The Physician and Sportsmedicine

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ipsm20

Neck strength in Rugby Union players: a

systematic review of the literature

Christian Chavarro-Nieto, Martyn Beaven, Nicholas Gill & Kim Hébert-Losier

To cite this article: Christian Chavarro-Nieto, Martyn Beaven, Nicholas Gill & Kim Hébert-Losier
(2021): Neck strength in Rugby Union players: a systematic review of the literature, The Physician
and Sportsmedicine, DOI: 10.1080/00913847.2021.1886574

To link to this article: https://doi.org/10.1080/00913847.2021.1886574

Published online: 14 Feb 2021.

Submit your article to this journal

Article views: 205

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=ipsm20
THE PHYSICIAN AND SPORTSMEDICINE
https://doi.org/10.1080/00913847.2021.1886574

REVIEW

Neck strength in Rugby Union players: a systematic review of the literature

a a
Christian Chavarro-Nieto , Martyn Beaven , Nicholas Gilla,b and Kim Hébert-Losier a

a
Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of Health, University of Waikato, Tauranga, New Zealand; bNew
Zealand Rugby, Thorndon, Wellington, New Zealand

ABSTRACT ARTICLE HISTORY

The incidence and severity of concussion injuries are increasing every year. Scientific evidence indicates Received 6 October 2020
that neck strength and girth could play a role in preventing head and neck injuries, or at least Accepted 2 February 2021
mitigating their severity. We aimed to examine the scientific literature addressing neck strength in
KEYWORDS
Rugby Union with a focus on the potential role of neck strength on injury incidence, neck assessment
Concussion; strength
protocols, neck strength measures, and neck strengthening exercises. training; football; injuries
We conducted a systematic search of the literature in January 2021 to locate published peer-
reviewed articles from PubMed, SPORTDiscusTM, Web of Science®, and Scopus® e-databases. Overall,
senior elite male players were stronger than younger-aged players. Forwards were stronger in extension
than any other directions assessed, and were generally stronger and possessed larger necks and greater
cross-sectional areas when compared to backs. Implementation of isometric exercise routines in
professional players was reported to improve neck strength in all directions. There were no studies
evaluating the incidence of concussion and neck strength or neck strengthening strategies in Rugby
Union. Strengthening the neck continues to be one of the targeted modifiable risk factors with respect
to limiting the severity and temporal effects of head injuries in Rugby Union, despite limited evidence
regarding direct associations between neck strength and concussion.

What we know effective prescription of neck strengthening exercises,

progressions, regressions, and associated benefits.
● Concussions and neck injuries are frequent in Rugby
● The neurological changes with neck exercises (i.e. pro­
Union. Strengthening the neck may reduce the number
prioception), isometric, eccentric, and concentric rou­
of head and neck injuries.
tines that decrease neck muscle imbalances, and
● Front row players are most susceptible to neck injuries.
relation of strength-related measures with neck and con­
Forwards typically possess greater body mass and stron­
cussion injuries in Rugby Union players need further
ger necks than backs.
investigation.
● Professional senior players with elite training and more com­
petitive international games are stronger in all neck strength
measures than any other age or level of competition.
1. Introduction
What we do not know Concussions are of major concern given their short- to middle-
term impacts on players, and their serious long-term sequelae
● Should we be doing an intervention in school-aged with links to cognitive decline [1] and chronic traumatic ence­
Rugby Union players to increase neck strength in this phalopathies later in life [2]. Concussion is the most common
vulnerable population? injury in professional Rugby Union with the England Rugby
● There are no studies in female players; therefore, little is Football Union (RFU) reporting that approximately 21% of
known regarding neck strength, strengthening programs, match-related injuries were concussions [3], with the inci­
and neck and head injuries in female Rugby Union athletes. dence increasing for the seventh successive season. In the
● The relationship between concussion injuries, neck strength, same period, Ireland Rugby Union reported 60 concussions
and strengthening programs in Rugby Union is unclear. in 160 professional rugby players [4]. Bitchell et al. [5] reported
concussions as the most common injury in professional Welsh
players, with an increase from 10.6 to 21.4 injuries/1000 hours
What we need to learn in the annual incidence of concussion across four seasons
from 2012 to 2016. Additionally, a concomitant increase in
● Prescribing neck strengthening exercises could decrease concussion severity from 86 days lost/1000 hours to
neck and head injuries. We need to investigate the 302 days lost/1000 hours was reported [5].Cross et al. [6]

CONTACT Christian Chavarro-Nieto [email protected] Division of Health, Engineering, Computing and Science, Te Huataki Waiora School of
Health, University of Waikato, Tauranga, New Zealand
© 2021 Informa UK Limited, trading as Taylor & Francis Group
2 C. CHAVARRO-NIETO ET AL.

indicated that players from the RFU with a traumatic brain a significant predictor of concussion [17]. An increase in neck
injury had a 60% increased risk of any subsequent injury over strength equivalent to one pound decreased the probability of
two seasons, hypothesized to be due to impaired neuromus­ concussion by 5%. Specifically in soccer, stronger necks have
cular control [7]. also been associated with lower head accelerations when
The Irish Rugby Injury Surveillance Project (IRIS) [8] mon­ purposely heading the ball, suggesting lower risk of concus­
itored over 600 male and female amateur players across the sion due to the strong association of heading with concussion
country. The most frequent match injury in males was concus­ in this sport [18,19]. However, what type of neck strengthen­
sion, representing 12% of all injuries reported. In females, ing program is the most effective for which level of play
concussion was also the most common match injury alongside remains undetermined. Implementing an 8-week isotonic
ankle sprains. The loose head prop and hooker were the player neck-strengthening program in university soccer players
positions with the most documented injuries in amateurs. increased neck flexion strength by 15% in both males and
These data highlight that concussion is not only of concern females, and extension strength by 22.5% in females.
at the professional level, but also in amateur Rugby Union However, this study found no significant decrease in head
where the number of participants continues to grow world­ accelerations with force application [20]. In contrast, an
wide [9]. 8-week neck training program involving manual resistance
In relation to costs, a report from Accident Compensation undertaken with high school players competing in contact
Corporation (ACC) in New Zealand highlighted that Rugby sports resulted in increased neck flexion, extension, and bilat­
Union had the largest number of injuries and claims compared eral side flexion strength, as well as a significant decrease in
to any other sport from 2012 to 2016. This report identified head acceleration [21].
the average cost associated with moderate-to-serious and Rugby is a unique field-based team sport as it is dominated
serious injuries to be the greatest for the head and neck by high force and frequency impacts without the use of
when grouped by anatomical region [10]. In the context of helmets [22]. Hence, addressing neck strength specifically in
injury type, concussion claims were ranked third in terms of Rugby should inform practice in relation to concussion. Given
mean cost after soft tissue and fracture/dislocation injuries. the potential for mitigating risk and harm, it is cogent to
Considering the socio-economic and medical impact of con­ critically examine and summarize the existing scientific litera­
cussion, various strategies are being implemented and trialed ture on the topic of neck strength in Rugby Union players.
to reduce the incidence and severity of these injuries. These Specifically, we aimed to systematically review and summarize
include rule changes introduced by World Rugby in 2017; the scientific literature that addressed neck strength in Rugby
however, recent data suggest that the overall incidence of Union players with a particular focus on the potential role of
concussion has remained unchanged. In fact, the data indicate neck strength on injury incidence, neck assessment protocols,
a significant increase in the number of concussions in the neck strength measures, and neck strengthening exercises.
tacklers tackling below the line of the shoulders compared
to games with players tackling following the previous regula­
tions [11]. 2. Materials and methods
In terms of modifiable risk factors for preventing concus­ 2.1 Information sources and search strategy
sion in athletes at an individual level, strengthening the neck
musculature and increasing neck girth is one strategy of We conducted a systematic review of the literature following
potential protective value. Necks with greater cross-sectional the Preferred Reporting Items for Systematic Reviews and
areas and stiffness can protect the head from linear and Meta-Analyses guidelines [23]. The first author (CC) performed
angular accelerations and displacements, as well as reduce a systematic search on 1st of January 2021 to locate published
peak velocities due to impacts [12,13]. In contact sports and peer-reviewed articles from four electronic databases:
healthy individuals, prior activation of neck muscles before PubMed, SciVerse Scopus®, SPORTDiscus™, and Web of
a collision has been shown to significantly decrease the peak Science®. The search strategy consisted of the following key­
linear velocity and change in acceleration of the head [14,15]. words and Boolean operators entered in the main search bar
However, it is not always possible to anticipate a collision in of each e-database: ‘neck AND strength AND rugby’. The exact
a dynamic on-field environment. resulting search syntax in PubMed was: (‘neck’[MeSH Terms]
The National Football League’s (NFL) Head, Neck, and Spine OR ‘neck’[All Fields]) AND strength [All Fields] AND
Committee [13] examined the biomechanics of head collisions (‘football’[MeSH Terms] OR ‘football’[All Fields] OR ‘rugby’[All
in 25 NFL male players in a laboratory experiment. Players with Fields]).
stronger necks had lower linear and angular head accelera­
tions, suggestive of a lower risk of concussion due to lesser
2.2 Inclusion and exclusion criteria
forces. The Committee highlighted the potential for an
increased injury risk in populations with weaker necks, such The primary interest of this literature review was to identify
as females and youth players. In young (17 to 19 years) NFL original research studies that evaluated neck strength, neck-
male players, extension neck strength was shown to be strengthening interventions, and/or included head or neck
greater than flexion and bilateral flexion [16]. To reduce neck injury outcomes in Rugby Union. The search included articles
injuries, the group recommended addressing neck strength published up until January 1st, 2021. Studies were screened for
and muscle imbalances. Similarly, total neck strength in high inclusion based on the following criteria: included neck
school students participating in contact sports was strength assessment measures in Rugby Union players, neck
 THE PHYSICIAN AND SPORTSMEDICINE 3

