The ratio of change in muscle thickness between superficial and deep cervical flexor muscles

Pain and disability associated with musculoskeletal conditions represent a significant health burden in Australia. International figures indicate that at any point in time approximately 10–15% of the population will be suffering an episode of neck pain, and 40% will suffer neck pain during a twelve-month period (


There has been emerging evidence over recent years of the importance of activation of the deep cervical musculature to neck stability and imbalance between activation of the superficial and deep cervical neck flexor muscles with patients experiencing neck pain and disability, (Goo et al, 2015).


A recent study by Goo et al (2015) set out to investigate the imbalance of muscle recruitment in cervical flexor muscles during the cranio-cervical flexion test (CCFT), using ultrasonography. The purpose of the study was to determine if there was an optimal level of pressure in clinical cranio-cervical flexion test to achieve the least imbalance between the muscle groups. The study recruited university students with current neck pain, a score greater than 5 on the Neck Disability Index (NDI) and without evidence of neurological disorder or having previous treatment. The authors studied the cross section area change of the Sternocleidomastoid and Longus Colli and Capitus during the test. They found that the greatest imbalances during the test was at a pressure of 22 mmHg, due to considerable muscle thickness changes, followed by pressures of 28-30 mmHg due to changes in muscle recruitment patterns. The least imbalance was assessed at 24-26 mmHg.

Neck flexor


While there are some limitations to the results, the authors suggest that an optimal level of pressure during the test and subsequent treatment to achieve the greatest balance between the superficial and deep cervical flexor muscles might be best achieved at 24 and 26 mmHg. The findings may also suggest that without access to ultrasound, manual palpation of the superficial cervical flexor musculature may be of benefit to control overactivity.


Workplace Physiotherapy incorporate exercise based intervention to encourage appropriate activation of the superficial and deep cervical flexor muscles during treatment, postural correction and work-related activities.



Goo M, Kim S-G, Jun D. (2015). The ratio of change in muscle thickness between superficial and deep cervical flexor muscles during the craniocervical flexion test and a suggestion regarding clinical treatment of patients with musculoskeletal neck pain. J Phys Ther Sci. 2015 Aug; 27(8): 2473–2475.



The comments above are the implicit advice of Workplace Physiotherapy. The views expressed are based on current evidence-based research and accepted best practice approaches. Unless otherwise stated, these comments are not the view of WorkCover NSW or any other professional body. No reproduction or forwarding of this advice is permitted without the consent of the author.


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