EVALUATING THE EFFECTS OF A NOVEL
NEUROMUSCULAR NECK TRAINING DEVICE ON
MULTIPLANAR STATIC AND DYNAMIC NECK STRENGTH:
A PILOT STUDY
THEODORE H. VERSTEEGH,1 JAMES P. DICKEY,2 CAROLYN A. EMERY,3 LISA K. FISCHER,4
JOY C. MACDERMID,5 AND DAVID M. WALTON5
1
School of Physical Therapy, Western University, Elborn College, London, Ontario, Canada; 2School of Kinesiology, Western
University, London, Ontario, Canada; 3Sport Injury Prevention Research Center, Faculty of Kinesiology, University of Calgary,
Calgary, Alberta, Canada; 4Faculty of Health Sciences, Western University, London, Ontario, Canada; and 5School of Physical
Therapy, Western University, London, Ontario, Canada
ABSTRACT
Versteegh, TH, Dickey, JP, Emery, CA, Fischer, LK, MacDer-
mid, JC, and Walton, DM. Evaluating the effects of a novel
neuromuscular neck training device on multiplanar static and
dynamic neck strength: A pilot study. J Strength Cond Res
XX(X): 000–000, 2019—The neck serves an important function
in damping the transference of acceleration forces between
the head and the trunk, such as that occurring during contact
sports or motor vehicle collisions. An inability to adequately
dissipate forces has been proposed as a potential mechanism
for clinical conditions such as whiplash or concussion, but
current approaches to neck training may not be targeting the
correct mechanisms. The purpose of this study was to explore
the training effect of a novel neuromuscular strengthening pro-
tocol on dynamic and static neck strength. This was a quasiex-
perimental pilot study design with intervention (n = 8) and
control (n = 10) groups. The intervention group was trained
(twice/week, ;10 minutes, for 7 weeks) on a training device
that uses self-generated centripetal force to create a dynamic
rotational resistance. This protocol is intended to target the
ability of the neck muscles to perform coordinated multiplanar
plyometric contractions. Both groups also continued with tra-
ditional neck strengthening that included training on a straight-
plane, isotonic, 4-way neck machine. Performance on the train-
ing device showed improvement after routine practice within 1
week, as evidenced by a trend toward increased peak speed in
revolutions per minute (RPM). After 7 weeks, peak RPM
increased from 122.8 (95% confidence interval [CI], 91.3–
154.4) to 252.3 (95% CI, 241.5–263.1). There was also
Address correspondence to Theodore H. Versteegh, tverstee@uwo.ca.
00(00)/1–9
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a large positive effect size (Hedge’s d, 0.68) in isometric com-
posite (multiplane) neck strength favoring the intervention
group over the control group (difference, 20 N; 95% CI, 28
to 48). The largest magnitude strength improvement in a single
plane was in axial rotation and also favored the intervention
group over the control group (Hedge’s d, 1.24; difference,
46 N; 95% CI, 9–83). Future studies should explore whether
the dynamic training presented here could help reduce the risk
of sports concussion, whiplash, or other head-neck trauma.
KEY WORDS axial rotation, plyometric, centripetal, cervical
strengthening
INTRODUCTION
C
oncussions are a major concern in contact sports,
and research is currently underway to explore
preventative measures to reduce the risk of expo-
sure (2,10,12,18). Most concussion prevention
measures are focused on policy and equipment, including
changes to rules or equipment with less focus on the indi-
vidual player (9). One area of research that is gaining atten-
tion at the player level is the role the neck muscles, which
may play in damping the acceleration experienced by the
head (5,8,15,24,29). This is important because the primary
cause of most concussions are the linear and rotational ac-
celerations of the head resulting from impact (19).
Alsalaheen et al. (1) suggested that there are 2 important
but unrelated constructs that influence the role the neck
muscles in mitigating acceleration forces of the head and
the neck: the musculoskeletal attribute of girth and strength,
and the neuromuscular attributes of electromyographic
(EMG) amplitude and latency. Biomechanical studies have
shown that people with a stiffer and stronger neck experi-
ence less acceleration from impacts to the head (7,8,15,29).
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 Evaluating a Neuromuscular Neck Training Device
Figure 1. Neuromuscular training device. The small weighted arm
swings freely about the centrally mounted axis such that the athlete
wearing the helmet and using coordinated head movements can get the
weighted arm spinning. The faster the individual can get the weighted
arm spinning, the greater the centripetal force generated and the
stronger and faster the neck muscles need to respond and contract to
maintain the weight spinning.
Eckner et al. (8) demonstrated that neck strength in each
cardinal plane of motion is inversely proportional to the
magnitude of head acceleration experienced from a low-
level but sudden force applied to the head in that plane of
motion. Jin et al. (15) used finite element modeling to find an
inverse relationship between contraction velocity of the neck
muscles and accelerations measured at the head; the faster
the muscles respond to perturbation, the lesser the acceler-
ation experienced by the head. Collins et al. (5) captured
strength and anthropomorphic data in 6,662 high-school
athletes and followed them for a standard sports season,
during which 179 were diagnosed with a concussion. Using
multivariate logistic regression, it was found that only com-
posite (4-plane) neck strength remained as a significant pre-
dictor of concussion diagnosis. In a critical appraisal and
synthesis of the relevant literature, Gilchrist et al. (11) found
enough evidence to endorse training of the neck muscles
through all planes of available motion as a potential strategy
for concussion risk management. They further suggested
that such training should move from single-plane isotonic
resistance training focused on strength or hypertrophy, to
dynamic plyometric-type training programs focused more
the TM
2 Journal of Strength and Conditioning Research
Copyright © 2019 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
on optimizing neck muscle reactivity. They theorized that
the ability to rapidly dissipate anticipated or unanticipated
impact energy could be improved through more efficient
and shorter latency excitation-contraction coupling. In other
words, the shorter amount of time it takes the neck to
respond to a blow, the more efficiently it can absorb that
force. The analogy of viewing the neck muscles as damping
springs appears appropriate here, where more rapid recruit-
ment of motor units of the neck muscle complex (including
trapezius, sternocleidomastoid, scalenes, splenius capitis, and
the deep segmental muscles) should, in theory, be more
resilient to sudden load, reducing the energy transfer to
the head and the brain. A focus on dynamic plyometric
training of the neck muscles is also supported by Hrysomallis
(14), following a systematic review of the relevant literature.
Plyometric training has shown some potential for injury pre-
vention in other body regions (23). Collectively, the current
body of evidence, although not large, appears to support
rigorous evaluation of more dynamic approaches to neck
muscle training for risk management in any injury mecha-
nism involving transfer of energy between the head and the
trunk.
Toward this, a new neck training protocol focused on
dynamic, multiplanar plyometric training has been designed.
Akin to a “hula hoop” for the neck, the protocol leverages
self-generated centripetal force using the neck to keep
a weighted arm rotating about the top of a custom-fitted
helmet. In theory, the use of self-generated force should
present less risk of overexertion and injury than that created
by an external machine, although several questions need to
be answered before a fully powered clinical trial can be
appropriately undertaken. These include recruitment and
retention of participants, estimates of effect size following
the training, and collection of any adverse events. As such,
the purpose of this pilot study was to explore the feasibility
of a planned future trial to explore the effectiveness of train-
ing on the novel neuromuscular strengthening device shown
in Figure 1. This pilot study involved a 7-week training pro-
tocol in a sample drawn from a highly trained athletic pop-
ulation of university football players.
TABLE 1. Subject demographics (mean 6 SD).
Intervention Control
(n = 8) (n = 10)
Neck girth (cm) 43.8 6 2.3 43.5 6 3.0
Age (y) 20.8 6 1.4 20.8 6 1.8
Height (m) 1.886 6 0.062 1.903 6 0.056
Body mass (kg) 112.4 6 21.5 113.9 6 20.2