strengthening exercises in Rugby Union players, or neck study, study characteristics, strength assessments, and out­
strength, neck strengthening exercises, and neck injuries in come data were extracted. Data were grouped and extracted
Rugby Union players. Studies were not excluded based on sex, under three main themes of interest: neck strength measures,
age, or level of competition. Only original peer-reviewed neck strengthening exercise programs, and incidence of inju­
research articles written in English were included. ries. Data were managed and analyzed using Microsoft® Office
Excel 2016 (Redmond, Washington, USA).
2.3 Screening process
Duplicates from the database search were removed first. Two 3. Results
authors (CC, KHL) independently screened all titles, abstracts, 3.1 Included studies
and full texts for inclusion criteria. The study selection process
was replicated for articles that were included through manual The flow diagram from the search strategy and screening
process is shown in Figure 1. Fourteen studies met the elig­
searches of other databases and the reference lists of full text
screened. The authors met at each screening stage (i.e. titles, ibility criteria.
abstracts, and full texts) to resolve any disagreement in terms
of inclusion, with a third reviewer not needed to resolve out­ 3.2 Study characteristics
standing disagreements.
The main characteristics of the 14 studies that met inclusion
are presented in Table 1. Based on the Newcastle – Ottawa
2.4 Quality assessment Scale (NOS), most studies were of moderate quality (n = 11,
Two reviewers (CC, IH) independently assessed the methodolo­ 79%) [12,31–40]. Only two articles were of strong methodolo­
gical quality of included studies (n = 14) using the Newcastle – gical quality [41,42], with one study ranked as weak [43]. Item-
Ottawa Scale (NOS) adapted for cross-sectional studies [24]. The by-item NOS ratings for each study are presented as
reliability for NOS adapted for cross-sectional studies based on Supplementary Material.
intraclass correlation coefficient (ICC) and confidence interval
values within (ICC, 0.98; 95% CI, 0.94–0.99) and between (ICC, 3.3 Participants
0.94; 95% CI, 0.80–0.98) raters is excellent [25]. Prior to assess­
ment, the two reviewers met to discuss and familiarize them­ The 14 articles that met inclusion involved 1066 male players
selves with the scales. All identifiable information (i.e. authors, (mean sample size: 76 participants). Rugby players were pro­
affiliations, countries, and sources of publication) were removed fessional in seven of these studies (50%) [12,32,35,38,40,42,43],
from articles by a third party to blind the two reviewers to school-aged in three (21%) [31,33,34], amateur (e.g. club) in
reduce the assessment bias. Disagreements in the risk of bias three (21%) [36,39,41], and semiprofessional in one (7%) [37].
assessment scores were resolved by discussion between the Studies were conducted mostly in the United Kingdom (n = 5)
reviewers and consensus scores are presented in this article. [31–34,42] and Australia (n = 4) [12,35,37,40]. Ireland [41,43],
The NOS is a methodology assessment tool for observa­ Italy [39], New Zealand [36], and South Africa [38] were also
tional studies recommended by the Cochrane Collaboration represented in one to two studies each, see Table 1.
[26]. The tool uses a ‘star system,’ wherein more stars indicate
a superior methodological quality and lower risk of bias. The
3.4 Neck strength measures
NOS awards a maximum of 10 stars: Five for selection (repre­
sentativeness of the sample, sample size, non-respondents, 3.4.1 Overview
and ascertainment of the exposure), two for comparability, All studies tested neck flexion and extension. The majority of
and three for outcome (assessment of outcome and statistical studies (n = 12) also included left and right lateral flexion
test). Reviewers agreed that for the statistical test item, the [12,31,32,34–39,41–43]. Six studies also evaluated bilateral
highest star rating would be allocated for the reporting of rotation [31,32,34,37,39,42] Table 2.
confidence intervals, quartiles, or limits of agreement. The
methodological quality of studies was divided into three 3.4.2 Protocol
groups based on the number of stars awarded: weak (0 to 3 Most of these studies measured peak isometric strength with
stars), moderate (4 to 6 stars), and strong (7 to 10 stars) [27]. a customized load cell device (see Strength Assessment,
The design of each study was classified first as experimental or Table 2). Six of the studies undertook a ‘break test’ with the
observational, and then as randomized controlled trial, cross- peak force measured in kilograms or Newtons [32–34,41–43].
sectional or cohort [28–30]. No article was excluded from this The ‘break test’ measures the peak isometric strength against
review based on quality score or study design. an incremental load resistance. For this test, the head was held
in the neutral anatomical position and resistance was applied
to evoke a maximal muscle contraction in the desired direc­
2.5 Data extraction and synthesis
tion using a cable attached to a handheld dynamometer
The first author (CC) extracted data from the selected full-text (Figure 2) until the initiation of the movement (i.e. positional
articles using a standardized form, and the last author (KHL) failure).
verified the data extracted. For each study, study design, Three studies performed an isometric strength test with
participant information, level of competition, location of the the force measured using a head harness or strap attached
4 C. CHAVARRO-NIETO ET AL.

150 records identified via database search:

• PubMed (n=51)
• SPORTDiscusTM (n=41)
• Web of Science® (n=32)
• and SciVerse Scopus® (n=26)
Identification

Records after duplicates removed

(n=92)
Screening

Titles/abstract screened
(n=92)

Records excluded
(n=69)

Full articles assessed for

eligibility
(n=23)
Eligibility

Additional records identified

through manual search
(n=2)

Full articles assessed for

eligibility
(n=25)

Additional records identify by

references
Included

(n=1)

Full-text articles excluded, with

reasons
(n =12)

• Articles in Rugby
league (n =4)
• Articles in National
Studies included in formal Football league (n=2)
systematic review • Articles in Australian
(n=14)
Football league (n=1)
• No neck strength
included (n=2)

Figure 1. Preferred reporting items for systematic reviews and meta-analyses flow chart.

