72
Therapeutic Exercise for the Cervical
Spine
Christopher J. Durall, PT, DPT, MS, SCS, LAT, CSCS
Neck pain affects most adults at some point in their lives, and
nearly 20% of the population suffers from persistent or recur-
rent symptoms (Croft et al. 2001, Binder 2006). Individuals with
neck pain may have deficits in coordination (Falla et al. 2004a,
Chui et  al. 2005), strength, endurance (O’Leary et  al. 2007b),
repositioning acuity (Kristjansson et  al. 2003, Sjolander et  al.
2008), postural stability (Michaelson et al. 2003), or oculomotor
control (Treleaven et  al. 2005a). Patients with neck pain may
also have mobility deficits in the cervical and/or upper thoracic
regions (Childs et  al. 2008). Therapeutic exercise has shown
considerable promise as an intervention for individuals with
neck pain (Kay et al. 2005, Gross et al. 2007), despite a lack of
consensus among clinicians and researchers on optimal exer-
cises or guidelines. In this section, exercises intended to correct
deficits are discussed, with the objectives of reducing symptoms,
improving function, and preventing recurrence.
EXERCISES TO IMPROVE MUSCULAR
COORDINATION, ENDURANCE, OR
STRENGTH
Deficits in cervical muscle performance may occur rapidly fol-
lowing the onset of neck pain and may persist despite symp-
tom reduction or resolution (Sterling et al. 2003). Research has
shown that exercises to improve coordination, endurance, or
strength can aid neck symptom resolution (Sarig-Bahat 2003).
This is logical given that the neck musculature provides nearly
80% of the mechanical stability of the cervical spine (Panjabi
et al. 1998).
The deep cervical flexor (DCF) muscles (longus capitus and
colli, rectus capitus anterior and lateralis, hyoid muscles) and
deep cervical extensor (DCE) muscles (semispinalis cervicis,
multifidus, rectus capitus posterior major and minor), in par-
ticular, appear prone to impairment in patients with neck pain
(Sterling et al. 2003). These muscles have a high density of type I
fibers and muscle spindles and are vulnerable to pain inhibition
(Boyd-Clark et al. 2002). Reduced control and capacity of the
deeper neck muscles can result in unwanted segmental motion
or buckling during contraction of the multisegmental superfi-
cial muscles (Winters & Peles 1990). Thus the initial rehabili-
tation emphasis should be toward improving performance or
coordination of the deeper cervical muscles.  (SCF) relaxed. The nodding movement will flatten the cervical lordosis
EXERCISES TO IMPROVE MUSCULAR
COORDINATION
Patients with neck pain tend to have impaired DCF activity and
elevated superficial cervical flexor (SCF; sternocleidomastoid
[SCM], anterior scalene) activity during craniocervical flexion
(Falla et al. 2004a, Chui et al. 2005). One exercise reported to help
reverse this aberrant neck flexor synergy uses a pressure device
positioned inferior to the occiput to provide feedback (Fig. 72.1).
For this exercise the patient attempts to flatten the cervical lordo-
sis, which requires DCF contraction (Mayoux-Benhamou et al.
1994), while minimizing SCF activation. The contractile effort
with this exercise should be low and the patient should focus on
precise control of the movement. Low-load exercises (20% maxi-
mal voluntary contraction) have been shown to facilitate more
selective activation of the deeper cervical flexor and extensor
muscles, while minimizing activity in their more superficial syn-
ergists (O’Leary et al. 2007a). Gentle, low-load exercise has also
been shown to produce a superior, immediate hypoalgesic effect
relative to higher-load exercise and is more appropriate when
pain is a primary concern. Exercising above the pain threshold
can impair neuromuscular control (Falla et al. 2007).
The pressure device–assisted craniocervical flexion exercise
is as effective at increasing cervical flexion strength as an endur-
ance exercise program in patients with chronic neck pain (Falla
et al. 2006). Moreover, the perception that the exercise program
was beneficial was roughly 10% greater in the group that per-
formed craniocervical flexion with a pressure device. Of inter-
est, this exercise was shown to improve repositioning acuity in
people with neck pain to nearly the same extent as a propriocep-
tive training regimen (Jull et al. 2007).
Fig. 72.1  With the patient hook-lying and in neutral craniocervical
spine alignment, a pneumatic pressure device is inflated to 20 mm Hg
and placed between the upper cervical spine (below occiput) and table.
The patient is instructed to slowly and subtly nod his or her head as
though saying “yes” while trying to keep the superficial cervical flexor
and increase device pressure. The clinician should monitor for unwanted
SCF activation, which is usually most apparent in the sternocleidomas-
toid (SCM). The patient can place the tongue on the roof of the mouth,
with lips together but teeth slightly apart, to decrease platysma and/or
hyoid activation. Initially, the patient can practice controlling and varying
pressure in the device. As tolerated, the patient should practice holding
increased levels of pressure until he or she can sustain 30 mm Hg for 10
seconds with minimal SCF activation.
487
488 SECTION 7  Spinal Disorders

