A Patient's Story

Meet Sarah, who is the patient we feature in the video below. She didn’t have any major trauma. She just got into the habit of less-than-ideal postures when she started working from home during COVID. That built up over time to a point where she was having pretty bad neck pain and headaches. She would get some temporary relief from her massage therapist and chiro but the pain kept coming back. Her physio gave her some stretches and strengthening exercises to do at home which, again seemed to improve things a bit but not completely. Her pain was even starting to disrupt her sleep.

How could this happen? Let’s take a look at what we call the deconditioning cycle.

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Neck Muscle Deconditioning (Weakness)

Ever heard the term “Use it or Lose it”? Our bodies are amazingly efficient machines so if we aren’t using them, they will quickly waste away. We call this atrophy. Think about if you’ve ever seen someone (or had it yourself) come out of a cast after a broken bone. Remember how shrivelled up and stiff that arm or leg is after being in the cast for only a few weeks? That’s what not using an area of our body does. It becomes a vicious circle because if we are weaker, we are more vulnerable to injury so when we try to resume activity, we experience pain much easier. Pain is our body’s danger warning system so we automatically reduce using the area. That disuse results in more weakness. We call this process the Deconditioning cycle and it looks like this:

Deconditioning Cycle

The Deconditioning Cycle

So, let’s look at how this can apply to our necks. What does a neck have to do all day long?

Let’s see:

  • Hold your head up
  • Shoulder checking
  • Shrugging your shoulders when we don’t know the answer
  • Head-butting somebody in a bar fight

You know, standard, everyday stuff. How strong does a neck have to be to do those things? Except for the head-butting scenario, one would assume neck muscles don’t have to be very strong. Well, that may be a bad assumption. Check this out.

How Strong Does A Neck Need To Be?

Neck Pain, Headache and Concussion Rehab (MCU)

Neck, Headache & Concussion Rehab

Here is an example we typically see in the clinic.

When we measure someone’s neck strength on our MCU, we ask them to push their head back into a pressure sensor as hard as they can. When testing the muscles at the back of the neck, males should normally be able to generate between 25-35 lbs of force and women between 20-30 lbs. It is not uncommon for us to see test results in people with neck pain being 50% weaker than that. So in males, this means their muscles can generate a max of 12-17 lbs and females: 10-15 lbs.

Think about that for a minute. Let’s take a situation where your head isn’t perfectly balanced on top of your shoulders. Like the posture Sarah was in when she was working on her computer. That slouched posture means her head protrudes out in front of her shoulders. The average head weighs about 8-12 lbs, so if your muscles can only maximally generate 14 or 15 lbs, then they have to be working pretty hard just to hold your head up to fight gravity.

This is where the Deconditioning Cycle bites you…

If you ask your muscles to work that hard, they fatigue pretty quickly and start becoming painful. So then what? We normally switch positions, which temporarily offloads the muscles and feels better. Offloading resting the muscles might feel better, BUT, if the muscles aren’t working to hold up our head, we are now hanging on our ligaments, which isn’t ideal.  Excessive strain on our ligaments causes them to stretch, which builds over time to become an injury called a sprain.

You know this if you’ve ever gone over on an ankle. The pain and swelling that happens when you sprain your ankle are because the ligaments were overstretched. The same thing happens to our necks, upper backs and shoulders when we slouch. The difference is that slouching stretches the ligaments more slowly than rolling your ankle, but the end result is the same.

What Does Mr. Science Say?

Don’t believe me? Let’s check out some research.

One of the ways to show if muscle and soft tissues are deconditioning is to look for the build-up of fat in the muscle, which we can see on an MRI. We saw from the deconditioning cycle when we’re in pain or injured, we stop using an area and it undergoes atrophy. This results in a shrinkage in the size of the muscle as well as a build-up of fat in the tissue.

This paper, published in the Journal Spine, looked at the timing for the development of muscle fatty infiltrates (MFI), which is a build-up of fat in the neck muscles following whiplash.

MRI of chronic neck pain following whiplash injury

Not surprisingly, they found that neck muscles atrophied very quickly after injury. The build-up of fat in the muscles was seen within two weeks. They also found a direct correlation between the amount of atrophy and the severity of pain and disability.

If you want to geek out and read the paper, you can check it out here.

So, the two key points these authors want you to know is:

  • Atrophy and weakness happens pretty quickly (within 2 weeks of injury)
  • Increased atrophy (weakness) means more severe pain and disability (measured 3 months after injury)

What's The FIx?

Two things to do:

  1. Improve your environment and habits to reduce the amount of strain that occurs
  2. Increase your body’s strength to better cope with the stuff we ask it to do all day long

Improving the environment typically involves a combo of ergonomics and habits:

  • Sit up straight.
  • Get a sit/stand workstation

Great ideas, however, what about trying to improve the strength of your neck so that it can better tolerate the stresses and strains your activities ask of it?

Neck Muscle Strengthening

So it is one thing to identify whether a muscle is atrophied and weak but then, perhaps the bigger question is can this be reversed or cured?

This study, published in the Journal of Muscle and Nerve demonstrated changes in the neck muscles following a strengthening rehabilitation program. Using MRI, they found significant increases in muscle size (hypertrophy), as well as significant decreases in Fat build-up in those completing the rehabilitation program.  These changes coincided with increased muscle strength and reduced neck disability.

Take-Home Message (The Bottom Line)

  • Use it or lose it means atrophy and weakness occur quite quickly if we aren’t moving and using our body properly. This is called Deconditioning.
  • Pain automatically causes us to reduce or avoid using the area
  • Research has demonstrated on MRI that muscle gets replaced by fat very quickly when we stop moving and using our muscles
  • The amount of deconditioning directly correlates with the severity of pain and disability you have
  • Deconditioning is reversible through a structured and individualized exercise rehab program

It makes sense that a weak neck has a harder time doing its job all day long. Asking an area to work harder than normal means it can become pretty sore much easier. Think about how sore you can be when you first get back to the gym and try working out. That soreness, called DOMS (Delayed Onset Muscle Soreness) is because you have asked the muscles to work harder than they were prepared to do. The same thing happens when your neck muscles are weak.

Watch Dr. Batinić test a patient (Sarah) on the MCU and explain how we diagnose whether underlying weakness is causing your ongoing neck pain.


  1. Elliott JM et al. The Rapid and Progressive Degeneration of the Cervical Multifidus in Whiplash: An MRI Study of Fatty Infiltration. Spine 2015 Jun 15;40(12):E694-700.
  2. O’Leary S et al. Morphological changes in the cervical muscles of women with chronic whiplash can be modified with exercise – a pilot study. Muscle & Nerve Nov 2015;52(5):772-779.
Tags: Calgary neck painconcussionNeck Exercisesneck machineNeck pain treatmentRehabilitationTech NeckWhiplash

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