to a load cell device to a fixed frame in a seated or lying [39] measured neck strength in a seated position with the
position in a ‘make test’ manner [31,35,40]. To measure neck players attached to a customized ergometer with the neck
strength, Snodgrass et al. [37] attached the hand held strength measured against a load cell and electromyogra­
dynamometer to the forehead of players, and players had phy electrodes placed on the neck muscles to determine
to press as hard as possible against the device using the neuromuscular activation levels. Only one study examined
neck muscles. Salmon et al. [36] and Naish et al. [35] used dynamic isokinetic neck strength using an isokinetic dynam­
a fixed-frame dynamometer in a rugby-specific contact/col­ ometer [38].
lision position, the former assessing neck strength, and the The majority of studies (n = 12) evaluated neck strength
latter performing training exercises in this position and sitting with the head in a neutral position [12,31–35,37–­
assessing strength in a ‘make test’ fashion. Maconi et al. 31–35,37–39,41–43]; whilst one study assessed contact or
Table 1. Characteristics of the included studies.
Level of competition
Study NOS rating* Location Player characteristics Study design Study characteristics
Barrett et al. [31] Moderate Senior school-aged 32 males Randomized controlled trial (prospective) Duration: 1 season
6 stars United Kingdom Age: 17.3 ± NR y Injuries: No
Mass: 87.59 ± NR kg Intervention: Strengthening
Height: 181.34 ± NR cm
Davies et al. [32] Moderate Senior professional and 40 males Cohort (cross-sectional) Duration: 1 season
6 stars Age-grade professional 21 seniors Injuries: No
Wales Age: 19 ± 1 y Intervention: No
Mass: 109 ± 7 kg
Height: 182 ± 5 cm
19 age-grade
Age: 27 ± 5 y
Mass: 114 ± 6 kg
Height: 185 ± 4 cm
Dempsey et al. [12] Moderate Elite professional 10 males Case series (cross-sectional) Duration: 1 season
4 stars Australia Age: NR Injuries: No
Mass: 98 ± 10.5 kg Intervention: No
Height: 189 ± 7 cm
Geary et al. [41] Strong Amateur 25 males Cohort (reliability) Duration: 1 season
7 stars Ireland Age: 19.3 ± 1.3 y Injuries: No
Mass: 95.2 ± 13.2 kg Intervention: No
Height: 185 ± 6 cm
Geary et al. [43] Weak Professional 25 males Case control (retrospective) Duration: 1 season
3 stars Ireland 15 professionals as subjects Injuries: No
Age: 19.3 ± 1.3 y Intervention: Strengthening
Mass: 95.2 ± 13.2 kg
Height: 185 ± 6 cm
10 semiprofessionals as controls
Age: 20.7 ± 1.25 y
Mass: 101.3 ± 12.3 kg
Height: 185 ± 2.7 cm
Hamilton et al. [33] Moderate School children 382 males Cohort (cross-sectional) Duration: 1 season
6 stars Scotland Age: 15 ± 2.1 y Injuries: No
Mass: 66.1 ± 11.3 kg Intervention: No
Height: 172 ± 7.3 cm
Hamilton, Gatherer [42] Strong Professional 27 males Cohort (retrospective) Duration: 1 season
7 stars Wales Age: 22.3 ± 3.9 y Injuries: No
Mass: 97.9 ± 10.7 kg Intervention: No
Height: 186.2 ± 6.4 cm
Hamilton et al. [34] Moderate Senior school-aged and adult 52 males Cohort (cross-sectional) Duration: 1 season
6 stars senior school-aged Scotland 30 under18 Injuries: No
Age: 16.7 ± NR y Intervention: No
Mass: 96.0 ± 13.69 kg
Height: 178.7 ± 5.54 cm
22 adults
Age: 27.2 ± NR y
Mass: 107.8 ± 13.67 kg
Height: 178.7 ± 5.91 cm
THE PHYSICIAN AND SPORTSMEDICINE

(Continued )
5
 6

Table 1. (Continued).
Level of competition
Study NOS rating* Location Player characteristics Study design Study characteristics
Konrath, Appleby [40] Moderate Professional 40 males (22 forwards, 18 backs) Case series (cross-sectional) Duration: 1 season
4 stars Australia Age forwards: 24.8 ± 4.1 y Injuries: No
Age backs: 24.3 ± 3.9 y Intervention: No
Mass forwards:109.8 ± 6.2 kg
C. CHAVARRO-NIETO ET AL.

Mass backs: 92.1 ± 8.2 kg

Height forwards: 187 ± 7 cm
Height backs: 181 ± 9.9 cm
Olivier, Du Toit [38] Moderate Senior elite professional 189 males Case series (cross-sectional) Duration: 1 season
5 stars South Africa Age: 24.31 ± NR y Injuries: No
Mass: 99.04 ± NR kg Intervention: No
Height: 183.44 ± NR cm
Maconi et al. [39] Moderate Third division amateur 23 males Cohort (retrospective) Duration: 1 season
5 stars Italy Age: NR Injuries: No
Subjects n = 12 Intervention: Strengthening
Mass: 94.3 ± 19.1 kg
Height: 186 ± 6 cm
Control n = 11
Mass: 92.5 ± 17.2 kg
Height: 182 ± 8 cm
Naish et al. [35] Moderate Professional 27 males Cohort (retrospective) Duration: 2 seasons
6 stars Australia Age: 25.2 ± 3.9 y Injuries: Yes
Mass: 102 ± 11.9 kg Intervention: Strengthening
Height: 187.1 ± 6.3 cm
Salmon et al. [36] Moderate Amateur 41 males Cohort (prospective) Duration: 1 season
6 stars New Zealand Age forwards: 22.6 ± 2.7 y Injuries: No
Age backs: 21.6 ± 2.7y Intervention: No
Mass forwards: 103.1 ± 10.8 kg
Mass backs: 80.4 ± 22.2 kg
Height forwards: 182.9 ± 6.1 cm
Height backs: 180.1 ± 5.5 cm
Snodgrass et al. [37] Moderate Semiprofessional 142 males Cohort (prospective) Duration: 1 season
6 stars Australia Past neck injury group Injuries: Yes
Age: 22 ± NR y Intervention: No
Mass: 99 ± NR kg
Height: 184 ± 0.07 cm
No past injury group
Age: 20 ± NR y
Mass: 104 ± NR kg
Height: 183 ± 0.06 cm
Notes. Values are means ± standard deviation.
Abbreviations: NOS, Newcastle-Ottawa Scale; NR, not reported
* Weak: 0 to 3 stars. Moderate: 4 to 6 stars. Strong: 7 to 10 stars.
Table 2. Neck strength assessment and outcomes in Rugby Union.
Study Participants Strength assessment Outcomes
Barrett 34 school-aged players (17 test players Test: Peak isometric Peak isometric strength pre and post 6-week neck strengthening program (tested group)
et al. and 17 controls) Equipment: Load cell and head harness Pre/Post:
[31] Type: Make test Flexion: 24.6/27.7 kg
Position: Seated, neck neutral Extension: 38.7/45.6 kg
Direction: Extension, flexion, lateral left and right Lateral left: 33.4/39.9 kg
flexion Lateral right: 33.1/39.1 kg
Protocol: Mean of 3 RM x each direction and rest Flexion with left rotation: 21.5/24.4 kg
period of 30 seconds Flexion with right rotation: 21.8/23.6 kg
Extension with left rotation: 31.4/35.9 kg
Extension with right rotation: 31.6/35.8 kg
Key findings:
No significant differences in any direction between groups.
Davies 19 age-graded professional and 21 senior Test: Peak isometric Peak isometric strength
et al. front-row forwards players. Equipment: Cell load and head harness Baseline (SD) age-grade players:
[32] Type: Break test Flexion: 26 ± 8 kg
Position: Seated, neck neutral Extension: 52 ± 6 kg
Direction: Extension, flexion, lateral left and right Lateral left: 35 ± 8 kg
flexion and left and right flexion and extension in 45° Lateral right: 38 ± 10 kg
rotation Flexion in 45° rotation left: 22 ± 4 kg
Protocol: Mean of 3 RM x each direction and rest Flexion in 45° rotation right: 20 ± 6 kg
period of 15 seconds Extension in 45°rotation left: 38 ± 9 kg
Extension in 45°rotation right: 39 ± 10 kg
PTF/PTE ratio: 0.5
Baseline (SD) senior players:
Flexion: 44 ± 12 kg
Extension: 71 ± 9 kg
Lateral left: 59 ± 11 kg
Lateral right: 61 ± 11 kg
Flexion in 45° rotation left: 40 ± 8 kg
Flexion in 45° rotation right: 41 ± 11 kg
Extension in 45°rotation left: 66 ± 9 kg
Extension in 45°rotation right: 68 ± 11 kg
PTF/PTE ratio: 0.6
Key findings:
Senior players were significantly stronger than age-grade players in all neck strength measures.
Dempsey 10 professional players. Test: Peak isometric Peak isometric strength
et al. Equipment: Load cell and head harness Baseline mean (SD)
[12] Type: NR Flexion: 293.8 ± 65.1 N
Position: lying, neck neutral Extension: 222 ± 49.3 N
Direction: Extension, flexion, lateral left and right Lateral left: 221.9 ± 38.8 N
flexion Lateral right: 216.6 ± 43.2 N
Protocol: Peak of 3 RM x each direction holds and Key findings:
rest period of 60 seconds Positive correlations were found between neck strength flexion, extension, and angular and linear
accelerations in a simulated tackling situation.
(Continued )
THE PHYSICIAN AND SPORTSMEDICINE
7
 8

Table 2. (Continued).
Study Participants Strength assessment Outcomes
Geary et al. 25 amateur players. Test: Peak isometric Peak isometric strength
C. CHAVARRO-NIETO ET AL.