Figure 2. Flow diagram of subject recruitment and training.
METHODS
Experimental Approach to the Problem
This pilot study was designed as a quasiexperimental clinical
trial with an intervention group and a control group, with
a planned subanalysis of the change in performance metrics
on the neuromuscular training device in the intervention
group. All consenting participants continued to engage in
team-mandated off-season training sessions. The interven-
tion group also participated in a 7-week neuromuscular
neck-training program (exposure variable) involving 2 ses-
sions per week of approximately 10 minutes each. The
outcome variables in the study were change in multiplanar
isometric neck strength and performance on the neuromus-
cular training device after training. Strength changes in the
transverse plane (axial rotation) were of particular interest as
strengthening in this direction is clinically challenging.
Subjects
Participants for this pilot study were selected from a list of
current players who had participated in spring training and
performed baseline strength testing. There were 38 eligible
players for this study in total. For feasibility, selection was
based on players who were locally available to train during
the 7 weeks leading up to the start of the fall football season.
The control group was selected to match the intervention
group on height (threshold 6 5 cm), body mass (68 kg), age
(62 years), and neck girth (63 cm) (Table 1). All subjects
were between 18 and 23 years of age. Subjects were excluded
if, at the time of recruitment, team medical staff indicated
that there were any concussion symptoms or musculoskel-
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etal issues that prevented them from participation in their
team prescribed preseason training. Figure 2 presents a flow
diagram of the participants through each stage of the study.
Formal written informed consent was obtained from all sub-
jects before participation in the study. The Western Univer-
sity Human Research Ethics Board approved the project
before recruitment.
Procedures
Self-reported age, height, and body mass were collected
from each player at the start of the study. Neck girth was
measured using a flexible measuring tape at the level just
below the thyroid cartilage. Isometric neck strength (re-
corded in newtons) was measured using a handheld dyna-
mometer according to a previously described assessment
protocol (28). This protocol uses self-generated resistance
from the subject’s upper extremity to press into the dyna-
mometer to evaluate isometric neck strength in flexion,
extension, and right and left side flexion, side-flexion/rota-
tion, and axial rotation. This protocol has shown good to
excellent test-retest reliability (intersession intraclass correla-
tion coefficient range from 0.87 to 0.95 and SEM range from
12.7 to 20 N for all tested directions). The strength values for
the 3 cardinal planes of motion were used for analysis (sag-
ittal plane: flexion/extension, frontal plane: right and left side
flexion, and transverse plane: right and left axial rotation).
The average between the right and left sides for side-flexion
and rotation was used for their respective single plane iso-
metric strength analyses. A single metric termed “composite
neck strength” was also calculated as the arithmetic mean of
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Evaluating a Neuromuscular Neck Training Device

