Building a Robust Neck Testing and Training Protocol

In the modern training environment, the neck is gaining prominence driven by the increased awareness for injury reduction, specifically concussion reduction, which is of paramount importance for full contact and collision sports. There’s growing evidence that neck-strengthening interventions show a possible reduction in traumatic brain injury (TBI) and concussion, and that neck thickness is a mitigating factor.

Often cited is the now famous Collins et al.(2014) study where the researchers noted that “every one pound increase in neck strength leads to a decrease in five percent chance of sustaining a concussion.” This has led to a mix of novel neck training solutions which are increasingly more objective. Neck training itself is and has been highly subjective, but according to Carl Valle in his post about prioritizing neck training for athletes, “Neck-strengthening exercises, even crude ones, can make a difference in the incidence and severity of concussions.”

So is it worth pursuing? The answer increasingly points to yes. However, the main challenge with neck strength is monitoring change and improvement. I’ve often found athletes or coaches don’t remain consistent with neck strength because it doesn’t have the same appeal as movements that give impactful, visceral feedback like adding 10kg to a squat PB or hitting a new bench max, so it’s often lumped into the “nice to have but not necessary” category of exercises.

I’m not going to belabor the points about neck anatomy and function, because Carl’s post does an excellent job. The key point on neck anatomy is Carl’s statement: “The joint system of the neck isn’t just the cervical region—we must use the nuchal ligament and even the jaw, shoulder, and clavicle.”

MMA, Golf, and Motorsport

Part of the problem with necks, and subsequently testing and training them, is described in Honda et al.(2018): “There is no agreed-upon scale as to what constitutes as strong, moderate, and weak neck strength. For example, football players will likely have stronger necks than soccer players, yet in their respective studies, they were broken down into strong, moderate, and weak necks.” A lack of agreement as to what constitutes a strong or weak neck is problematic.

I’ve been endeavoring to use neck strengthening in some fashion for many years. Currently, I’m implementing neck strengthening for three very different sports contexts in my day-to-day practice. The first is the concussion and TBI risk I perceive in mixed martial arts (MMA). The MMA athlete’s use of the head and subsequently the neck to apply pressure and post in grappling means strength is also important.

This is totally different than the second major sport I’m involved with—golf. Golf neck injury incidence is higher than I anticipated. Obviously, it’s not a contact injury, but it does account for 20% of injuries with no significant gender difference. Presently, at the European Tour Performance Institute, we’re starting to dig into neck injury from golf and looking at a means of testing so we can objectify interventions.

The neck is a common overuse injury site in golf, with repeat rotation of the T-spine and C-spine in different directions, says @WSWayland. Share on X

The neck is a common overuse injury site in golf, with repeat rotation of the T-spine and C-spine in different directions. It stands to reason that with long practice days and poor levels of robustness, this a potential injury hot spot. As of 2019, some very high-profile golf athletes have had to take time out due to neck injuries.

“Unfortunately due to a neck strain that I’ve had for a few weeks, I’m forced to withdraw from the API. I’ve been receiving treatment, but it hasn’t improved enough to play. My lower back is fine, and I have no long-term concerns, and I hope to be ready for The Players.”—Tiger Woods

Both MMA and golf athletes are chasing neck strength improvements, but for different reasons—one is a desire to reduce concussive risk and potential TBI, and the other is for training and playing volume tolerance.

My third area of interest is how the neck functions in motorsport, which is different than MMA and golf. The motorsport athlete (obvious collision risk aside) has to have a strong neck both to handle g-forces and to stabilize the vestibular system—in particular minimizing disturbance to the vestibulo-ocular reflex. And the key to this is stabilizing the eyes during tremors caused by machine vibration, which is particularly common in F1 where stiff suspensions allow for greater control and stability but cause a lot of vibration.

Though unappreciated by many, both motorcycle athletes and racing car drivers have complicated visual strategies to anticipate corners and to decide when to engage in an exit strategy using visual markers. For example, poor visual acuity of just a 0.5-second delay can mean a difference of 15.5m travel if the rider travels 70mph. A stable head means fewer mistakes.

MMA, golf, and motorsport are very different sports that need meaningful outcomes achieved by sensible neck training interventions, says @WSWayland. Share on X

These are very different sports that need outcomes achieved by a sensible neck training intervention—much like all these athletes would undertake a strength program if they wanted to improve a raw measure like IMTP. In other words, they would undertake a similar intervention to improve scores in a measure of raw neck strength, which would hopefully transfer to meaningful sporting outcomes. As neck strength matures, we can start using sport-specific positioning.

Lofi Solutions, Luggage Scales, and Finding a “Pure” Neck Test

F1 strength coach and physio Patrick Harding took a pragmatic step, taking the Collins study’s use of luggage scales and applying it meaningfully to a population that values neck strength—F1 drivers. These athletes have a very strong case for applying neck strength given the sheer amount of g-force they need to tolerate and to mitigate concussion risk in a possible accident.