[41] Equipment: Handheld dynamometer, load cell, and Baseline (SD) forwards:
head harness Flexion: 357.1 ± 51.6 N
Type: Break test Extension: 637.1 ± 75.1 N
Position: Seated, head neutral Lateral left: 581.1 ± 105.4 N
Direction: Extension, flexion, lateral left and right Lateral right: 576.4 ± 79.4 N
flexion Total: 2151.9 ± 231.1 N
Protocol: Mean of 3 RM x each direction holds and Baseline (SD) backs:
rest period of 60 seconds Flexion: 322.2 ± 53.6 N
Extension: 537.8 ± 82.2 N
Lateral left: 471.3 ± 73.5 N
Lateral right: 482.7 ± 93.7 N
Total: 1814.2 ± 211.2 N
Key findings:
Forwards significantly stronger in extension vs backs, as well as in total isometric neck strength.
Geary et al. 15 professional Test: Peak isometric Peak isometric strength pre and post 5-week neck strengthening program
[43] and 10 semiprofessional Equipment: Handheld dynamometer and head Pre (SD)/Post (SD)
players. harness Flexion: 334.4 ± 39.3/396 ± 75.5 N
Type: Break test Extension: 606.1 ± 97.3/733.8 ± 127.1 N
Position: Seated, head neutral Lateral left: 555.5 ± 88.3/657.1 ± 122.9 N
Direction: Extension, flexion, lateral left and right Lateral right: 570 ± 106.5/668 N ± 142.1 N
flexion Key findings:
Protocol: Peak of 3 RM x each direction holds and A 5-week neck strengthening program significantly increased sagittal (flexion and extension) and frontal
rest period of 60 seconds (lateral right and left) plane isometric measures.
Hamilton 382 schoolchildren players. Test: Peak isometric extension strength Peak isometric extension strength
et al. Equipment: Customized neck device with a load cell Baseline (SD) by age:
[33] Type: Break test 12 y: 18 ± 3.1 kg
Position: Seated, head neutral 13 y: 21 ± 3.9 kg
Direction: Extension 14 y: 25 ± 5.7 kg
Protocol: Mean of 3 RM x each direction and rest 15 y: 28 ± 6.0 kg
period of 30 seconds 16 y: 30 ± 6.0 kg
17 y: 32 ± 6.3 kg
18 y: 34 ± 8.1 kg
Key findings:
Peak isometric neck extension strength increased with age from 18 kg at 12 y to 34 kg at 18 y.
(Continued )
Table 2. (Continued).
Study Participants Strength assessment Outcomes
Hamilton, 27 professional players. Test: Peak isometric Peak isometric strength
Gatherer Equipment: Customized neck device with a load cell Baseline (SD) forwards:
[42] Type: Break test Flexion: 32 ± 5.6 kg
Position: Seated, head neutral Extension: 44.9 ± 7.1 kg
Direction: Extension, flexion, lateral left and right Left lateral flexion 42.9 ± 7.7 kg
flexion, Left and right rotation Right lateral flexion: 43.1 ± 7.5 kg
Protocol: Mean of 3 RM x each direction and rest Rotation left: 37.5 ± 6.9 kg
period of 30 seconds Rotation right: 38.5 ± 5.5 kg
Baseline (± SD) backs:
Flexion: 28.5 ± 3.9 kg
Extension: 39.5 ± 5.2 kg
Lateral left: 35 ± 4.5 kg
Lateral right: 35 ± 4.5 kg
Flexion with left rotation: 33 ± 3.3 kg
Flexion with right rotation: 33.4 ± 3 kg
All players PTF/PTE ratio: 0.7
Key findings:
Forwards were significantly stronger than backs in all directions, except flexion.
Hamilton 30 senior school-aged and 22 male adult Test: Peak isometric Peak isometric strength
et al. senior school-aged front-row players. Equipment: Customized neck device with a load cell Baseline [95% CI] under 19 y:
[34] Type: Break test Flexion: 22.5 [20.4 to 24.72] kg
Position: Seated, head neutral Extension: 41.7 [39.36 to 44.18] kg
Direction: Extension, flexion, lateral left and right Lateral left: 32.2 [30.04 to 34.45] kg
flexion, Left and right rotation Lateral right: 31.8 [29.66 to 24.01] kg
Protocol: The mean 3 RM x each direction holds and Baseline [95% CI] adults:
rest period of 60 seconds Flexion: 25.4 [22.94 to 27.86] kg
Extension: 53.7 [48.42 to 58.99] kg
Lateral left: 40.5 [36.36 to 44.71] kg
Lateral right: 42.4 [39.24 to 45.73] kg
Key findings:
Adults were significantly stronger than the under-19 group in all directions, except in flexion.
Konrath, 40 professional players. Test: Peak isometric Peak isometric strength
Appleby Equipment: Customized neck device with a load cell Forwards:
[40] and velcro head strap Flexion: 295.2 N
Type: Make test Extension: 328 N
Position: Supine and prone and head horizontal to PTF/PTE ratio: 0.92
the floor Backs:
Direction: Extension and flexion Flexion: 244 N
Protocol: The peak of 3 RM x each direction with Extension: 229 N
5 sec duration and rest period of 60 seconds PTF/PTE ratio: 1.28
Key findings:
Forwards were significantly stronger in flexion and extension vs backs.
Forwards had significantly lower isometric flexion to extension ratios than backs.
(Continued )
THE PHYSICIAN AND SPORTSMEDICINE
9
 10

Table 2. (Continued).
Study Participants Strength assessment Outcomes
Maconi 23 amateur players and 11 controls Test: Peak isometric Peak isometric strength pre and post 12-week neck strengthening program
et al. Equipment: Customized ergometer load cell Pre (SD)/Post (SD)
[39] Type: Flexion of the head against an unmovable Flexion: 135 ± 47/202 ± 44 N
support Extension: 164 ± 37/214 ± 41 N
Position: Seated, neck neutral Lateral left: 137.5 ± 29.7/141.6 ± 35 N [no significant increase post training]
Direction: Extension, flexion, lateral left and right Lateral Right: 144.2 ± 30.5/146.1 ± 31.8 N [no significant increase post training]
C. CHAVARRO-NIETO ET AL.