Journal of Strength and Conditioning Research
the

TABLE 2. Isometric strength values pre and post testing with mean change in newton (N) and effect sizes of the difference between control (Con) and
intervention (Int) groups (95% CI).*†

Percent change in Between-group difference

Pretest Posttest Strength change strength in strength change Effect size (Hedge’s d)

Composite neck strength

TM

Con 300 (266–335) 312 (275–349) 12 (210 to 34) 4.0

Int 310 (278–343) 342 (307–377) 32 (13 to 50)z 10.3 20 (28 to 48) 0.68 (20.27 to 1.64)
Axial rotation
Con 246 (196–298) 243 (190–298) 23 (227 to 21) 21.2
Int 254 (213–296) 297 (267–327) 43 (9 to 76)z 16.9 46 (9 to 83)z 1.24 (0.23 to 2.26)z
Side-flexion
Con 267 (240–293) 276 (245–307) 9 (218 to 37) 3.4
Int 281 (245–317) 306 (273–339) 25 (16 to 35)z 8.9 16 (212 to 44) 0.51 (20.43 to 1.46)
Flexion
Con 328 (275–381) 393 (350–436) 65 (28–102)z 19.8
Int 363 (318–408) 398 (337–459) 35 (5 to 65)z 9.6 230 (275 to 16) 20.62 (21.58 to 0.33)
Extension
Con 444 (373–515) 433 (355–511) 210.5 (250 to 29) 22.4
Int 429 (380–478) 448 (383–514) 19 (221 to 59) 4.4 30 (223 to 82) 0.54 (20.41 to 1.49)

*CI = confidence interval.

†Int = intervention (n = 8), Con = control (n = 10), effect size calculated using the difference between the mean change in strength values of intervention and control. Qualitative
analysis of effect size thresholds: small 0.2, moderate 0.5, large 0.8 (6).
zDenotes statistical significance, as 95% confidence interval does not include zero.
 the TM

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TABLE 3. Pre- and posttraining performance of the intervention group (n = 8) (95% CI).*

Percent
Pretest Posttest Change change Effect size (Hedge’s d)

RPMpeak 122.8 (91.3–154.4) 252.3 (241.5–263.1) 129.5 (103.7 to 155.3) +105.5 4.36 (2.56–6.16)
Tcw50 32.3 (21.2–41.3) 16.6 (14.0–19.1) 15.7 (1.6 to 29.8) 248.7 1.55 (0.43–2.67)
Tccw50 33.0 (21.4–44.7) 14.4 (13.6–15.2) 18.6 (26.3 to 43.5) 256.4 1.79 (0.63–2.95)

*RPMpeak = peak number of revolutions per minute of the spinning weight, Tcw50, Tccw50 = time to complete 50 revolutions in
clockwise and counterclockwise directions, respectively, in seconds.

