In the presence of neck pain and injury, there are marked changes in muscle function in terms of motor control intensity endurance and activation patterns.  To understand which muscles are affected, it is important to understand the muscles in the neck area and their functions.
Muscles of Neck
It can be simplified based on position and depth. It can be broadly divided into the prevertebral and cervical regions associated with the sternocleidomastoid muscle .
Muscles of anterior neck
Muscles in anterior region
- Surface: platysma and sternocleidomastoid
- Suprahyoid: digastric muscle mandibular hyoid hyoid stylohyoid
- Subhyoid: Sternohyoid muscle Sternohyoid bone Hyoid bone 
Muscles in vertebral region
These are the muscles that wrap around the vertebrae, forming the musculoskeletal column. It can be further divided into the anterior (anterior) side (paravertebral) and posterior side relative to the cervical spine.
Prevertebral skin (prevertebral skin)
These are also known as deep neck flexors. This includes:
- Rectus Capitis Anterior
- Rectus Capitis Lateralis
- Longus capitis
- Neck length/neck length (3 parts: up-slope down-slope vertical)
Spinal muscles (paraspinal muscles)
Scales – front, middle, rear and minor scalenes
Posterior vertebral muscles
Can be further divided into intrinsic and extrinsic muscles.
Extrinsic muscles: trapezius and levator scapulae
- Superficial muscles: splenic muscle of the head, splenic muscle of the neck
- Deep muscles:
- Suboccipital group – posterior rectus major, posterior rectus minor, inferior oblique, superior oblique
- Transverse spinalis – semispinalis cervicis rotatores cervicis multifidus (these are also called deep neck extensors)
- Interspinales and intertransversarii
Neck muscles by function
When classifying muscles, it is useful for us to conceptually think of them as global pushers and local stabilizers.  See more core muscles
Global movers participate in torque generation and generate range of motion. They operate in a phasic manner, i.e. on/off, and their movement depends on the direction. When dysfunctional, cramping pain and limited range of motion can occur. trapezius levator scapula sternocleidomastoid The spleen and scalenes are superficial muscles that act as an overall propulsion in the neck region.
- Superficial neck flexors: sternocleidomastoid and anterior scalene
- Superficial cervical extensors:
- Level 1: Upper trapezius levator scapula
- Level 2: Splenius capitis and cervicis
Local stabilizers are deep muscles that control segmental control and neutral positioning of the joint. Their activity is tonic rather than phased, and they operate at a much lower level of contraction over long periods of time. Functional inhibition due to localized muscle dysfunction Delayed timing or recruitment deficits and loss of segmental control and neutral joint localization.
There are three main groups of cervical muscles that form a sleeve around the spine that control posture and segmental motion (local stabilizers):
- Deep Neck Flexors – Longus colli, Longus capitulus, Rectus capitus anterior, and Posterior capitis
- Neck deep extensors – semispinatus cervicalis, capitis and multifidus (segmental stabilizers).
- Suboccipital muscles – posterior rectus major and minor and superior and inferior oblique heads. 
- The suboccipital muscles are important for providing proprioception, and they provide input to the visual and vestibular systems. They control craniocervical lordosis and small head-to-neck movements. Dysfunction that causes sensorimotor disturbances alters kinesthetic sensations, such as decreased balance Joint position alters oculomotor control and can cause cervicogenic dizziness.
Cervical Muscle Function in Pain
- Even under low load and non-functional tasks, the activity of the deep neck flexors is reduced, while the activity and neuromuscular efficiency of the superficial muscles are reduced This change in activation can be seen in functional and cognitive tasks And does not depend on the cause or duration of the neck pain.  
- People with neck pain have difficulty relaxing the superficial neck flexors even after cessation of activity. 
- These changes in muscle function occur shortly after the pain starts and do not automatically return to normal after the pain goes away. 
- Changes in the function of the deep neck muscles can affect function as it affects the support and control of the cervical spine and can lead to overloading of specific segments 
- Studies have shown that both neck flexors and extensors lose strength and endurance in the presence of neck pain , and co-activation ceases, especially when performing functional tasks. 
- Superficial neck muscles fatigue faster
- Decreased maximal and low contraction cervical muscle endurance 
- Loss of feedforward activation – this affects the timing of activation and can be seen when the patient makes rapid arm movements.  When a patient without neck pain quickly raises his/her arm, the neck muscles activate within 50 milliseconds of deltoid muscle activation in a patient with neck pain Both the superficial and deep neck flexors are markedly deficient, which can lead to increased stress on the cervical spine. 