flexion and left and right rotation Flexion with left rotation: 130 ± 31/165 ± 31 N
Protocol: The peak of 3 RM x each direction of 3 sec Flexion with right rotation: 129 ± 31/154 ± 22 N
and rest period of 30 seconds Key findings:
Flexion, extension, flexion with left and right rotation neck strength measures increased significantly
after a 12-week training program. There were no significant changes in right and left flexion with
training.
Naish et al. 27 professional players Test: Peak isometric Peak isometric strength pre and post neck strengthening program at week 5
[35] Equipment: Customized load cell device, head Pre (SD)/Post (SD)
harness, and immovable metal frame Flexion: 277.6 ± 63.0/288 ± 64.1 N
Type: Make test Extension: 367.7 ± 47.9/372.4 ± 50.9 N
Position: Seated, head neutral Lateral left: 363.2 ± 53.9/372.2 ± 50.6 N
Direction: Extension, flexion, lateral left and right Lateral right: 376.4 ± 44.7/383.6 ± 51.9 N
flexion Key findings:
Protocol: The peak of 3 RM x each direction with An intervention of neck strengthening did not significantly affect strength values at week 5.
5 sec duration and rest period of 30 seconds
Olivier, Du 189 professional players Test: Peak isokinetic torque Peak isokinetic strength
Toit [38] Equipment: Isokinetic dynamometer Baseline [95% CI] front row forwards:
Type: Isokinetic test Flexion: 42.6 [39.76, 45.54] Nm
Position: Seated, head neutral Extension: 65.6 [62.12, 69.0] Nm
Direction: Flexion, extension, lateral left and right Lateral left: 64.8 [60.65, 67.51] Nm
flexion Lateral right: 65.1 [61.08, 69.16] Nm
Protocol: The peak of 3 RM x each direction and NR Baseline [95% CI] backs:
rest period Flexion: 33.5 [32.26, 34.76] Nm
Extension: 46.1 [44.38, 47.86] Nm
Lateral left: 50.4 [48.25, 52.55] Nm
Lateral right: 50 [48.21, 51.81] Nm
Difference of peak torque relative to body weight
PTF/BW PTE/BW
Front row 0.38 [0.36, 0.40] 0.59 [0.56,0.62]
Second row 0.4 [0.36,0.44] 0.57 [0.52,0.62]
Back row 0.41[0.38, 0.44] 0.58 [0.54,0.62]
Backline 0.4 [0.38, 0.42] 0.55[0.53,0.57]
All players PTF/PTE: 70% [68.40–71.6]
Key findings:
Among positions the difference of peak torque relative to body weight was small.
Extension of front row forwards significantly greater than any other player. Front row forwards were
significantly stronger than backs in all peak torque measures.
Peak torque ratio: Front row forwards demonstrated PTF/PTE ratios 65% lower than any other position.
(Continued )
Table 2. (Continued).
Study Participants Strength assessment Outcomes
Salmon 41 amateur players. Test: Peak isometric Peak isometric strength pre and post 20-week Rugby Union season
et al. Equipment: Load cell and fixed-frame dynamometer Pre (SD)/Post (SD) forwards:
[36] Type: Bracing against the bench Flexion: 238.8 ± 149.4/245.7 ± 125.80 N
Position: Contact posture (tackle/scrummaging) Extension: 326.6 ± 116.9/367 ± 116.73 N
Direction: Extension, flexion, lateral left and right Lateral left: 195 ± 97.9/234.5 ± 93.31 N
flexion Lateral right: 221.5 ± 128.7/233.9 ± 90.05 N
Protocol: 1 RM x each direction, held by 5s and rest Pre (SD)/Post (SD) backs:
period of 60 seconds Flexion 161.8 ± 51.3/175.9 ± 57.7 N
Extension 253.4 ± 74.09/276 ± 60.5 N
Lateral left: 169.3 ± 64.59/196.7 ± 63.46 N
Lateral right: 182.2 ± 73.19/190.8 ± 48.41 N
Key findings:
Forwards exhibited higher peak values at baseline in all directions vs backs.
After a 20-week in-season follow-up, neck strength in significantly improved in forwards in extension
16%, flexion 19%, left 35% and right 27% lateral flexion and backs in extension 10%, flexion 21%, and
left lateral flexion in 27%.
Forwards demonstrated significant improvements (35.3–59.1 N) in all directions post-season compared
to controls.
Snodgrass 142 semiprofessional players. Test: Peak isometric Peak isometric strength
et al. Equipment: Handheld dynamometer Baseline (± SD) no history of neck injury:
[37] Type: Push against a manually applied force Flexion: 17.9 ± 3.5 kg
Position: Seated, neck neutral Extension: 23.2 ± 2.7 kg
Direction: Extension, flexion, lateral left and right Lateral left: 18 ± 3.6 kg
flexion and left and right flexion and extension with Lateral right: 17.3 ± 3.6 kg
rotation Flexion with left rotation: 14.5 ± 2.2 kg
Protocol: The mean of 3 RM x each direction NR rest Flexion with right rotation: 15.3 ± 2.7 kg
period Baseline (± SD) history of neck injury:
Flexion: 18.2 ± 3.7 kg
Extension: 22.6 ± 19.0, kg
Lateral left: 18.1 ± 3.8 kg
Lateral right: 17.5 ± 4.0 kg
Flexion with left rotation: 14.7 ± 2.2 kg
Flexion with right rotation: 15.8 ± 3.1 kg
Key findings:
No significant difference was observed in strength between players with and without a history of neck
injuries.
Notes. Values are means ± standard deviation, means [95% confidence intervals], and minimum – maximum ranges.
Abbreviations: BW, bodyweight; CI, confidence interval; PTF, peak torque flexion.; PTE, peak torque extension; RM repetition maximal; N, Newton; Nm, Newton-meter; NR, No report; SD, standard deviation.
THE PHYSICIAN AND SPORTSMEDICINE
11
12 C. CHAVARRO-NIETO ET AL.