all 6 movements. This allowed easier comparison of findings
against those reported by Collins et al. (5) and was intended
to facilitate interpretation of results for clinical and condi-
tioning personnel and to determine if the training protocol
could also be expected to improve strength across all planes
when considered together.
Both the intervention and control groups participated in
their team prescribed off-season training program that
included 2 neck-training days per week. One day would
involve training on a 4-way uniplanar (flexion/extension and
right/left side-flexion) isotonic neck-strengthening machine,
2 sets of 8–12 repetitions in each direction. The second day
involved “manual neck” strengthening with a workout part-
ner, wherein the partner applied manual resistance to neck
movement in each of the same 4 directions, 1 set of 5–8
repetitions. The 2 different protocols were separated by 3–
4 days and were administered under the guidance of the
team’s strength and conditioning coach.
Pretest. The intervention group players were fitted with
a secure football helmet with flange-mounted bearing
attached to the top (Figure 1). A 25-cm rod extended from
this bearing such that the rod was perpendicular to the bear-
ing and parallel to the floor. A small mass (125 g) was
located at the distal end of the rod (weighted arm). With
the helmet tightly secured on the head, the players were
seated on a bench with their back unsupported and feet flat
on the ground. Players then created coordinated circumduc-
tion movements of the head using the neck muscles to start
the weighted arm spinning about its axis while keeping the
rest of the trunk as motionless as possible. As spin speed
increased, the small weight provided increased resistance
to the neck muscles through centripetal force. Once the sub-
ject felt comfortable with the movement pattern, they com-
pleted 3 sets of 50 revolutions in each direction (clockwise
and counterclockwise), for a total of 6 sets. The weight
selection and protocol of 50 revolutions in each direction
was informed by prior in-laboratory testing with select mem-
bers of the target population, feasibility of training time, and
as best as possible matched to the theory of intensity needed
for neuromuscular adaptations and coordination of neck
muscle activity. Each set was timed with a stopwatch and
recorded (time clockwise [Tcw50] and time counterclockwise
[Tccw50]). A portable cycling computer was used to count the
revolutions and calculate the velocity of each revolution of
the set. The peak velocity achieved in kilometers per hour
was then stored on the cycling computer and recorded for
analysis. Given speed (km$h21) and the preset distance per
revolution (200 cm) from the cycling computer, the peak
revolutions per minute (RPMpeak) was calculated. The best
Tcw50, Tccw50, and the best RPMpeak of all 6 sets were used
as outcomes.
Because this type of training has not been previously
examined, an effective training protocol has not yet been
established. Therefore, the meta-analysis of Peterson et al.
(22) on maximizing strength development in athletes was
used as a rough guide for creating the intervention training
protocol. The intervention consisted of 2 high-intensity
training sessions per week with an average of 8 sets per
training session. Each session lasted between 8 and 12 mi-
nutes and was separated by 2–3 days of rest. In weeks 1–3,
the players performed 3 timed sets of 50 revolutions in each
direction. For each training session, the best RPMpeak of the
6 sets was recorded. In weeks 4–7, the players performed 5
sets of 50 revolutions in each direction, with the best of the
10 sets RPMpeak achieved recorded for each session.
Posttest. On the final training session, the players again
completed 3 timed sets of 50 revolutions in each direction.
The best Tcw50 and Tccw50 were recorded along with the best
RPMpeak of the 6 sets. After completing the neuromuscular
evaluation and a short rest (approximately 3–5 minutes), the
isometric neck strength protocol was repeated using the
handheld dynamometer. The control group also performed
the follow-up isometric neck strength testing.
Adherence was measured as the proportion of neuromus-
cular training sessions that each subject attended over the
maximum offered (n = 14). Dropout rate was defined as
subjects who completed baseline (pre) testing for the inter-
vention group with the neuromuscular training device but
did not complete the final follow-up (post) testing. Questions
about adverse events from the previous session were asked at

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 Evaluating a Neuromuscular Neck Training Device

Figure 3. Mean RPMpeak for the intervention group performance on the neuromuscular training device for each of the 14 training sessions with 95%
confidence intervals.*Start of significant difference in RPMpeak for training sessions from session 1 indicated by point estimates outside of 95% confidence
intervals. All subsequent sessions were also significantly different than session 1. RPMpeak = peak number of revolutions per minute of the spinning weight.