- Muscular atrophy of the neck muscles in patients with neck pain 
- Fatty infiltration has been found in deep flexor and extensor muscles in individuals with chronic whiplash-related disease, but not in episodes of chronic insidious neck pain 
- Studies have shown that head and neck cancer survivors with temporomandibular joint pain and cervical pain have multiple active trigger points, suggesting peripheral and central sensitization 
Cranio-cervical flexion test (CCFT)
The CCFT has been found to be a valid and reliable test that can be used as an assessment tool in clinical practice.  Assessment of Motor Control of Longus capitis and Cervical Muscle Activation and Isometric Endurance While Observing Longus Capitis and Scalenus Anterior Muscle Interaction muscle
The PBU is placed under the occipital bone and then inflated to 20 mmHg. 
- Instruct the patient to move the head vertically (as if saying “yes”). The movements are gentle and slow. This nodding action causes pressure to increase in the inflation pressure sensor. For the first stage of the test, the pressure should be increased by 2 mmHg to 22 mmHg The superficial muscles remain relaxed.
- Tell the patient to hold this position for 10 seconds.
- The patient then relaxes back to 20 mmHg, this time using the same movement to increase the pressure again to 24 mmHg and hold for 5 seconds. The patient must repeat this action until a pressure of 30 mmHg is reached.
Flexion of the neck requires activation of the deep neck flexors. The superficial neck flexors cannot be used to perform this movement. With each phase the range of motion should increase. People without neck pain will be able to hold the contraction for 10 seconds in stage 3 (26 mm Hg) or higher. People with neck pain often only reach stage 1 or 2 before losing neutral position or contracting the superficial neck muscles. 
Neck Flexor Endurance Test
- The patient is positioned supine with the knees bent. The patient must retract the chin (craniocervical flexion). The patient must then raise the head 2.5 cm above the base while maintaining the chin tucked position. 
- The test has been found to have good intra-rater reliability when used in patients with neck pain 
- The test has been shown to be a reliable tool for measuring rehabilitation progress in patients with neck pain 
- Different studies have documented the timing of this test 
- Asymptomatic males (average = 25 seconds) asymptomatic females (20 seconds) – (Olson et al., 20016)
- Asymptomatic males (mean = 63.73 seconds) asymptomatic females (38.43 seconds) – (Olson et al. 20016)
- Men with neck pain have longer neck flexor endurance than women. 
- Although the duration varies, several studies have found that men have longer retention times than women, so this should be taken into account when interpreting the test
- Asymptomatic group (mean = 39 seconds) Neck pain group (mean – 24 seconds) – (Harris et al 2005)
Neck Flexor Endurance Test Video by Clinically Relevant
Neck Extensor Endurance Tests
The patient lies prone with the head resting on the edge of the bed. The head can be supported on a stool with the arms at the patient’s side. The patient is then asked to perform jaw retraction (craniocervical flexion) and to keep the head in this position while removing the stool. patient must Keep your head in a horizontal position.  Testing is easy because no tools are required, but testing can take up valuable time that could be spent on other testing.  Test the cervical spine with the patient prone in neutral at the elbow and craniocervical region for deeper cervical extension group. Rotation can also be evaluated at this location.  Correlating neck flexor endurance tests with neck extensor endurance tests showed that neck extensor endurance was significantly higher than neck flexor endurance in people with neck pain. These results are the same It is suitable for acute to chronic neck pain patients of different ages.  Rehabilitation of muscle performance or muscle strength is “the ability of a muscle to generate force regardless of movement (isometric vs isotonic), load (body segment vs free weights) or intensity (‘low load’ vs high load). “high load”) . For a muscle to control a body part, it must first have sufficient strength.  To train muscle performance, the muscle must perform repetitive movements about an axis of rotation in a single plane against some resistance (body part or added weight). this type Training has been shown to improve proprioception in this area, such as when people with neck pain perform controlled head-up movements.  Early rehabilitation of the patient should be emphasized and the exercise program should include motor control and general strengthening of the neck muscle.  Neck flexors Deep neck flexor exercises have been shown to reduce neck pain.  