Three studies evaluated neck strength differences between

age groups and indicated that neck strength increases with
age from school children to professional players [32–34]. In
the study by Hamilton et al. [34], adult amateur players
demonstrated significantly stronger neck strength in all direc­
tions except flexion compared to under-19s level players. In
school-aged players, extension neck strength (the only direc­
tion assessed) was significantly greater in 18 compared to 12-
year-old players [33]. Likewise, Davies et al. [32] reported that
senior players were significantly stronger than younger age-
grade players in all directions (flexion, extension, bilateral side
flexion, and bilateral side flexion and extension with rotation
measures).
Figure 2. Illustration of ‘break test’ to assess the neck extension muscles.
Dempsey et al. [12] measured neck flexion and extension in
ten professional players, as well as peak angular and linear
accelerations using three-dimensional cameras. The test con­
scrummaging positions [36], and one study recorded the sisted of a tackle situation, and the attacking player was tracked
neck strength lying on a bench in a supine or prone with body markers and the contact with the defender was
position [40]. analyzed. These authors found a significant reduction in medial
and lateral angular and linear accelerations of the head in
3.4.3 Outcomes players with stronger flexion and extension neck strength [44].
In five studies, neck strength was evaluated by playing
position and compared between forwards and backs [36,38,­ 3.5 Neck strengthening programs
38,40–42]. In all studies, forwards were stronger than backs,
but not in all directions across studies. For instance, Geary Four of the included studies implemented a neck-
et al. [41] showed that amateur forwards were significantly strengthening program [31,35,39,43] (Table 3). The stated
stronger in extension than backs, but not in flexion or goals of the studies included increasing neck strength
bilateral side flexion, whereas Olivier, Du Toit [38] found [31,35,43], resilience to fatigue, and range of motion [31];
significantly stronger necks in forwards compared to backs reducing neck soreness [39] and neck injuries [35]; and identi­
in flexion, extension, and bilateral side flexion. Konrath, fying neck imbalances as a potential risk factor for injuries [31].
Appleby [40] reported significantly stronger necks in exten­ All four training programs implemented isometric routines,
sion and flexion for forwards than backs, with larger neck with one study also implementing concentric exercises [39].
girth and longer necks with greater cross-sectional area and In the two studies involving professional players, one used
muscle mass for forwards in both studies. Of note, Salmon rigid cables [35] and the other manual resistance [43] for
et al. [36] highlighted that peak force in all directions sig­ neck strengthening; although the studies were performed at
nificantly correlated with neck girth in amateur players, with the same level of competition and implemented similar train­
greater increase in neck strength measures over a season in ing protocols (two to three sets of 3 or 4 reps of neck holds of
amateur forwards than backs despite forwards being stron­ 3 to 10 s in four directions twice a week), differences between
ger at baseline. outcomes are likely due to the difference in timing of the
strength test, strength test measures, and training loads. The
other two studies performed training exercises using elastic
3.4.4 Normative values cords with variable resistance loads in school-aged [31] and
In relation to peak isometric strength by level of competi­ amateur players [39]. All four studies implemented neck flex­
tion, Davies et al. [32] showed greater values in extension, ion, extension, and bilateral flexion exercises; with one study
flexion, left lateral, and right lateral directions when com­ incorporating right and left rotation [31]. These exercises were
paring senior to junior school-aged players. Hamilton et al. executed two to three times per week, usually three to four
[33] indicated differences in peak isometric strength in sets of four to twelve repetitions per session. The program
extension from 12 to 18 years. In amateur players, Geary duration varied from five to twelve weeks.
et al. [41] indicated greater values in extension, flexion, and After implementing a 5-week strengthening training pro­
bilateral side flexion compared to the results by Salmon gram, Geary et al. [43] found significant increases in neck
et al. [36] and Maconi et al. [39] strength in flexion (18%), extension (20%), and left (18%) and
Flexion-to-extension strength ratios in Rugby Union were, on right (17%) lateral flexion. Maconi et al. [39] found greater
average, from 0.65 Olivier, Du Toit [38] to 0.7 Hamilton, Gatherer gains in strength in neck flexion (50%), extension (30%), and
[42]. Forwards exhibited a significantly lower ratio than backs bilateral rotation (left 27%, right 19%) following 12 weeks of
[38,40], indicating that forwards have greater extension strength strengthening, but not in lateral flexion. In contrast, Naish
relative to flexion strength. Results from Davies et al. [32] high­ et al. [35] found no significant improvements in strength
lighted that age-grade players also had lower flexion-to-extension after a 26-week strengthening training period when measured
ratio than senior players, with lesser neck flexor strength (41%) at week five of the program, with no further assessment
compared to senior players, with no difference between positions. performed thereafter. Similarly, Barrett et al. [31] reported
Table 3. Neck training protocols and results.
Study Participants Training program Protocol Outcomes
Barrett 34 senior school-aged players (17 test 6-week duration Type: Isometric Mean change (%) intervention/control:
et al. players and 17 controls) Isometric holds with a head harness and custom variable Frequency: 3 x per Flexion: 15.7/14.7%
[31] resistance elastic cords. week Extension: 21.7/13.2%
The control trained and played as normal. Sets and reps: 4 sets x 6 Mean change (raw units) intervention/control:
reps Flexion: 3.1/2.7 kg
Load: 50% MVC Extension: 6.9/4.4 kg
Key findings:
A 6-week neck strengthening program did not significantly increase neck
strength in any direction compared to controls.
Geary 15 professional and 10 control 5-week duration Type: Isometric Mean increases [95% CI]:
et al. semiprofessional players Isometric holds in flexion, extension, and left and right Frequency: 2 x per Flexion: 61.6 [33.1, 90.03] N
[43] lateral flexion against a manual resistance. week. Extension: 127.6 [68.2, 187.0] N
Sets and reps: 1 set x 3 Left lateral flexion: 101.5 [46.4, 156.6] N
reps Right lateral flexion: 98 [47.6, 148.3] N
Load: 10 s holds against Key findings:
manual resistance A 5-week neck strengthening program significantly increased sagittal and
frontal isometric measures.
Maconi 23 amateur male players and 11 12-week duration Type: Isometric Pre (SD)/Post (SD):
et al. control Isometric and concentric strengthening using elastic Frequency: 3 x per Flexion: 135 ± 47/202 ± 44 N
[39] bands. week Extension: 164 ± 37/214 ± 41 N
Sets and reps: 3 sets Flexion with left rotation: 130 ± 31/165 ± 31 N
x 10 reps Flexion with right rotation: 129 ± 31/154 ± 22 N
Load: 10 s holds at 70% Right lateral flexion: 144.2 ± 30/146.1 ± 31 N
MVC Left lateral flexion: 137.5 ± 29.7/141.6 ± 35.0 N
Type: Concentric Key findings:
Frequency: 3 x per A 12-week neck strengthening program significantly increased all neck
week strength measures, except for left and right lateral flexion.
Sets and reps: 3 sets x 8
reps
Naish 27 professional players 26-week duration Preseason: Weeks 1–13 Pre (SD)/Post (SD)
et al. Isometric cable holds in flexion, extension, and left and Type: Isometric Flexion: 277.6 N ± 63/288 N ± 64.1
[35] right lateral flexion. Frequency: 2 x per Extension: 367.7 N ± 47.9/372.4 N ± 50.9
week Lateral left: 363.2 N ± 53.9/372.2 N ± 50.6
Sets and reps: 2–3 sets Lateral right: 376.4 N ± 44.7/383.6 N ± 51.9
x 4–12 reps Key findings:
Load: 70%-100% 1RM A 26-week neck strengthening program did not significantly improve neck
Maintenance phase: strength measures after 5 weeks.
Weeks 14–26
Type: Isometric
Frequency: 1–2 x per
week.
Sets and reps: 2–3 sets
of 3–4 reps.
Load: 3 s holds %MVC
NR
Notes. Values are means ± standard deviation, means [95% confidence intervals], and minimum – maximum ranges.
THE PHYSICIAN AND SPORTSMEDICINE

Abbreviations: CI, confidence interval; MVC, maximal voluntary contraction; N, Newton; NR, not report; RM, maximal repetition; SD, standard deviation.
13
 14

Table 4. Neck strength and injuries.

Study Participants Duration Neck strength measure and/or training program Outcomes
Naish et al. 27 professional Super Rugby 26-week training 26-week training program 2-season neck injury report:
C. CHAVARRO-NIETO ET AL.

[35] Union players. program Isometric cable holds in flexion, extension, and left and right First season (no neck training program):
lateral flexion. Players injured: 8
Preseason: weeks 1–13 Number of injuries: 12
Type: Isometric Training injuries: 1
Frequency: 2 x per week Match injuries: 11
Sets and reps: 2–3 sets x 4–12 reps Second season (with neck training program):
Load: 70%-100% 1RM Players injured: 6
Maintenance phase: weeks 14–26 Number of injuries: 6
Type: Isometric Training injuries: 4
Frequency: 1–2 x per week. Matches injuries: 2
Sets and reps: 2–3 sets of 3–4 reps. Key findings:
Load: 3 s holds Significant reduction in match neck injuries, not in peak strength values after
a neck strengthening program.
Snodgrass 142 semiprofessional players. Pre-season Pre-season assessment of neck strength, anthropometrics, Characteristics of the 11 neck injuries:
et al. [37] proprioception, and range of motion. Position:
Neck injuries monitored during a competitive Rugby Union season. Front row: 5 (45%)
Back row: 5 (45%)
Wing: 1 (10%)
Phase of play:
Tackle: 7 (64%)
Scrum: 1 (9%)
Ruck: 2 (18%)
Maul: 1 (9%)
Concussion:
Yes: 4(36%)
No: 6 (55%)
*missing data
Previous neck injury:
Yes: 7 (63%)
No: 4 (36%)
Key findings:
Older and more experience players had more history of previous neck injuries.
Abbreviations: RM, maximal repetition.
 THE PHYSICIAN AND SPORTSMEDICINE 15

that a 6-week training program did not significantly increase between studies, and no dynamic and eccentric testing pro­
neck strength in any direction. cedures. As such, important physical properties (i.e. stiffness)
of the neck musculature are not currently being examined
with respect to their association to neck, head, or concussion
3.6 Neck strength measures, training programs, and injury risk in Rugby Union [46].
injuries
Two of the studies reviewed considered the relationship 4.1.1 Methodological discussion
between neck strength measures, neck strength training pro­ Salmon et al. [36] assessed amateur players with a fixed-frame
grams, and injuries in Rugby Union [35,37] (see Table 4). Naish dynamometer in a rugby specific position (similar body posi­
et al. [35] performed a 26-week isometric neck-strengthening tion to player running into contact or scrum position) and
program in professional players across two competition sea­ found stronger necks in all directions for forwards compared
sons. In the second season, a neck strengthening program was to backs at baseline. At the conclusion of a playing season,
introduced (13-week strengthening period followed by a 13- both forwards and backs (except in right lateral flexion) exhib­
week maintenance) and compared injury reports to the pre­ ited greater neck strength, with the improvement being some­
vious season. The results indicated that the athletes had what unexpected for the backs given their lesser contact
a significant reduction in neck injuries during matches played demands and associated neck loading. In contrast, Geary
within the neck strengthening program. In their retrospective et al. [41] assessed neck strength in a seated position in
analysis, there was a significant reduction in match neck inju­ a ‘break test’ fashion and found greater extension strength
ries from eleven to two after the intervention program. in forwards than backs, and not in any other direction. This
The other longitudinal study that aimed to understand the difference in strength outcomes between positions could be
association between physical characteristics and incidence of attributable to the rugby specific position used by Salmon
neck pain and injuries by Snodgrass et al. [37] evaluated 142 et al. [36] with the isolation of the neck muscles and the
semiprofessional players. The neck assessment included mea­ improved neuromuscular recruitment assumed in the scrum­
surements relating to neck strength, anthropometrics, proprio­ maging posture. Furthermore, it could be that this rugby
ception, and range of motion. No significant difference was specific position was more familiar for forwards given their
found in neck strength when comparing players with or with­ scrummaging on-field role, with the test position being unfa­
out a history of neck injury. On the other hand, a greater miliar for backs. From these studies, the considerable variation
number of previous neck injuries were observed with increas­ in test methods is clear; therefore comparing studies to build
ing age and playing experience. In-season neck injuries were up a picture of neck strength in players and to get a definitive
associated with a reduced range of motion in left and right relationship between neck strength and injury is challenging
lateral flexion. with the current literature.