each subsequent session (3). Acute head or neck pain asso-
ciated with the use of the neuromuscular training device was
of particular interest. Because this method of training in-
volves a novel method of exercising the neck muscles, it
was expected that subjects might experience delayed onset
muscle soreness (4). If the pain or duration were greater than
the subjects had experienced with other neck training pro-
grams, they were to inform the primary investigator. Other
adverse events, regardless of whether they were clearly
because of the training regimen (e.g., headache, dizziness),
were collected through direct questioning at the beginning
of each subsequent session.
dependent variables of performance on the neuromuscular
device in the intervention group only (TCW50, TCCW50,
RPMpeak). The independent variables were time (pre and
post) and group (intervention and control). Hedge’s d was
used for effect size calculations because this value is consid-
ered unbiased and more accurate than Cohen’s d when the
sample size is less than 20 (20). Effect sizes and 95% CIs
were calculated in Microsoft Excel (Microsoft; Redmond,
WA, USA) using the formulas described by Nakagawa and
Cuthill (20), whereas all other statistical analyses were con-
ducted in SPSS (v24.0, IBM, Armonk, NY).

Statistical Analyses RESULTS

Subject characteristics were explored descriptively (mean,
95% confidence interval [CI]), along with recruitment rate,
retention rate, adherence rates, dropouts, and adverse events
reported as proportions. Raw change along with 95% CIs
and percentage change were calculated for pre and post
values for isometric strength and for the neuromuscular
training device performance metrics. An important function
of pilot research is to provide an estimate for the magnitude
of effect of the intervention, for purposes of calculating the
sample size of a fully powered study. Accordingly, effect
sizes (Hedge’s d; 95% CI) (20) were calculated for the differ-
ences in the primary dependent variables of isometric neck
strength (N) for each direction of motion and the composite
value between the intervention and control groups. Effect
sizes were also calculated for the differences in the secondary
the TM
Of the 24 eligible participants, 21 consented to participate
for a recruitment rate of 88%. Of those, 18 completed the
pre- and posttest measures with a retention rate of 86%. Of
those entered into the intervention arm, 8 of 12 (67%)
completed at least 11 (79%) of the 14 training sessions over 7
weeks. Reasons for noncompletion were that 3 participants
declined to participate in the study and 1 participant was
involved in an unrelated motor vehicle collision before the
initiation of the training protocol. Although some did report
the experience of delayed onset muscle soreness for up to 24
hours after the training, none rated it as any more intense
than that experienced routinely after other types of training
sessions. No participant in the intervention group reported
any other adverse events at any time during the protocol.
Participants in the intervention group attended an average of

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Copyright © 2019 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.