CCF exercises were compared to CCF-assisted passive mobilization in a study of 18 participants with chronic neck pain who were randomized into 2 intervention groups. There was a decline in both groups In terms of pain relief, but only the exercise group had improved motor function and reduced superficial neck flexor activation during CCFT.  Endurance and strength training of the DNF muscles in a patient with neck pain reduces neck pain perception in this patient.  The first stage  Craniocervical flexion (CCF) motor control should be retrained  Correct movement should be retrained without activating the superficial muscles (when the patient can place their hand on the muscle to feel the contraction) Train endurance use of the deep cervical flexors pressure biofeedback.Progression – Hold for 10 seconds at 22, 24, 26, 28 and 30 mmHg for 10 repetitions, then repeat with eyes closed Functional training should be incorporated from the start and should be repeated throughout On day  the patient should attempt to “lift During the neck lengthening maneuver, the base of their skull is off the top of the neck” Phase 2 Increases endurance and strength by increasing the load with added gravity during the head-up movement. The patient is seated with their head against a wall and do neck flexion Move by sliding your head up the wall, then move your head away from the wall and hold for 10 seconds. Progress to 10 repetitions. The patient’s hand can rest on the superficial muscles. Make progress by moving away from the wall and repeating the exercise. progress to do Work out on your back, then in a different position Take it a step further by adding this movement to individual-specific functional tasks, including combined movements. Neck extensor stage 1  Patient prone in elbow or quadruped position depending on scapular control Patient starts Head in craniocervical flexion and perform the following movements: Craniocervical Extension Rotation Cervical Extension (C2-C7) Perform 3 sets of 10 repetitions through full ROM without fatigue Craniocervical Flexion – One way to cue movement is to tell the patient to keep the eyes focused downward while doing the movement (eg looking down to read a book) Phase 2  Begin with 0.5 kg and increase the load. Neck-specific resistance equipment can be used, or weights can be added to something like a bike helmet.Neck rotation proprioception and speed training ResourcesRayner & Smale Cervical Motor Control Part 1 – Clinical Anatomy of Cervical Spine. The Physical Therapy Blog shares knowledge and encourages growth. Deep Neck Flexor Stabilization Protocol
- ↑ Jump up to:1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 Brukner P. Brukner & Khan’s clinical sports medicine. North Ryde: McGraw-Hill; 2012.
- ↑ Jump up to:2.0 2.1 2.2 Drake R, Vogl AW, Mitchell AW. Gray’s anatomy for students E-book. Elsevier Health Sciences; 2009 Apr 4.
- ↑ Prevertebral muscles of the neck | Longus cervicis & capitis , Rectus capitis anterior & Lateralis. Available from: https://www.youtube.com/watch?v=pTWev6kO-Eg lasted accessed: 2021-7-24
- ↑ Paravertebral Muscles – The Scalenus Anterior muscle| Attachments | Nerve supply| Action | Relations. Available from: https://www.youtube.com/watch?v=yAYXUh2eO6A Lasted accessed: 2021-7-24
- ↑ Available from: https://www.youtube.com/watch?v=ySC8bDz7IOU lasted accessed: 2021-07-24
- ↑ Page P, Frank CC, Lardner R. Assessment and treatment of muscle imbalance: the Janda approach. Human kinetics; 2010.
- ↑ Cleland J. Orthopaedic clinical examination: an evidence-based approach for physical therapists. Saunders; 2005.
- ↑ Jump up to:8.0 8.1 8.2 Lluch E, Schomacher J, Gizzi L, Petzke F, Seegar D, Falla D. Immediate effects of active cranio-cervical flexion exercise versus passive mobilisation of the upper cervical spine on pain and performance on the cranio-cervical flexion test. Manual therapy. 2014 Feb 28;19(1):25-31.[Accessed 6 June 2018] Available from: https://scholar.google.com/scholar_url?url=http://www.academia.edu/download/42284311/Immediate_effects_of_active_cranio-cervi20160207-29568-1ms0ioz.pdf&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=9zQYW82bJojYyQSm7qHoCg&scisig=AAGBfm1N_YwuK7Gd4yPgXDTGK2AFy2Z2NA
- ↑ Jump up to:9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 Falla D. Unravelling the complexity of muscle impairment in chronic neck pain. Manual therapy. 2004 Aug 1;9(3):125-33. [Accessed 6 June 2018] Available from: https://scholar.google.com/scholar_url?url=http://www.o-sommet.nl/wp-content/uploads/Falla-Unravelling-the-complexity-of-muscle-impairment-in-chronic-neck-pain.pdf&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=hTgYW8acO4umywTp7IWQBA&scisig=AAGBfm3vrID42PWNto53owuYUjWySUqYhw
- ↑ Reddy RS, Meziat-Filho N, Ferreira AS, Tedla JS, Kandakurti JK, Kakaraparthi VN. Comparison of neck extensor muscle endurance and cervical proprioception between asymptomatic individuals and patients with chronic neck pain. Journal of Bodywork and Movement Therapies. 2021;26:180-6.