4.1.2 Position effects in neck strength

4. Discussion Variables such as greater body mass [36,38,40–42], larger neck
girths [36,38,40], and longer necks [36,40] were associated
4.1 Neck strength measures in Rugby Union
with stronger necks in forwards compared to backs. In profes­
In Rugby Union, neck strength has been measured in sional players, greater body mass was associated with larger
a number of studies with the intention of determining differ­ cross-sectional neck areas and stronger necks [42]. At this
ences between age groups, positions, and injury prevalence level, forwards from Geary et al. [43] displayed the highest
[12,31–43]. We examined the scientific literature addressing isometric strength values in this review. The test was per­
neck strength in Rugby Union with a focus on neck strength formed in a ‘break test’ manner, with forwards being stronger
assessment protocols training programs and relationships with than backs in all four directions. To date, there is no consensus
injuries. The studies included in this review were implemented regarding what strength values at this or at any level of
with male players; therefore, we advise against the general­ competition should be targeted and sufficient to minimize
ization of findings to female players due to – amongst other risk of injury. Indeed, levels of neck strength require further
reasons – the previously reported physiological differences investigation to assist coaches and players to understand what
between sexes [45]. Furthermore, pooling results across stu­ is required to prevent injury and/or decrease injury severity.
dies to make strong inferences is challenging given the var­ We strongly suggest that recommendations be prescribed
ious testing procedures, equipment, and units used. regarding neck strength in younger rugby athletes given the
Isometric neck strength was assessed in nearly all studies, ‘in-game’ stressors such as scrum, ruck, maul and collision and
except in one where isokinetic strength was examined [38]. the rising numbers of head injuries observed.
Overall, the ‘break test’ displayed greater neck strength values
compared to the other methods of testing although no direc­ 4.1.3 Neck strength ratios
tion comparisons between testing methods have been under­ With regard to the ratio between flexion and extension, for­
taken, and the outcome of these tests showed strength wards appear to have a significantly lower ratio compared to
variations based on player characteristics, positions, and level backs [38,40], with greater extension strength measures com­
of competition. Adopting a standardized method of assess­ pared to flexion. These findings are probably due to the neck
ment of neck strength to compare outcomes across studies is extension forces exerted by forwards to keep the neck stable
of upmost importance. Indeed, there is a lack of consistency during scrummaging. In relation to age, younger players
16 C. CHAVARRO-NIETO ET AL.

showed lower flexion to extension ratios compared to senior American Football and Rugby Union, these studies overall
players [32]. These discrepancies in neck musculature are highlight the importance of diverse neck training strategies
a potential risk factor for neck injuries, where a flexion to in decreasing the severity of impacts. Future research in rugby
extension ratio imbalance having been associated with higher should seek to implement neuromuscular, eccentric, and
head angular and linear accelerations in other cohorts [47]. anticipation for impact training to determine their relevance
Promoting strength symmetry between muscles is a strategy and effectiveness in the context of concussions in rugby.
used in practice in attempts to mitigate injury risk in other
anatomical parts of the body (e.g. knee) [48]. The neck is not
except as symmetry in muscle strength between flexors and 4.3 Neck strength measures, training programs, and
extensors is crucial in neck stabilization [49]. injuries
Injury risk factors, including neck asymmetries, previous injuries,
4.2 Neck strengthening training programs as well as deficits in range of motion and proprioception, have
not been linked to neck and head injuries in Rugby Union players
In the studies reviewed, four studies implemented neck strength­
[54]. Despite the introduction of a new tackle rule, the incidence
ening programs in Rugby Union players. Two studies reported
of concussions in professional players continue to increase
a significant increase in neck strength of the players post inter­
[11,55]. It would seem that improving neck strength should be
vention [39,43], and two reported no improvements [31,35]. In
a priority in any injury prevention and performance program in
a longer 12-week intervention that added concentric exercises,
Rugby Union. Neck strength values can assist in the preparation
Maconi et al. [39] found a significant increase in strength in all
and screening of rugby players at every level, i.e. targeting
directions except in bilateral side flexion. This research group
specific preseason training strategies; as well as providing
also noted improvements in coactivation of neck muscles, motor
a clinical tool to aid the rehabilitation of cervical injuries or return
recruitment, and muscle firing rate patterns of neck musculature
to play protocols. Few studies have examined the relationship
using electromyography.
between neck strength values, neck strengthening exercises, and
The American College of Sports Medicine (ACSM) guide­
the incidence of neck and head injuries [35,37].
lines for exercise prescription [50] recommend for resistance
Naish et al. [35] presented a paradoxical result, wherein the
strength training the following routine: frequency of 2 to 3
decrease in the number of neck match injuries was not asso­
times per week, with 2 to 4 sets of 8 to 12 repetitions at a load
ciated with changes in neck strength values after
of 60% to 70% for intermediate and >80% for experienced
a strengthening program. The researchers attributed this result
participants to improve strength and power. Based on these
to neurological changes in neck proprioception, greater stabili­
parameters, the most comprehensive training strategies were
zation of deep cervical flexors, and improvements in muscle co-
implemented by Geary et al. [43] and Naish et al. [35] using
activation due to the training program. A limitation could exist in
isometrics, and Maconi et al. [39] using isometrics and con­
the neck strength evaluation, which was only measured at week
centric exercises. Barrett et al. [31] performed lower training
five of the 26-week program, with no further assessments under­
intensities and repetitions than the ACSM recommendations,
taken. As such, it is uncertain whether neck strength changes
using 50% of maximal voluntary isometric contractions and 6
occurred after the initial 5-week period and the extent to which
repetitions. This exercise prescription might have not induced
they influenced the prevalence of neck injuries.
enough stimulus to produce improvement in strength.
None of the studies in the current review evaluated the asso­
As mentioned previously, most protocols undertaken in
ciation between neck strength or strengthening programs and the
rugby were performed with isometric exercises without
incidence of concussion injuries. However, Dempsey et al. [12]
dynamic, neuromuscular, or eccentric training routines.
found players with stronger necks in flexion and extension had
Lisman et al. [51] implemented an 8-week isometric resistance
a significant reduction in medial and lateral angular and linear
training for the neck muscles in collegiate NFL players. The
head accelerations. The pre-activation of the neck flexor and
intervention was effective in increasing left lateral flexion (7%)
extensor muscles before a collision has been shown to signifi­
and extension strength (10%), but did not affect tackling head
cantly decrease the peak linear velocity and deaccelerating of the
accelerations or activation of neck stabilizers during tackling.
head [14,15]. As such, there is the potential for neck strength to
These results hence suggest that isometric neck strength
reduce concussion risk in Rugby Union. However, the systematic
alone may be insufficient to reduce incidence and severity of
review by Le Flao et al. [56] found no clear relationship between
head injuries and that training stabilizer muscles, and that
neck strength and head/neck accelerations and their influence on
incorporating neck stabilization training modalities could be
concussion injuries, and a review of the literature by Hrysomallis
important. This proposition is supported by results from
[57] found inconsistent outcomes that increasing isometric neck
Schmidt et al. [52] who demonstrated that stronger and larger
strength reduce head accelerations and therefore a better head
necks were not protective of head injuries in NFL players,
stabilization with impact anticipation strategies.
whereas stiffer and more responsive neck musculatures to
cervical perturbations were protective. Modeling studies sub­
stantiate that strengthening strategies in American football
5. Conclusion
and other contact sports should include eccentric training
and preparation for impact exercises to reduce head injury In Rugby Union, neck strength has been measured through
metrics [53]. Despite very different rules and regulations different playing positions and levels of competition; however,
regarding mandated protective equipment between there is no consensus regarding a standardized method to
 THE PHYSICIAN AND SPORTSMEDICINE 17