85% of the 14 training sessions (mean = 11.9; range = 11–
14). Of the 12 enrolled into the control group, 2 participants
were lost to follow-up (1 missed posttesting and 1 was no
longer on the team at the end of the study period).
The mean isometric strength values, raw and percent
change, and observed effect sizes between the intervention
and control groups pre and post testing are presented in
Table 2. The point estimates indicated that composite neck
strength improvement favored the intervention group. Mean
change in composite strength of the intervention group was
32 N (95% CI, 13–50), whereas in the control group, it was
12 N (95% CI, 210 to 34). Change in axial rotation strength,
the direction of most interest, demonstrated the largest mean
difference between the control and intervention cohorts of
46 N (95% CI, 9–83) and the largest effect size with 95% CIs
that do not include zero (Hedge’s d Drotation = 1.24; 95%
CI, 0.23–2.26). As retention was not consistent between
groups, a sensitivity analysis in which only 8 control subjects
were selected as matched to the intervention group revealed
nearly identical findings to the full sample (not shown).
Pre- and postneuromuscular performance parameters over
the 7 weeks of training, along with mean change scores,
percent change, and effect sizes, are presented in Table 3.
The RPMpeak over each training session during the 7 weeks
of training is displayed in Figure 3. Consistent with a training
effect, all performance parameters showed a qualitative
improvement over the course of the 7 weeks of training
protocol, evident as early as training session 3.
DISCUSSION
The purpose of this pilot study was to investigate the
feasibility and anticipated training effect of a novel neuro-
muscular training device in a cohort of highly trained and
otherwise healthy athletes. Two-thirds of the subjects
approached for involvement in the intervention arm of the
study completed the training program. Subjects who trained
on the device demonstrated an 85% adherence rate with no
dropouts, and there were no adverse events reported to the
investigators by the subjects in the duration of the study.
This is slightly higher than the compliance rates seen in
other neuromuscular training programs in athletic popula-
tions ranging from 52 to 79% (13,21,25,26). Adherence has
previously been shown to significantly influence the effec-
tiveness of injury prevention programs (27), so this is an
important consideration in sample size calculations.
This new 7-week training protocol was demonstrated to
be potential for improving isometric composite neck
strength (increase of 20 N, 95% CI 28 to 48 N, over control)
with a moderate to large effect size (Hedge’s d = 0.68).
Additionally, training on the device in conjunction with tra-
ditional neck strengthening may be an effective means of
improving isometric neck axial rotation strength above tra-
ditional neck strengthening alone (mean increase of 46 N;
95% CI, 9–83 N, over control group). As both the interven-
tion group and control group continued their standard
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preseason training that involved using the 4-way neck
machine, it is not surprising that there was evidence of
improvement over time for flexion and side-flexion in both
groups. The 4-way neck machine trains the neck isotonically
in these directions and is known to improve isometric neck
strength in those planes (14). However, axial rotation
strength is not trained with the 4-way neck machine. There
are few methods available for training neck rotation strength
owing largely to the shape of the head that is not conducive
to adding rotational resistance. Yet forces in the horizontal
(rotational) plane have previously been associated with more
vulnerability to postconcussive syndrome (19). Although
purely speculative, this or any other protocol for training
dynamic contractions of the neck in a rotation direction
may have value for mitigating risk of long-term problems
from head-neck trauma.
Predictably, the results also indicate that training on the
neuromuscular device improves performance on the device;
however it is valuable to note the extent of change.
RPMpeak more than doubled, and both Tcw50 and Tccw50
times were roughly cut in half after the training, suggesting
that this change may be to the result of improved neuromus-
cular control or coordination. It is interesting to the authors
that the average RPMpeak after training was more than 250
RPM. This represents more than 4 revolutions per second
and would suggest that the neck muscles involved in the
training were contracting at a rate of more than 4 contrac-
tions per second to achieve this speed (or less than 250
milliseconds per contraction). In trials involving an unantic-
ipated head perturbation in a group of healthy adults, the
neck muscles responded with a peak latency of 224 milli-
seconds (1). Training on the device approached a similar
neuromuscular latency. It is also notable that the training
effect did not appear to reach a plateau after 7 weeks, mean-
ing that with continued training, it may be possible to
achieve higher speeds and further approach these potentially
important contraction latencies. The aim of this training
approach was to emphasize high-velocity muscle contrac-
tions and facilitate the short latency rate of force develop-
ment, as described by Gilchrist et al. (11). This training
approach is in line with the type of training, as suggested
by prior researchers, that should be investigated as a means
of training the neck to prevent concussion (11,16,17,24).
There were several limitations to this study. First, the
study population was a group of highly trained male
athletes (university football players) and not representative
of the general population. Different populations may
respond differently to the dynamic training presented
here, and other sporting populations that include both
male and female subjects who may benefit from dynamic
neck strengthening should also be investigated. Second,
measurement bias may have occurred because the subjects
were not blinded to the training they received and those in
the intervention group may have put more effort into their
neck strength assessments post training. The use of the
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 Evaluating a Neuromuscular Neck Training Device
