Check Up from the Neck Up
Insights and perspectives on injury prevention, rehabilitation, health and fitness
By Ryan Cidzik, MS, CSCS, RSCC, USAW, is Director of Football Strength and Conditioning at the University of Memphis. He has also worked with two NFL teams and NFL Europe. He can be reached at: firstname.lastname@example.org.
Research has shown that a strong neck may reduce the risk of concussion. In response, the University of Memphis has implemented a comprehensive neck testing and strengthening program. Football players at Memphis have suffered fewer concussions since neck strengthening has become a priority. One of our main goals as strength and conditioning coaches is injury prevention. We know that basketball players are prone to ankle injuries, so we strengthen the surrounding musculature. We know that female athletes are more likely to suffer ACL injuries than male athletes, so when working with women’s teams we implement a warmup proven to help prevent ACL tears.
We also know that concussions occur in football more often than any other sport, but what are we doing as strength coaches to help protect our players against them? I believe that including neck strengthening work and monitoring those methods in our football strength and conditioning programs could be one answer.
A study supporting this theory was published five years ago, and several concussion experts have spoken out in support of the idea. Though more research needs to be done, if it’s possible that a stronger neck may help prevent concussions, strength and conditioning coaches have a responsibility to help players achieve this.
Here at the University of Memphis, we have developed a program to test, monitor, and improve our football players’ neck strength. Since implementing the program two years, ago, we’ve seen the number of concussions sustained by our players decrease. I believe this program is at least part of the reason why.
WHY IT’S IMPORTANT
Concussions occur when there is linear and/or rotational acceleration-deceleration of the head—a sudden change in momentum that is forceful enough to jar the brain and damage the tissue in it. A study in the August 2007 issue of Neurosurgery reported that a stronger neck reduced these forces, which can in turn reduce the risk of a concussion.
In the study, researchers simulated 25 head impacts using dummies wearing helmets, and measured head translational and rotational accelerations, upper neck responses, head kinematics and biomechanics, head displacement, head rotation, and neck loads. When using a model with a stronger “neck,” they noted a decrease in head velocity and head injury criterion. They concluded that varied strength levels in the neck might “explain different concussion risks in professional and youth athletes, women, and children.” In other words, a weaker neck may predispose an athlete to concussion because they cannot create the internal muscle forces necessary to reduce the head acceleration caused by a strong hit.
Michael “Micky” Collins, PhD, Director of the University of Pittsburgh Medical Center’s Sports Medicine Concussion Program, spoke out in support of neck strength as a preventative measure when he was interviewed by Stack magazine in 2008. “One of the best ways to prevent concussions is through neck strength,” he said. “Having a strong neck actually allows the forces of the blow to be taken from the head down through the neck and into the torso. We really find that athletes with strong necks [have less risk of concussions].”
Robert Cantu, MD, FACS, FACSM, Co-Director of Boston University’s Center for the Study of Traumatic Encephalopathy, has similar beliefs. “It’s just straight physics,” Cantu told Fox Sports in 2010. “If you see the blow coming and you have a very strong neck and contract the neck muscles, you have a much greater chance to have significantly reduced the forces the brain will see.”
Kevin Guskiewicz, PhD, ATC, Chair of the University of North Carolina’s Department of Exercise and Sports Science program, has been quoted similarly. And the Sports Legacy Institute, an organization dedicated to concussion awareness and education, has published materials supporting the importance of neck strength.
Research, and comments like those just mentioned, have led us to implement a neck training program for our football players here at Memphis. We start with baseline testing so we know each player’s neck strength level and how much work needs to be done. We continue to test throughout the year to make sure that our training program is working and that our athletes are not losing neck strength.
Cervical neck strength testing with a machine called an isokinetic dynamometer is a very accurate method, but the equipment can be expensive and trained testers are needed to perform the evaluations. The good news is that you can test your players’ cervical neck strength by simply timing how long they can hold a dumbbell attached at the back of their head off the ground. A system of padded straps worn around the head, and basic equipment already in your weight room, is all you need.
We use isometric as opposed to dynamic testing because the main function of the neck muscles is to maintain postural balance, not to lift, push, or pull. Isometric testing is also a highly reliable method, as various studies have found muscle endurance (specifically static strength endurance) to be a good indicator of neck strength.