Controlled craniocervical flexion can also be done without
a pressure device (Fig. 72.2). This exercise can be done sitting
or standing initially to minimize gravity resistance and then
reclined as tolerated to increase gravity resistance. Once the
patient can nod while supine with minimal SCF activation, he
or she can practice flexing the lower cervical spine while sus-
taining upper cervical flexion (Fig. 72.3). The SCMs are required
to flex the lower cervical segments, so the patient does not need
to palpate the SCMs during the combined movement. Inability
to sustain upper cervical flexion during this exercise results in
head protrusion (Fig. 72.4), which indicates that the exercise is
too challenging and should be regressed. Krout and Anderson
(1966) reported that 12 of 15 patients with nonspecific neck
pain who performed controlled head/neck flexion while supine
experienced good to complete recovery. This exercise and the
craniocervical flexion exercise described previously involving
the pressure device were shown to produce equivalent neck
flexor strength gains following 6 weeks of twice-weekly train-
ing in a group of women with mild neck pain and disability
(O’Leary et al. 2007a). Exercises for the DCFs can be particularly

A B

C
Fig. 72.2  In sitting or standing, patient slowly and subtly nods head as though saying “yes” while palpating sternocleidomastoids (SCMs) to ensure
minimal activation (A). The starting position is sequentially reclined to increase gravity resistance (B, C).

Fig. 72.3  In supine, the patient nods the head as though saying “yes” Fig. 72.4  Head protrusion (i.e., upper cervical spine extension) from
and sustains this while flexing the lower cervical spine. inadequate deep cervical flexor (DCF) activation.