Effectively, a neck harness and a luggage scale are all we need to perform a simple neck strength test with lateral- and extension-resisted positions, which seem to be the easiest to execute (pictured below, and used in the Collins study).

While implementing different positions, I found that these two positions time and again offered the best values versus compromising position. I learned from many years of grappling that where the head goes, the body must follow. So, despite trying a few novel positions like standing and kneeling, as soon as ample resistance was applied, the athlete often found it difficult to maintain balance. I did find, however, that getting the athlete to sit next to a bench, which acts as a T-spine brace, gave us better scores because it minimized sitting balance as a limiting factor.

After deciding upon my testing protocol, I ran a few concurrent neck training interventions and saw 5-6kg increases in lateral neck strength in as little as four weeks. Extension saw smaller gains of 3kg. Most athletes are usually very strong in extension, especially grappling sport athletes where resisted extension happens regularly.

Patrick also used the scales to gauge resistance in training as well as testing. We can gauge how hard an athlete pulls on a neck harness during repetitive movements in order to apply the right amount of progressive force when they’re performing them manually.

I experimented with rotation- and flexion-based neck testing but found results inconsistent because the precise angles were harder to determine. It’s also difficult to tell the degree to which athletes anchors themselves and use their core muscles to try to game the outcomes. These tests are somewhat simplistic and don’t have the fidelity that we desire from a meaningful testing procedure.

Upgrade Your Testing with Load Cells

Luggage scales are cheap and are mechanical or digital but come in an array of build qualities, often have small load tolerances, and can be inaccurate and poorly constructed. The numbers obtained from luggage scales come from the tester who eyeballs the highest values as force is applied. Luggage scales also don’t record data.

In short, we can do better, especially with current load cell technology. Scientific grade load cells have increasingly dropped in price. Once the reserve of academic institutions, these devices are increasingly making weight room appearances, much like force platforms.

We've created a reliable #NeckTestingProtocol using a scientific grade load cell and software to use on the PGA European Tour, says @WSWayland. Share on X

Using the Ergotest 300kg force sensor with the MuscleLab software, we’ve devised our own neck testing protocol to use on the PGA European Tour. Initial trials show it has a high degree of test-retest reliability, and we’ll be conducting trials to quantify this along with its ability to predict neck injuries in golfers over the next year or so.

We developed the test, placing the athlete in the position pictured in the image below, to improve positional stability and to isolate the neck. We tried more “functional” positions (standing, kneeling, etc.), but found the athletes were thrown off balance and weren’t able to achieve a consistent score.

To carry out the test, we attached the force sensor to a suspension trainer to create a handle and then clipped it onto a neck training cap. We placed the cap on the athlete, who sits in the position shown above. The athlete is instructed to brace and not let their neck move during the test. The coach gradually applies force to the athlete for ~5 seconds into lateral flexion. We tried using rotation, but it was difficult to standardize. The test ends when the athlete loses their neutral head position (i.e., they start to fail and slip into lateral flexion).

The MusceLab software runs in the background during the test. Once the software is stopped, the peak force value immediately displays on the screen. We take three maximal tests in lateral left and then right side flexion and record the highest of the values on each side. We then measure peak force for general neck strength and can compare values to quantify any possible asymmetries.

This approach also allows us to record force data over time as opposed to the single point peak we used with a crude luggage scale measure. The tests used are exactly the same as those performed with the luggage scale. The software also allows us to gather RFD, which is not particularly salient to maximum neck strength testing but is a useful capacity to have.

The versatility of a simple load cell will help us test for trunk strength as well as other potential tests, says @WSWayland. Share on X

Another novelty is the ability to compare the luggage scale to the load cell. The luggage scale didn’t perform too horrendously, but precision is the aim of the game when it comes to measuring productive intervention. Going forward, the versatility of a simple load cell will help us test for trunk strength as well as other potential to-be-thought-of tests.

Using load cells or luggage scales, we can look at neck symmetry and effort sustainability by comparing each side using holds or quasi isometrics with chin to chest and head to trap style repetitions and look for a drop-off in effort or output. I’ve been operating on Patrick’s suggestion that probably no more than 5-10% asymmetry is desirable.

Interventions

Neck training interventions need not be complicated. The simplest start is manual exercises with a coach or partner providing resistance. Then move up to banded, loaded, and novel devices specific to neck training.

Basic neck training starts with the simple task of determining whether an athlete can find a neutral head position and work on head repositioning to do so. What constitutes neutral can be determined by the coach as an athlete’s position is often a dynamic, context-based endeavor. Neutral is often agreed to be a vertical stacked cervical spine with the chin slightly packed.

