relief compared to general exercise programs. 1, 2, 3

Core Exercise Program Structure

Strengthening Exercises (Primary Component)

• Perform high-intensity isometric neck strengthening exercises using elastic resistance bands, targeting flexion, extension, and rotation movements 4
• Isometric neck strength training produces dramatic improvements: 110% increase in flexion strength, 76% in rotation, and 69% in extension over 12 months 4
• Include scapulothoracic strengthening exercises focusing on rotator cuff and posterior shoulder girdle muscles, as scapular dysfunction is frequently present in neck pain patients 1, 2
• Begin with low resistance (40-60% of 1-repetition maximum) and higher repetitions (10-15 reps), performing 1 set of 8-12 repetitions, 2-3 days per week on non-consecutive days 5

Endurance Training Component

• Prescribe dynamic neck endurance exercises including lifting the head from supine and prone positions 4
• Craniocervical endurance exercises and low-load cervical-scapular endurance training provide long-term benefit for chronic neck pain 2
• Endurance training alone produces more modest improvements (28% flexion, 29% rotation, 16% extension strength gains) but remains effective for pain reduction 4

Stretching and Range of Motion

• Perform neck and shoulder stretching exercises 2-3 days per week, holding each stretch for 15-30 seconds, with 2-4 repetitions per stretch 5, 6
• Combined cervical and scapulothoracic stretching with strengthening reduces pain immediately post-treatment (SMD -0.35) and at intermediate follow-up (SMD -0.31) 2
• A regular stretching program performed twice daily, five days per week for four weeks significantly decreases neck pain (visual analog scale improvement of -1.4) and improves function (Northwick Park score improvement of -4.8) 6
• Exercise only through pain-free range of motion; emphasize external rotation and abduction movements 1

Exercise Execution Guidelines

Technique and Dosing

• Perform exercises in a rhythmical manner at moderate to slow controlled speed through full range of motion 5
• Exhale during the contraction/exertion phase and inhale during relaxation to prevent Valsalva maneuver 5
• Use pain threshold as intensity guide: discontinue if pain lasts more than one hour after exercise 5
• Progress resistance gradually based on pain tolerance, starting with as few as 2-3 repetitions if needed 5

Adjunctive Modalities

• Apply local heat before exercise to improve tissue elasticity and reduce pain 1, 7
• Ice, heat, and soft tissue massage can be used as adjunctive modalities to reduce pain/swelling 1
• Heat application has a higher strength of recommendation compared to ultrasound 1, 7

Critical Contraindications and Pitfalls

Exercises to AVOID

• Never prescribe overhead pulley exercises, as these encourage uncontrolled abduction and have the highest incidence of developing shoulder pain 5, 1
• Avoid vigorous, repetitive exercises and explosive movements that stress cervical structures 5
• Do not prescribe passive range-of-motion exercises performed aggressively or improperly, as these can cause more harm than benefit 1

Common Clinical Errors

• Do not rely solely on stretching and aerobic exercise without strengthening components, as this proves much less effective than strength training 4
• Avoid being overly restrictive with exercise prescription; a cautious but progressive approach is essential 5
• Do not rely solely on modalities (ultrasound, electrical stimulation) without the core strengthening and stretching program 5
• Upper extremity stretching and strengthening alone or general exercise programs show no benefit for chronic neck pain 2

Evidence-Based Outcomes and Adherence

Expected Results

• Both strength and endurance training for 12 months effectively decrease pain and disability in women with chronic nonspecific neck pain 4
• Specific neck exercises provide superior effectiveness for reducing pain (pooled SMD -0.41) and disability (pooled SMD -0.41) in the short to medium term compared to alternative exercise interventions 3
• Patients who exercise ≥3 times per week yield significantly greater improvement in neck function and quality of life compared to those exercising <3 times per week 6

Home Exercise Program Design

• Home exercise programs focusing on strength and endurance training, as well as self-mobilization, have positive effects when used alone or in combination with other conservative treatments 8
• Provide education on strategies for reducing load on the shoulder during daily activities and proper positioning 5, 1
• Cognitive behavioral therapy, distraction, mindfulness, relaxation, and guided imagery can be incorporated as adjunctive psychological interventions 9

Special Considerations

Cervicogenic Headache

• Low to moderate quality evidence supports self-mobilization, craniocervical endurance, and low-load cervical-scapular endurance exercises for long-term pain reduction in subacute/chronic cervicogenic headache 2

Acute Cervical Radiculopathy

• Low quality evidence supports neck strengthening exercise in acute cervical radiculopathy for short-term pain relief 2

Assessment of Motor Control

• Currently used strategies for selecting patients based on motor control dysfunction (such as the craniocervical flexion test) do not result in greater effectiveness of specific neck exercises and cannot be recommended for routine clinical practice 3