important for patients with cervicogenic headaches, who are
prone to have poor DCF strength and endurance (Watson &
Trott 1993, Jull et al. 1999) and weak cervical extensors (Placzek
et al. 1999).
Compared to the DCF, evidence-based recommendations
for facilitating selective activation of the DCE muscles are lack-
ing. O’Leary and colleagues (2009) proposed that flexing and
extending the lower cervical spine while maintaining a neutral
craniocervical spine challenges the deep lower cervical exten-
sors while minimizing activity of the more superficial extensors
(Fig. 72.5). One method for training the cervical extensors is
shown in Fig. 72.6. This exercise provides patient-controlled,
progressive resistance to the cervical extensors. Whether this
exercise selectively activates the DCE is unknown. Low-inten-
sity isometric exercises for the cervical rotators also have been
suggested to facilitate co-contraction of the neck flexors and
extensors (Jull et al. 2007).  with neck pain associated with sustained postures. Patients
Fig. 72.5  Patient eccentrically flexes the lower cervical spine while
maintaining a neutral craniocervical spine (i.e., head and upper cervical
spine do not flex or extend), then slowly returns to the starting position.
This exercise can be performed in four-point kneeling, prone on elbows,
or sitting.
A B
Fig. 72.6  While maintaining neutral craniocervical spine alignment in sitting or standing, the patient passes an elastic band around the cervical
spine (A), then slowly extends the elbows to provide progressive isometric challenge to the cervical extensors (B).
72  Therapeutic Exercise for the Cervical Spine 489
EXERCISES TO IMPROVE MUSCULAR
ENDURANCE OR STRENGTH
When an acceptable foundation of muscular coordination
has been established, endurance and strength conditioning
may be introduced. Previous studies have shown that endur-
ance training and/or strength training can reduce pain and
disability in patients with cervical strain, degenerative or
herniated discs, and chronic or recurrent neck disorders. An
endurance training approach utilizing low loads should be
considered initially to avoid symptom aggravation. Of note,
several investigators have found endurance training and
strength training to be equally efficacious in reducing chronic
neck pain, at least in women (Waling et al. 2000, Ylinen et al.
2006). Exercises to increase fatigue resistance of cervical and
upper thoracic muscles may be particularly useful for patients
with neck pain have been found to adopt a more forward-
head posture and have difficulty maintaining an upright pos-
ture when seated (Szeto et  al. 2002). Corrected posture in
sitting significantly reduces cervical, upper thoracic, shoul-
der, and facial muscle activity compared to forward-head
posture (McLean 2005).
Individuals with neck pain may also have impaired perfor-
mance of the axioscapular muscles (levator scapulae, trape-
zius) (Falla et al. 2004b). This phenomenon may be explained
by the dual influence of the axioscapular muscles on the cervi-
cal spine and the shoulder girdle (Behrsin & Maguire 1986).
Weakness of the trapezius muscles in particular has been
reported to coincide with neck disorders (Andersen et  al.
2008). Exercises known to elicit high levels of activation in the
trapezius muscles are listed in Table 72.1 (Moseley et al. 1992,
Ballantyne et al. 1993, Cools et al. 2007). Performing shoulder
abduction while standing with the back against a wall (Fig.
72.7) may help correct deficits in trapezius performance and
structural alignment simultaneously (Sahrmann 2002). Addi-
tional exercises for the axioscapular muscles have been used
in various neck rehabilitation protocols (e.g., shoulder abduc-
tion, flexion, extension, scapular retraction, wall or floor
push-ups, latissimus pull-downs, arm cycling), and associated
pain reduction benefits have been reported (Randløv et  al.
1998, Waling et al. 2000).
490 SECTION 7  Spinal Disorders