Prior to testing, players prepare by completing a general warmup to elevate their heart rate for three to five minutes. Then they complete a dynamic warmup, moving their head in six different directions. The first movement is flexion and extension. The player goes back and forth between the two for 15 seconds, holding each for about a second. Next is lateral flexion left and right, following the same timing. Third is rotation left and right. Finally, a partner applies light manual resistance, and the player again moves his head in all six directions, for a total of five repetitions in each direction. The athlete finishes the warmup by performing the isometric test, but with a lighter weight (35 pounds) than we use during actual testing.
For the test, the weight is attached to the back of the athlete’s head through a system of straps. There are two straps: One that goes around the player’s forehead, and one that goes around his chin. This allows the weight to be evenly distributed across the athlete’s head. Both straps meet at the back of his head and feed into a metal ring. A third strap is attached to the ring, and will eventually hold the dumbbell.
I constructed the straps that we use here at Memphis, and any coach can create a similar system. I asked our wrist strap company for a two-inch strap for the forehead and a one-inch strap for the chin. Each strap is three feet long. The metal ring can be bought at a hardware store.
The athlete then lies supine on a bench with his head extended over one end. His arms should be overhead, with elbows bent at 90 degrees and feet flat on the floor.
For safety reasons, it’s important that two coaches be present throughout the entire testing process. To begin, the first coach attaches a 55-pound dumbbell to the strap at the back of the athlete’s head and while still supporting the dumbbell, adjusts the weight’s strap so that it is two to four inches from the floor. The weight should stay this close to the floor so that if the athlete needs to stop the test, he can just drop his head back and the weight will hit the floor before he strains his neck.
The athlete should keep his head in a neutral position with chin tucked while the coach continues to hold the dumbbell. Past cervical strength testing studies use the neutral position because it is considered the most central position of the spine while preserving the normal lordotic curve. When the neck is neutral, the spinal cord is in the safest position because more space is available for the cord, meaning there is a decreased risk of compression.
As the first coach releases the dumbbell on a count of three, he or she should spot the athlete as he strives to maintain the same neutral position to failure. The second coach should be present to keep track of time and give the following coaching cues to the athlete:
The test is over as soon as the athlete can no longer hold the weight and his head breaks from a neutral position. The amount of time that the weight was held is recorded. Once the test is over, the athlete performs a cool-down. A static 15-second rotation to each of the six directions as done in the warmup should suffice.
Based on my experience, I recommend 55 pounds to test muscle endurance for collegiate or professional football players who do neck training on a regular basis. This is based on the average weight our players can hold for 30 seconds. Though weights as low as two kilograms have been used in clinical tests, small amounts of weight are not a good idea for our test because they can be held for long periods of time, which can cause neck pain.
Although all of our players use the same weight, I firmly believe that a lighter weight should be used when testing younger athletes. Since neck circumference is directly related to neck strength, a team’s average neck circumference can dictate how much weight to use. For example, our team’s average neck circumference is 17 inches and we use 55 pounds. So for each inch smaller your team’s average neck circumference is, you should drop the test weight by approximately 10 pounds.
Most of our incoming players are deficient in neck strength, and can hold the weight for an average of only 10 seconds. For these players, a strengthening program is needed. Returning players and incoming athletes who test well also participate in neck strengthening to make sure we keep their strength up.
Too often, the only thing coaches do when it comes to neck training is two sets of 10 reps on the four-way neck machine. But if you wanted to increase strength in the bench press, would you do the exact same workout every day? Of course not. Training the neck shouldn’t be any different. We should approach the task with the same, if not more, meticulousness and serious thought process that we apply to working any other muscle group.
The six major movements we target are:
While the cervical obliques are predominantly slow twitch muscles, they need different forms of activation and stimulation just like any other muscles in the body. We utilize a variety of exercises, methods, ranges of motion, and tempos in our neck strengthening program.
While most of our training involves manual eccentric-based work—manual work is the best because of the activation, hypertrophy, and kinesthetic awareness involved—we also use various resistances, including weights, bands, machines, stability balls, Airex pads, and combination methods. Some of the exercises neck strengthening exercises we do include:
Rotations should be done at least once or twice per week. Rotation is the most common mechanism of a concussion in football, so while we incorporate most of the neck movements into our weekly training program, we never neglect rotations.