4-way neck machine by control and intervention groups
and other training techniques was also not documented or
controlled, preventing the exploration of combined train-
ing. This, along with other potentially unknown variables,
may have been confounding variables. Although potential
differences were seen with the 7-week training program, it
is likely that the protocol could yet be refined to optimize
the training effect. For instance, Conley et al. (6) demon-
strated an increase in head extension strength of 34% after
a 12-week training program involving 3 training sessions
per week. Different training programs, such as longer dura-
tion, more training sessions or more sets per session,
greater or fewer revolutions per set, and using a heavier
or lighter weight on the spinning arm, may influence the
dose response and produce greater differences and results.
It is also recognized that CIs are influenced by sample size;
therefore, larger sample sizes will produce more accurate
results. Future studies can consider variations to the train-
ing program parameters and also consider monitoring the
cross-sectional area, fiber composition, EMG response of
key muscles, and kinematic responses to head perturbation
trials before and after training on this device to help define
the physiological response to training.
In summary, this pilot study has demonstrated that the
protocol seems to be feasible in that all 8 participants
completed at least 79% of the training, and no adverse
events were reported. It has also provided important
information for conducting a fully powered study. For
example, a trial comparing improvements in composite neck
strength using the device over and above a control group
using traditional neck strengthening could be conducted by
recruiting a minimum of 67 football players. With an
expected 88% recruitment rate and 86% retention rate, this
would provide 25 subjects per arm and would achieve 80%
power to detect differences of 20 N or more in composite
neck strength (6). Recognizing that neck strength is only one
of many factors that influence concussion and whiplash risk,
longer and larger multivariate trials will be needed to deter-
mine whether this type of training program does contribute
to reducing the sequelae of head impacts.
PRACTICAL APPLICATIONS
Prior research suggests that neck strength may play
a significant protective role in the incidence of concussion.
It has also been suggested that research into neck-training
programs with a goal of decreasing concussion risk should
focus on multiplanar dynamic, plyometric-type contrac-
tions that increase the short-latency rate of force devel-
opment. The results of this pilot study provide a method
of neck training that is consistent with the suggested
approach and has demonstrated effectiveness at improv-
ing dynamic neck strength as measured by performance
on this device. For the strength and conditioning coach,
physical therapist, or clinician, the type of neuromuscular
training described in this study provides a time-efficient
the TM
8 Journal of Strength and Conditioning Research
Copyright © 2019 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
method of multiplanar neck training that includes axial
rotation. This is a direction of strengthening that is very
difficult to achieve through traditional methods. The
presented method also offers these professionals a novel
means of dynamic neck strengthening for their clients
with a more ballistic or plyometric-type of approach to
neck muscle training than traditional neck strengthening
alone.
ACKNOWLEDGMENTS
The authors thank all the players who participated in this
study and trained on the device during their off-season. The
authors also confirm that no financial support was received
to conduct this research. The author T. H. Versteegh is the
developer and owner of the patent of the training device
used for the intervention group in this research and
cofounder in the company that owns the rights to this
patent. The author L. Fischer’s spouse is also a cofounder in
this company. The other authors have no personal, financial,
or institutional interest in the device described in this article.
The results of this study do not constitute endorsement by
the National Strength and Conditioning Association.
This research received no external funding. J. MacDermid
was supported by a Canadian Institutes of Health Research
Chair in Gender, Work and Health and the Dr. James Roth
Chair in Musculoskeletal Measurement and Knowledge
Translation.
REFERENCES
1. Alsalaheen, B, Bean, R, Almeida, A, Eckner, J, and Lorincz, M.
Characterization of cervical neuromuscular response to head-neck
perturbation in active young adults. J Electromyogr Kinesiol 39: 70–
76, 2018.
2. Benson, BW, McIntosh, AS, Maddocks, D, Herring, SA, Raftery, M,
and Dvorak, J. What are the most effective risk-reduction strategies
in sport concussion? Br J Sports Med 47: 321–326, 2013.
3. Carlesso, LC, Macdermid, JC, and Santaguida, LP. Standardization
of adverse event terminology and reporting in orthopaedic physical
therapy: Application to the cervical spine. J Orthop Sports Phys Ther
40: 455–463, 2010.
4. Cheung, K, Hume, PA, and Maxwell, L. Delayed onset muscle
soreness. Sports Med 33: 145–164, 2003.
5. Collins, CL, Fletcher, EN, Fields, SK, Kluchurosky, L, Rohrkemper,
MK, Comstock, RD, and Cantu, RC. Neck strength: A protective
factor reducing risk for concussion in high school sports. J Prim Prev
35: 309–319, 2014.
6. Conley, MS, Stone, MH, Nimmons, M, and Dudley, GA. Specificity
of resistance training responses in neck muscle size and strength.
Eur J Appl Physiol Occup Physiol 75: 443–448, 1997.
7. Dirisala, V, Karami, G, and Ziejewski, M. Effects of neck damping
properties on brain response under impact loading. Int J Numer
Method Biomed Eng 28: 472–494, 2012.
8. Eckner, JT, Oh, YK, Joshi, MS, Richardson, JK, and Ashton-Miller,
JA. Effect of neck muscle strength and anticipatory cervical muscle
activation on the kinematic response of the head to impulsive loads.
Am J Sports Med 42: 566–576, 2014.
9. Emery, CA, Black, AM, Kolstad, A, Martinez, G, Nettel-Aguirre, A,
Engebretsen, L, et al. What strategies can be used to effectively
reduce the risk of concussion in sport? A systematic review. Br J
Sports Med 51: 978–984, 2017.