TABLE Exercises With High Levels of Trapezius

72.1 Electromyographic Activity
EXERCISES WITH HIGH LEVELS OF UPPER TRAPEZIUS EMG
ACTIVITY
Prone rowing
Military press
“T” with neutral rotation or w/ER
Shoulder shrugs
Lateral raises T
Upright rows
EXERCISES WITH HIGH LEVELS OF MIDDLE TRAPEZIUS EMG
ACTIVITY
Prone extension L
Prone rowing
Side-lying ER
Side-lying forward flexion
“T” with neutral rotation or w/ER
EXERCISES WITH HIGH LEVELS OF LOWER TRAPEZIUS EMG
ACTIVITY
Abduction
Bilateral ER at 0 degrees of abduction
Empty-can in standing
Flexion in standing/sitting or side lying
Prone ER at 90 degrees of abduction
Fig. 72.8  Sagittal view of the cervical spine showing the synergistic
Prone rowing
relation between the trapezius and longus capitus and colli. The longus
Side-lying ER
capitus must prevent the occiput from extending for the trapezius to
“T” with ER
use this fixed origin from which to elevate the shoulder girdle. L, force
“Y”
vectors for the longus colli and capitus muscles; T, trapezius. (From Por-
EMG, electromyography; “T”, prone horizontal abduction, starting at terfield JA, DeRosa C: Mechanical Neck Pain: Perspectives in Functional
90 degrees of abduction; ER, external rotation; empty-can, scaption w/ Anatomy. Philadelphia, WB Saunders Co., 1995. **Fig. 3-6, p. 54.)
glenohumeral internal rotation; “Y”, prone horizontal abduction, start-
ing ≈120 degrees of abduction.
of the upper trapezius must be fixed to enable the muscle to
upwardly rotate the scapula. Inadequate fixation will result in
craniocervical extension. Thus, in this example, the DCF mus-
cles must be activated to stabilize the head and cervical spine by
neutralizing the extension moment of the upper trapezius (Fig.
72.8) (Porterfield & DeRosa 1995). This reinforces the impor-
tance of creating a foundation of motor control/coordination
in the deeper cervical muscles before higher-resistance training
exercises are introduced.
Higher-resistance training of the cervical musculature may
be necessary to significantly reduce pain and disability in indi-
viduals with chronic or recurrent neck disorders or to provide
adequate muscular stabilization and force dissipation in select
patients (e.g., wrestlers, football players). Ylinen and colleagues
(2006) reported the greatest strength gains and symptom reduc-
tion in women with chronic neck pain occurred during the first
2 months with strength training or endurance training. This
suggests a concerted effort may be required for at least 8 weeks
to reap the benefits of endurance or strength training on neck
pain. In another study, Ylinen et al. (2007a) reported the gains
in neck strength and motion achieved during a 12-month exer-
cise program were largely maintained 3 years later. This sug-
gests patients should be encouraged to continue endurance and/
or strength training, presumably with an independent “mainte-
Fig. 72.7  With scapulae, buttocks, and occiput contacting the wall,
the patient abducts both arms along the wall as far as possible while nance” program, for up to 1 year to prevent symptom recurrence.
maintaining contact with the wall. Endurance and/or strength training can be particularly
effective for women (Ylinen et al. 2003, 2006, 2007a, 2007b).
Women have a greater incidence of neck pain and higher
It is worth noting that the cervical spine and head must be prevalence of chronic neck pain than men (Hagen et al. 2000),
fixed during upper trapezius or levator scapulae activation for which may be attributable to lower muscle strength (Vasavada
meaningful force transmission to the scapulae. During arm et al. 2008). Maximal moments of the neck muscles are roughly
elevation, for instance, the head and cervical spine attachments 1.5 to 2.5 times lower in women than men, even when adjusted

