Table 3.

Exercise intervention algorithm for treatment selection.

Assessment	Treatment	Progression
Muscular endurance of the cervical flexors was evaluated with the deep neck flexor endurance test and evaluated based on hold time in seconds	Prepare participant in supine, hook-lying position and ensure craniocervical and cervical regions are in a neutral position (support with a folded towel if necessary). Teach the craniocervical flexion action. Use instructions of “feel the back of your head slide up the bed as you nod your chin.” Goal: 10 × 10-second holds	Begin with craniocervical flexion. Cue patient to “keep chin tucked in, lift, and hold your head up.” Goal: 10 × 10-second holds
Craniocervical and cervical extensors	Patient either prone on elbows or in four-point kneeling position. Suboccipital muscles—Focus on a neutral neck position: (1) Require the participant to perform craniocervical extension (chin down) and (2) Require the participant to perform craniocervical rotation (the saying “no” action). Assess quality of movement and for smooth coordination. Goal: 3 sets of 5	Patient either prone on elbows or in four-point kneeling position. Deep cervical extensors: the craniocervical region remains in neutral and the axis of motion is now at C7. Instruct the participant to curl their neck first into flexion and then to curl their neck back to extension. The participant will often require manual facilitation to achieve the correct action. To assist in maintaining the craniocervical neutral position, let the participant imagine they have a book between their hands and they must keep their eyes on the book as they lift their head. Check that muscles such as splenius capitis are not overactive. Goal: 10 × 10-second holds
Muscle length test: upper trapezius, latissimus dorsi, pectoralis minor, pectoralis major, levator scapulae, anterior and middle scalenes, and the suboccipital muscles; also scored as tight or normal	Stretching of muscles determined to have decreased length Patient to perform 3 × 30-second stretches for each muscle Goal: 3 sets of 30-second holds for each muscle	Self-overpressure to stretching of muscles will be added as appropriate
Manual muscle tests performed for the lower trapezius, rhomboids, middle trapezius, and serratus anterior	Patient to perform exercises without exacerbation of symptoms Progressed based on patient response All patients begin with thin elastic bands Goal: 3 sets of 10	Patient will be progressed to medium, heavy, and extra heavy for resistance as appropriate, based on the patient’s ability