Flexion is also important because most head contact occurs as a direct hit to the front of the facemask. This movement is also typically 25 percent weaker than extension, which is why the neck strength test is based on forward flexion.
In addition to the neck muscles, we train the upper trapezius, which is very important for dissipating forces, once or twice per week. The upper trapezius is one of the major superficial muscles of the posterior neck. It sits between the cervical spine and next to and/or over all of the other major cervical posterior muscles and helps to extend, rotate, and laterally flex the neck.
Our athletes also work on maintaining range of motion. A stiff or sore athlete cannot properly absorb force, hence increasing the chance of a concussion. Various stretching and re-lengthening methods such as the six-way stretch performed after testing should be part of your team’s neck training.
We work on neck strengthening year-round. At the start of the off-season in January, neck strength is tested. All month long, we train the neck three days per week and perform upper trapezius work once per week. The focus is on re-teaching the athletes proper form and re-teaching their neck muscles how to perform our exercises. Work capacity is gradually increased throughout the month.
During February, we start training the neck four days a week and do upper trapezius work twice a week. We continue to increase work capacity and begin introducing perturbation training—reacting to a sudden unexpected force or movement—to improve reaction time.
Just before spring practice begins in March, neck strength is tested again. Spring ball runs through March and April, and we back off neck training to three days per week and upper trapezius work once a week. We decrease volume to accommodate the increased stress of practice. The focus is on re-lengthening the muscles after workouts and practice.
Before our summer programming begins in May, neck strength is tested again. Then over the summer, players train the neck four days per week and perform upper trapezius exercises twice a week. At this time, more advanced methods of training are introduced, and when the players’ summer training is completed at the end of July, neck strength is tested once again.
Our preseason camp is in August, and then the season begins. During this time, we back off to three days of neck training per week and one day of trapezius work. We don’t introduce any new exercises during the season and again focus on re-lengthening the muscles after workouts and practices.
Based on the methods described in this article, we have observed a very positive trend over the last two years here at Memphis. Evidence is emerging that proves our testing and training methods are reducing head injuries suffered by our players.
We saw significantly fewer concussions—50 percent less—during the 2010 and 2011 seasons. Players who missed playing time due to a head or neck injury also decreased 50 percent over the past two years.
While we cannot prevent all concussions from occurring, we need to do our part as strength coaches to provide our athletes with the best protection possible. My worst fear is to watch an athlete suffer an injury and not be certain I did everything I could to help avoid that injury. If our neck strengthening program prevents just one concussion, it’s time well spent in the weightroom.
Sidebar: MORE THAN STRENGTH
When we periodically test our players’ neck strength throughout the year here at the University of Memphis, we also perform two more tests. We give them a cervical range of motion test and we measure head and neck circumference. Here’s why: Range of motion: A 2004 study in the Journal of Athletic Training showed that if an athlete has decreased cervical spine range of motion, it compromised their ability to move their head out of the way of a hit, therefore increasing the chance of a concussion. Normal cervical range of motion should be 55 degrees of extension, 45 degrees of forward flexion, 45 degrees of lateral flexion, and 70 degrees of rotation.
When a player has insufficient range of motion, he is prescribed extra re-lengthening methods consisting of mostly static stretching and “pin-and-stretch” techniques. A local massage school gave the team a sports massage course and I taught them some other techniques I learned during my time with the New York Jets.
Neck circumference: In the two years we’ve been doing a neck training program, we’ve noticed a connection between neck circumference and neck strength. We don’t test neck strength during the season because we want to avoid any injury or overuse of the neck muscles, but we do measure neck circumference. When a player’s neck circumference drops, it’s an indicator that they need more neck training. If a player’s measurement drops during the season, I adjust his training program to concentrate on hypertrophy.
Head circumference: The circumference of the neck should be proportionate to the size of the athlete’s head to avoid the “bobble head” effect. Biomechanics show us that an athlete who has a large head and a long and small neck is at greater risk for a head injury than an athlete with a smaller head and a shorter and thicker neck.