for body size (Jordan et al. 1999). Consequently the neck flex-
ors and extensors are roughly 30% and 20% weaker, respec-
tively, in healthy females than in males (Vasavada et al. 2008).
This suggests that, in women, the mechanical demands on the
neck muscles may be closer to their maximal moment-gener-
ating capacity. As a result, neck muscles may fatigue sooner
in women, diminishing the muscles’ capacity to stabilize the
cervical spine.
The intensity, volume (repetitions and sets), and frequency
of endurance and strengthening exercises should be “titrated”
to stimulate the desired adaptive changes without undesirable
side effects such as symptom aggravation or poor adherence
(Haskell 1994). Patients with high irritability may tolerate only
brief bouts of very-low-intensity exercise through a limited arc,
whereas patients with moderate or low irritability may be toler-
ant of longer and more intense exercise sessions.
Evidence suggests that the majority of strength gains occur
in response to the first exercise set stimulus (Pollock et  al.
1993, Durall et al. 2006). Accordingly, the American College
of Sports Medicine (2002) recommends one set per exercise,
with each set performed to volitional exhaustion. Pollock and
colleagues (1993) reported that strength gains in the cervical
extensors were not statistically different between healthy sub-
jects who performed one set of 8 to 12 repetitions or two sets
of 8 to 12 repetitions twice each week for 12 weeks. Randløv
et  al. (1998) found no difference in pain, ADLs, strength, or
endurance outcomes between groups of patients who per-
formed one set or five sets of cervical and shoulder exercises
over 3 months.  “Skywriting” or tracing patterns on wall with eyes with head
EXERCISES TO IMPROVE
REPOSITIONING ACUITY,
OCULOMOTOR CONTROL,
OR POSTURAL STABILITY
Research has shown that people with chronic or recurrent neck
disorders or neck pain secondary to cervical spine trauma are
prone to deficits in head/neck repositioning acuity (Kristjans-
son et al. 2003, Sjolander et al. 2008), postural stability (Michael-
son et al. 2003, Treleaven et al. 2005b), and oculomotor control
(Treleaven et  al. 2005b)—apparently as a result of impaired
afferentiation from cervical mechanoreceptors (Dejong et  al.
1977). A growing body of evidence supports the use of exercises
to ameliorate these deficits (Sarig-Bahat 2003).
Repositioning acuity can be fostered by using a light source
(e.g., focused-beam headlamp or laser pointer affixed to a head-
band) and a target (e.g., dart board, archery target) (Fig. 72.9).
Relocation exercises, like the one demonstrated in Fig. 72.9, are
commonly performed sitting but also can be done standing.
Labile surfaces (e.g., ball, dome, wobble board) can be used to
increase the challenge.
Oculomotor exercises, designed to improve eye/head cou-
pling and gaze stability, can be progressed from eye movements
with the head stationary to trunk and/or head movements with
visual fixation on a target. These exercises can be made more
challenging by increasing the speed and range of eye, head, or
trunk movements or by altering backgrounds and visual targets.
Exercises to improve oculomotor control (Table 72.2) have been
shown to reduce dizziness and pain and to improve postural
control, cervical ROM, and function (Revel et al. 1994, Taimela
et al. 2000).
72  Therapeutic Exercise for the Cervical Spine 491
Fig. 72.9  Starting with eyes open, the patient’s head/neck is moved
passively until the light is aimed at a designated focal point on the tar-
get (e.g., bulls-eye). Next, with eyes closed or covered, the patient’s
head is passively moved in multiple directions to disorient him or her
(as for “Pin the Tail on the Donkey”). Following this, the patient actively
repositions the head/neck in an effort to aim the light source at the des-
ignated focal point again. While holding this position, the patient opens
or uncovers his or her eyes to assess repositioning accuracy.
TABLE
72.2 Exercises to Improve Oculomotor Control
stationary
Rotate eyes and head to same side, in both left and right directions.
Move eyes to target followed by head with eyes remaining
focused on the target.
Move eyes then head to look between two targets positioned
horizontally or vertically.
Maintain fixed gaze on target while weight shifting or rotating
torso (passively or actively).
Maintain fixed gaze on target while head is passively or actively
rotated.
Quickly move head and/or eyes, then focus on designated
location on target.
Move eyes and head in opposite directions.
TABLE
72.3 Exercises to Improve Postural Stability
Seated weight shifting on different surfaces (stool, dome, wobble
board, ball)
Balancing on floor or labile surface (pillow, foam, dome, trampoline,
wobble board) with different stances (preferred, narrow, tandem,
single leg)
Standing weight shifting on various surfaces
Moving upper extremities in different patterns while balancing
Playing “catch” while balancing
Walking while rotating or flexing/extending head
Walking while balancing foam pad or pillow on vertex of head
Performing oculomotor or repositioning exercises while balancing
Activities intended to improve postural stability are listed in
Table 72.3. Postural stability exercises are often progressed from
stable to labile surfaces and from bilateral to unilateral stances.
These exercises are not unique to cervical spine treatment,
and other techniques for challenging postural stability can be
incorporated. Taimela et al. (2000) reported that patients with
492 SECTION 7  Spinal Disorders

chronic neck pain who received eye fixation exercises, seated

wobble board training, exercises to improve cervical muscle
endurance and coordination, along with relaxation training and
behavioral support had greater reductions in neck symptoms,
improvements in general health, and improvements in their
ability to work than patients who were educated on neck care or
instructed in a traditional cervical spine home exercise program. 