- ↑ Smith AC, Albin SR, Abbott R, Crawford RJ, Hoggarth MA, Wasielewski M et al. Confirming the geography of fatty infiltration in the deep cervical extensor muscles in whiplash recovery. Sci Rep. 2020;10:11471.
- ↑ Ortiz-Comino L, Fernández-Lao C, Castro-Martín E, Lozano-Lozano M, Cantarero-Villanueva I, Arroyo-Morales M, Martín-Martín L. Myofascial pain, widespread pressure hypersensitivity, and hyperalgesia in the face, neck, and shoulder regions, in survivors of head and neck cancer. Supportive Care in Cancer. 2019 Nov 21:1-8.
- ↑ Araujo FX, Ferreira GE, Scholl Schell M, Castro MP, Ribeiro DC, Silva MF. Measurement Properties of the Craniocervical Flexion Test: A Systematic Review. Phys Ther. 2020;100(7):1094-1117.
- ↑ Jump up to:14.0 14.1 14.2 14.3 14.4 Painkra JP, Kumar S, Anwer S, Kumar R, Nezamuddin M, Equebal A. Reliability of an assessment of deep neck flexor muscle endurance test: A cross-sectional study. International Journal of Therapy and Rehabilitation. 2014 May;21(5):227-31. [Accessed 8 June 2018] Available from: https://www.researchgate.net/profile/Suraj_Kumar12/publication/262380062_Reliability_of_an_assessment_of_deep_neck_flexor_muscle_endurance_test_A_cross-sectional_study/links/00b495379678f7cfe8000000/Reliability-of-an-assessment-of-deep-neck-flexor-muscle-endurance-test-A-cross-sectional-study.pdf
- ↑ Jump up to:15.0 15.1 15.2 15.3 Parazza S, Vanti C, O’Reilly C, Villafañe JH, Moreno JM, De Miguel EE. The relationship between cervical flexor endurance, cervical extensor endurance, VAS, and disability in subjects with neck pain. Chiropractic & manual therapies. 2014 Dec;22(1):10. [Accessed 8 June 2018] Available from: https://www.researchgate.net/profile/Carla_Vanti/publication/260443297_The_relationship_between_cervical_flexor_endurance_cervical_extensor_endurance_VAS_and_disability_in_subjects_with_neck_pain/links/00b7d532f6107a06c7000000.pdf
- ↑ Jump up to:16.0 16.1 16.2 16.3 Clark NC, et al., Proprioception in musculoskeletal rehabilitation. Part 2: Clinical assessment and intervention,Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.01.009 [Accessed 7 Jun 2018] Available from: http://www.academia.edu/download/39999329/Proprioception_in_musculoskeletal_rehabi20151114-26033-wibkio.pdf
- ↑ Jull GA, O’leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. Journal of Manipulative & Physiological Therapeutics. 2008 Sep [Accessed 7 Jun 2018] 1;31(7):525-33. Available from: https://scholar.google.com/scholar_url?url=http://portalsaude.dominiotemporario.com/doc/teste_cranio_cervical.pdf&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=i1IZW_DMNYGnywSN4o3ABQ&scisig=AAGBfm3AjnSQA5jlgWBbIawh20NsI2sFmA
- ↑ Nazari G, Bobos P, Billis E, MacDermid JC. Cervical flexor muscle training reduces pain, anxiety, and depression levels in patients with chronic neck pain by a clinically important amount: A prospective cohort study. Physiother Res Int. 2018;23(3):e1712.
- ↑ Suvarnnato, T., Puntumetakul, R., Uthaikhup, S. and Boucaut, R., 2019. Effect of specific deep cervical muscle exercises on functional disability, pain intensity, craniovertebral angle, and neck-muscle strength in chronic mechanical neck pain: a randomized controlled trial. Journal of pain research, 12, p.915.
- ↑ Rehab My Patient. Cervical Proprioception LASER Points In Range Rotation Eyes Open 2 Published on Aug 30, 2017 [Accessed 6 June 2018] Available from: https://www.youtube.com/watch?v=h-0ny-oJLXM
- ↑ Rehab My Patient. Cervical Proprioception LASER Points In Range Rotation Eyes Closed 2. Published on Aug 30, 2017 [Accessed 6 June 2018] Available from: https://www.youtube.com/watch?v=_mkveStrW8k
- ↑ Motion Guidance. Cervical Rotation Neck Proprioception Exercise with Motion Sensor. Published on Apr 23, 2018 [Accessed 6 June 2018] Available from: https://www.youtube.com/watch?v=EflMNYITmBw