Positioning

For gravity to no gravity neck training, the athlete simply lifts the head from a rested position to an active position. This is the ground floor on the neck training spectra and can be performed in a sustained isometric fashion or by doing repetitions. Have the athlete lay on the floor or a bench and lift their head only a few millimeters to sustain a light contraction. They’re not drawing the chin to chest; they’re elevating the head slightly.

Video 1. This video shows how to position an athlete on a bench for the first step in neck training.

Manual Drills

Partner-resisted manual drills take us from the simple position drills to partner-resisted positioning drills. Here we can introduce flexion, extension, and lateral movements with simple partner applied manual resistance. The only problem with this approach is the lack of objectivity as it can be difficult to gauge the efforts of the athlete and the person applying the manual pressure.

Video 2. Athletes demonstrate partner kneeling manual isometric neck training.

Long duration isometrics can be performed seated, standing, and using bodyweight to encourage head stabilization. Bodyweight work like this acts as an excellent partner drill; encouraging trust and teamwork to achieve your goal is always a bonus.

Video 3. Athletes partner together to perform long duration isometric neck training.

Banded

Banded neck work is a straightforward adaption allowing for a low tech and travelable solution for neck strength. It lets athletes include the variations mentioned above, including gravity plus resistance to no gravity, banded plus perturbations, quasi iso lateral, and banded plus high tension irradiations.

Bands allow us to anchor from just about anywhere and challenge the neck in a variety of angles and tensions. It’s also safer and more practical than the traditional neck harness nodding dog work we often do. Adjustments come as simply as walking away from the anchor point or upgrading to a stronger band or bungee cord.

Video 4. Neck training with bands allows us to anchor from just about anywhere and challenge the neck in a variety of angles and tensions.

The versatility of bands lets us apply positions specific to a sport. Outwardly simple, it means the driver can brace in a fashion that is sport-specific under similar constraints.

Video 5. The versatility of bands lets us apply positions specific to a sport, as illustrated in this video by Jeff Richter.

When testing the neck in sport-specific positions, we need to look for ways to create stability to allow the neck to be trained. Part of the problem with neck strength training is that achieving qualitative gains can be tricky since very high force production for the neck requires enormous peripheral stability.

One way to create stability is through irradiation by implementing grip as a stability modifier. Anyone who has ever clenched a fist in anger quickly feels the irradiation move up the arm and into the T-spine and shoulder structure. Gripping then further allows the neck to achieve greater force potential.

I’ve experimented with a six-point kneeling position test as a simple means for MMA and Superbike (and potentially rugby) because it allows the athlete to brace the neck in quasi sport-specific position. Using a low-set barbell allows the athlete to brace to grip, which sets the shoulder while they brace laterally during the test.

Video 6. This six-point kneeling position test works tremendously well for low angle collision sports.

Power and Rate of Force Development

A simple set-up using a metronome app allows us to practice quasi iso explosive movements. The intent is to brace rapidly on the beat for reps and to relax on the next subsequent beat. Athletes can perform this in prominent resisted sport positions. It’s important because neck bracing is often not a sustained position but a rapid contract and relax affair that often involves an amount of anticipation.

Video 7. We can practice quasi iso explosive movements using a metronome app to replicate the rapid contract and relax aspects of neck bracing.

Future Considerations

Once we learn more about what constitutes a strong neck, we can begin to plan for the task at hand objectively. It seems that what we know right now is very limited. A further consideration might be a vestibular challenge: the apparent increase in challenge to neck strength when we add visual challenges and tasks. I’ve suspected this for some time and have conferred with Indy Car Strength Coach Jeff Richter about it.

With objective measures that load cells give us, we can begin investigating whether this is true. We see this relationship in neck pain with decreased ocular motor control scores. There may be a need for combined neck and vision training in post-injury athletes to restore some semblance of normal function. This would be a big part of return-to-play procedures and integration into neck training.

Make Neck Interventions Work for You

Neck training is partly a battle of consciousness-raising and appreciating the difference between neck training for injury prevention, rehab, and performance enhancement as well as identifying the needs of the athlete and their sport neck performance requirements. When we transition from basic drills, we need to integrate neck training strategies that reflect the demands of the sport.

When we transition from basic drills, we need to integrate #NeckTraining strategies that reflect the demands of the sport, says @WSWayland. Share on X

For example, intensive manual drills might not be the best fit for a motorsport athlete when we may need to consider neck training plus eye movement drills. Conversely, this might not be the best approach when trying to help an MMA fighter resist head control and deal with concussive blows. As with our approaches in all other aspects of preparation, we need to implement a “general to specific” paradigm.

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Daniel Coughlan lectures at the University of Essex, within the School of Sport, Rehabilitation and Exercise Sciences, where he also leads the university’s Sports Performance Research Group. He is the Head of Strength and Conditioning for the European Tour, and the Sports Science and Medicine Lead for England Golf. In these roles, he uses a wide range of approaches to support an athlete’s performance, and works collaboratively with a diverse blend of professionals.