EXERCISES TO IMPROVE MOBILITY

Some evidence supports the use of self-stretching exercises to
relieve pain, at least in the short term, in patients with neck pain.
Ylinen et al. (2007b) compared the effectiveness of twice-weekly
manual therapy (deep muscle massage, stretching, and joint-spe-
cific mobilization techniques) with a stretching regimen (lateral
flexion, ipsilateral flexion plus rotation, flexion—each held 30
seconds and repeated three times plus neck retraction performed
five times for 3 to 5 seconds) performed five times a week in A
patients with nonspecific chronic neck pain. Stretching and man-
ual therapy were found to be equally effective in abolishing pain
at the 4- and 12-week follow-ups. Manual therapy was slightly
more effective in decreasing disability and neck stiffness com-
pared with stretching, but the clinical difference was minimal.
Childs and colleagues (2008) suggested that flexibility exer-
cises should be considered for the anterior/medial/posterior
scalenes, upper trapezius, levator scapulae, pectoralis minor,
and pectoralis major. Stretching of the SCF muscles may be a
necessary emphasis, especially the anterior scalene and SCM
(Fig. 72.10), which promote a forward-head posture when
shortened. Addressing length impairments in other muscles
may be beneficial for certain patients. For instance, patients B
with neck pain associated with an increased thoracic kyphosis Fig. 72.11  Thoracic spine extension self-mobilization using a chair
may benefit from pectoralis minor stretching and/or thoracic back (A) or a foam roller (B) to create a movement fulcrum.
extension self-mobilization using a chair back or foam roller to
create a fulcrum (Fig. 72.11).

A B
Fig. 72.10  To stretch the anterior and middle scalene, the ipsilateral first rib is firmly stabilized, then the head/neck is extended and laterally flexed
(A). To stretch the sternocleidomastoid (SCM), the clavicle is stabilized, then the head/neck is extended, laterally flexed, and contralaterally rotated,
and the upper cervical spine is flexed (as if nodding “yes”) (B).