10. Frémont, P, Bradley, L, Tator, CH, Skinner, J, and Fischer, LK;
Canadian Concussion Collaborative. Recommendations for
policy development regarding sport-related concussion
prevention and management in Canada. Br J Sports Med 49: 88–
89, 2015.
11. Gilchrist, I, Storr, M, Chapman, E, and Pelland, L. Neck muscle
strength training in the risk management of concussion in contact
sports: Critical appraisal of application to practice. J Athl
Enhancement 04: 1–19, 2015.
12. Harmon, KG, Drezner, JA, Gammons, M, Guskiewicz, KM,
Halstead, M, Herring, SA, et al. American Medical Society for sports
medicine position statement: Concussion in sport. Br J Sports Med
47: 15–26, 2013.
13. Hägglund, M, Atroshi, I, Wagner, P, and Waldén, M. Superior
compliance with a neuromuscular training programme is associated
with fewer ACL injuries and fewer acute knee injuries in female
adolescent football players: Secondary analysis of an RCT. Br J
Sports Med 47: 974–979, 2013.
14. Hrysomallis, C. Neck muscular strength, training, performance and
sport injury risk: A review. Sports Med 46: 1111–1124, 2016.
15. Jin, X, Feng, Z, Mika, V, Li, H, Viano, DC, and Yang, KH. The role of
neck muscle activities on the risk of mild traumatic brain injury in
American football. J Biomech Eng 1: 139, 2017.
16. Lisman, P, Signorile, JF, Del Rossi, G, and Asfour, S. Investigation of
the effects of cervical strength training on neck strength, EMG, and
head kinematics during a football tackle. Int J Sports Sci Eng 06: 131–
140, 2012.
17. Mansell, J, Tierney, RT, Sitler, MR, Swanik, KA, and Stearne, D.
Resistance training and head-neck segment dynamic stabilization in
male and female collegiate soccer players. J Athl Train 40: 310–319,
2005.
18. McCrory, P, Meeuwisse, W, Dvorák, J, Aubry, M, Bailes, J, Broglio,
S, et al. Consensus statement on concussion in sport-the 5(th)
international conference on concussion in sport held in Berlin, 2016.
Br J Sports Med 51: 838–847, 2017.
19. Meaney, DF and Smith, DH. Biomechanics of concussion. Clin
Sports Med 30: 19–31, 2011, vii.
Copyright © 2019 National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
the TM
Journal of Strength and Conditioning Research | www.nsca.com
20. Nakagawa, S and Cuthill, IC. Effect size, confidence interval and
statistical significance: A practical guide for biologists. Biol Rev Camb
Philos Soc 82: 591–605, 2007.
21. Pasanen, K, Parkkari, J, Pasanen, M, Hiilloskorpi, H, Mäkinen, T,
Järvinen, M, et al. Neuromuscular training and the risk of leg injuries
in female floorball players: Cluster randomised controlled study.
BMJ 337: a295, 2008.
22. Peterson, MD, Rhea, MR, and Alvar, BA. Maximizing strength
development in athletes: A meta-analysis to determine the
dose-response relationship. J Strength Cond Res 18: 377–382,
2004.
23. Rössler, R, Donath, L, Verhagen, E, Junge, A, Schweizer, T, and
Faude, O. Exercise-based injury prevention in child and adolescent
sport: A systematic review and meta-analysis. Sports Med 44: 1733–
1748, 2014.
24. Schmidt, JD, Guskiewicz, KM, Blackburn, JT, Mihalik, JP,
Siegmund, GP, and Marshall, SW. The influence of cervical muscle
characteristics on head impact biomechanics in football. Am J Sports
Med 42: 2056–2066, 2014.
25. Steffen, K, Bakka, HM, Myklebust, G, and Bahr, R. Performance
aspects of an injury prevention program: A ten-week intervention in
adolescent female football players. Scand J Med Sci Sports 18: 596–
604, 2008.
26. Steffen, K, Emery, CA, Romiti, M, Kang, J, Bizzini, M, Dvorák, J,
et al. High adherence to a neuromuscular injury prevention
programme (FIFA 11+) improves functional balance and reduces
injury risk in Canadian youth female football players: A cluster
randomised trial. Br J Sports Med 47: 794–802, 2013.
27. van Reijen, M, Vriend, I, van Mechelen, W, Finch, CF, and Verhagen, EA.
Compliance with sport injury prevention interventions in randomised
controlled trials: A systematic review. Sports Med 46: 1125–1139, 2016.
28. Versteegh, T, Beaudet, D, Greenbaum, M, Hellyer, L, Tritton, A, and
Walton, D. Evaluating the reliability of a novel neck-strength
assessment protocol for healthy adults using self-generated
resistance with a hand-held dynamometer. Physiother Can 67: 58–64,
2015.
29. Viano, DC, Casson, IR, and Pellman, EJ. Concussion in professional
football: Biomechanics of the struck player—Part 14. Neurosurgery 61:
313–318, 2007.
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