Patients lacking cervical rotation may benefit from active or
active-assisted rotation on a partially inflated beach ball (Fig.
72.12). To facilitate rotation, a nylon or cotton strap can be used
to impart an anteriorly directed force on the contralateral artic-
ular process of the hypomobile cervical segment as the patient
actively rotates. This facilitated rotation exercise (performed sit-
ting without a beach ball) was reported to be effective in reduc-
ing cervicogenic headache symptoms by 50% within 4 weeks in
patients who had a loss of rotation in full flexion of 10 degrees
or more (Hall et al. 2007).
A strap, pillow case, or towel can also be used to create a ful-
crum for extension below a hypomobile cervical segment (Fig.
72.13, A). Alternatively, patients can be educated to use their
index and/or middle fingers to create a dynamic, accommodat-
ing fulcrum, thereby “biasing” the extension movement to the
restricted motion segment (Fig. 72.13, B).
Nerve mobilization techniques may be beneficial for patients
with neck and arm pain to facilitate improved nervous tissue
Fig. 72.12  Facilitated head/neck rotation using a partially inflated
beach ball and/or a strap.
A B
Fig. 72.13  Cervical extension self-mobilization using a strap (A) or the index and/or middle fingers (B) to create a dynamic, accommodating move-
ment fulcrum.
72  Therapeutic Exercise for the Cervical Spine 493
gliding (Murphy et al. 2006). Coppieters et al. (2009) reported
that nerve excursion was greater with a gliding technique (alter-
nate ends of nerve are concurrently tensed and slacked) than
with a tensioning technique. Readers are encouraged to consult
additional sources for nerve mobilization techniques.
Patients with radicular or referred symptoms may also
benefit from directionally specific exercises. McKenzie (2009)
advocated performing repeated movements (with concurrent
manual procedures as needed) in directions that promote distal-
to-proximal symptom migration (“centralization”). At the time
of this writing there were no published clinical trials using spe-
cific exercise movements to promote symptom centralization
exclusively in patients with cervical radiculopathy, so the effi-
cacy of centralization procedures for this particular subgroup
of patients is unknown. However, it is evident that patients with
cervical radiculopathy benefit from a multimodal treatment
approach (Costello 2008). Kjellman and Oberg (2002) reported
that the McKenzie method was no more effective than general
exercise or low-intensity ultrasound in combination with edu-
cation in reducing disability in patients with nonspecific neck
pain.
A popular exercise in the McKenzie approach, cervical
retraction (Fig. 72.14), can be used to increase flexion ROM
in the upper cervical segments (Ordway et  al. 1999), reduce
anterior shearing of the lower cervical segments, and train
the DCFs and cervical extensors in synchrony (Mayoux-
Benhamou et  al. 1994). This may be particularly important
for patients with a more forward-head posture. As previously
described, a strap or the index and middle fingers can be used
to focalize the lower cervical extension that occurs during
retraction.
The heterogeneous, multifactorial nature of neck pain makes
it difficult to develop “one-size-fits-all” exercise programs.
Clinicians should select exercises according to identified defi-
cits, functional limitations, and the patient’s irritability level.
Comprehensive exercise programs for patients with neck pain
should include exercises to improve aerobic conditioning and
performance of the trunk/torso muscles (See Rehabilitation
Protocol 72.1).
494 SECTION 7  Spinal Disorders
REHABILITATION PROTOCOL 72.1    Sample Therapeutic Exercise Program for Patient With Nonspecific
Neck Pain
Phase 1
• Status: High irritability; nearly constant pain that limits activities
of daily living (ADLs)
• Emphasis: Slow, controlled, minimally painful exercises to
improve muscle coordination and proprioception
• Chin nods in sitting (phase 1 of deep cervical flexor progression)
or using pressure device
• Light targeting (or other target practice)
• Walking while balancing foam pad on head
• Weight shifting or rotating torso on stool or therapy ball with
fixed gaze
• Side-lying shoulder external rotation and/or prone shoulder
extension
• Repeated movement(s) in direction of symptom centralization (if
indicated)
• Daily walking for 10 to 20 minutes
Phase 2
• Status: Low to moderate irritability; pain with increased activity
• Emphasis: Muscular endurance
• Four-way neck isometrics with low-resistance elastic band/tub-
ing
• Isometric retraction with low-resistance elastic band/tubing (see
Fig. 72.8)
• Prone horizontal shoulder abduction starting at 90 degrees of
abduction (“T”), with shoulder external rotation
Fig. 72.14  Cervical retraction self-mobilization.
REFERENCES
A complete reference list is available at https://expertconsult
.inkling.com/.
• Bilateral shoulder external rotation at 0 degrees abduction with
low to moderate resistance elastic band/tubing
• Shoulder abduction standing with back against wall (aka wall
slide)
• Side-lying shoulder flexion
• Progress proprioceptive exercises
• Sternocleidomastoid, anterior scalene, pec minor stretching
• Thoracic spine extension self-mobilization using foam roller
• Low to moderate intensity aerobic exercise for 20+ minutes 
Phase 3
• Status: Very low or no irritability; very little or no pain with
activity
• Emphasis: Muscle strengthening
• Shoulder flexion with contralateral leg extension in quadruped
(aka Bird dog or Pointer exercise)
• Four-way isometrics with moderate to heavy resistance elastic
band/tubing
• Isometric retraction with moderate to heavy resistance elastic
band/tubing (see Fig. 72.8)
• I, Y, Ts with dumbbells
• Chest press, rows, shoulder raises
• Progress proprioceptive exercises as needed (PRN)
• Continue stretching and thoracic spine extension self-mobilization
PRN
• Moderate to high intensity aerobic exercise for 20+ minutes
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