assess neck strength in Rugby Union. All studies have been 8. theIrishRugbyInjurySurveillanceProject(IRIS). The Irish Rugby Injury
completed in a male population, with an obvious gap pertain­ Surveillance Project (IRIS)In: Group AbTIRISIPS, editor. 2017-2018
Report: Ireland Rugby Football Union; 2019. p. 31
ing to the assessment of neck strength in female athletes.
9. WorldRugby: development/player-numbers. http://www.worldrug
Nonetheless, senior elite male players were stronger than byorg/development/player-numbers. (2016). Accessed.
younger-aged players, which could be due to their immature 10. King D, Hume PA, Hardaker N, et al. Sports-related injuries in New
musculature and/or lesser training experience. Forwards were Zealand: national insurance (Accident Compensation Corporation)
stronger in extension than any other directions assessed, and claims for five sporting codes from 2012 to 2016. Br J Sports Med.
2019;53(16):1026–1033.
when compared to backs, were generally stronger and pos­
11. Stokes KA, Locke D, Roberts S, et al. Does reducing the height of
sessed larger necks and greater cross-sectional areas. the tackle through law change in elite men’s Rugby Union (The
Implementation of isometric exercise routines in profes­ Championship, England) reduce the incidence of concussion?
sional players has been reported to improve neck strength in A controlled study in 126 games. Br J Sports Med. 2019.
all directions. Whilst the training programs across levels DOI:10.1136/bjsports-2019-101557..
12. Dempsey AR, Fairchild TJ, Appleby BB The relationship between
showed different outcomes, establishing an evidence-based
neck strength and head accelerations in a rugby tackle. 33
strengthening routine with different exercise modalities (i.e. International Conference of Biomechanics in Sports (2015) Section
isometric, eccentric, and concentric) is essential. Moving for­ Conference Proceedings Archive2015.
ward, work should be undertaken to further standardize and 13. Viano DC, Casson IR, Pellman EJ. Concussion in professional foot­
develop guidelines regarding strength test protocols and ball: biomechanics of the struck player-part 14. Neurosurgery.
2007;61(2):313–328.
benchmark values, as well as training protocols across age
14. Eckner JT, Oh YK, Joshi MS, et al. Effect of neck muscle strength and
groups and performance levels. anticipatory cervical muscle activation on the kinematic response
of the head to impulsive loads. Am J Sports Med. 2014;42
(3):566–576.
Acknowledgments 15. Simoneau M, Denninger M, Hain TC. Role of loading on head
stability and effective neck stiffness and viscosity. J Biomech.
The authors thank Ivana Hanzlíková for the Quality assessment of the 2008;41(10):2097–2103.
articles. 16. Franco JL, Herzog A. A comparative assessment of neck muscle
strength and vertebral stability. J Orthop Sports Phys Ther. 1987;8
(7):351–356.
17. Collins CL, Fletcher EN, Fields SK, et al. Neck strength: a protective
Declaration of interest factor reducing risk for concussion in high school sports. J Prim
None to declare. Prev. 2014;35(5):309–319. .
18. Caccese JB, Buckley TA, Tierney RT, et al. Head and neck size and
neck strength predict linear and rotational acceleration during
ORCID purposeful soccer heading. Sports Biomech. 2018;17(4):462–476.
19. Peek K, Elliott JM, Orr R. Higher neck strength is associated with
Christian Chavarro-Nieto http://orcid.org/0000-0002-5130-3883 lower head acceleration during purposeful heading in soccer:
Martyn Beaven http://orcid.org/0000-0003-2900-7460 a systematic review. J Sci Med Sport. 2020;23(5):453–462.
Kim Hébert-Losier http://orcid.org/0000-0003-1087-4986 20. Mansell J, Tierney RT, Sitler MR, et al. Resistance training and
head-neck segment dynamic stabilization in male and female col­
legiate soccer players. J Athl Train. 2005;40(4):310.
References 21. Eckner JT, Goshtasbi A, Curtis K, et al. Feasibility and effect of
cervical resistance training on head kinematics in youth athletes:
1. Hume PA, Theadom A, Lewis GN, et al. A comparison of cognitive a pilot study. Am J Phys Med Rehabil. 2018;97(4):292. .
function in former Rugby Union players compared with former 22. Austin D, Gabbett T, Jenkins D. The physical demands of super 14
non-contact-sport players and the impact of concussion history. rugby union. J Sci Med Sport. 2011;14(3):259–263.
Sports Med. 2017;47(6):1209–1220. 23. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for
2. Stewart W, McNamara PH, Lawlor B, et al. Chronic traumatic ence­ systematic reviews and meta-analyses: the PRISMA statement.
phalopathy: a potential late and under recognized consequence of 2010.
Rugby Union? QJM. 2016;109(1):11–15. 24. Modesti PA, Reboldi G, Cappuccio FP, et al. Panethnic differences in
3. RugbyFootballUnion, Surveillance. England professional Rugby injury blood pressure in Europe: a systematic review and meta-analysis.
surveillance project report. In: Group AbtEPRISPS, editor. 2016–2017 PloS One. 2016;11(1):e0147601. .
Season Report. https://www.englandrugby.com/mm/Document/ 25. Hanzlíková I, Hébert-Losier K. Is the landing error scoring system
General/General/01/32/91/95/InjurySurveillanceReport2016-17_ reliable and valid? A systematic review. Sports Health. 2020;12
English.pdf: England Rugby; 2018. (2):181–188.
4. Cosgrave M, Williams S. The epidemiology of concussion in profes­ 26. Hoegberg LCG, Refsgaard F, Pedersen SH, et al. Potential pharma­
sional rugby union in Ireland. Physical Therapy in Sport. cobezoar formation of large size extended-release tablets and their
2019;35:99–105. dissolution - an in vitro study. Clin Toxicol (Phila). 2018;1–11.
5. Bitchell CL, Mathema P, Moore IS. Four-year match injury surveil­ DOI:10.1080/15563650.2018.1513138..
lance in male Welsh professional Rugby Union teams. Physical 27. Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa scale
Therapy in Sport. 2020;42:26–32. (NOS) for assessing the quality of nonrandomised studies in
6. Cross M, Kemp S, Smith A, et al. Professional Rugby Union players meta-analyses. Ottawa: Ottawa Hospital Research Institute. 2011.
have a 60% greater risk of time loss injury after concussion: a 28. McKeon PO, Medina JM, Hertel J. Hierarchy of research design in
2-season prospective study of clinical outcomes. Br J Sports Med. evidence-based sports medicine. Athl Ther Today. 2006;11(4):42–45.
2016;50(15):926–931. 29. Von Elm E, Altman DG, Egger M, et al. The Strengthening the
7. Howell DR, Osternig LR, Chou L-S. Return to activity after concus­ Reporting of Observational Studies in Epidemiology (STROBE)
sion affects dual-task gait balance control recovery. Med Sci Sports statement: guidelines for reporting observational studies. PLOS
Exerc. 2015;47(4):673–680. Med. 2007;4(10):e296.
18 C. CHAVARRO-NIETO ET AL.

30. Vandenbroucke JP, Von Elm E, Altman DG, et al. Strengthening the 43. Geary GBS, Delahunt E, Delahunt E. Effects of neck strength train­
Reporting of Observational Studies in Epidemiology (STROBE): ing on isometric neck strength in rugby union players. Clin J Sport
explanation and elaboration. PLOS Med. 2007;4(10):e297. Med. 2014;24(6):502–508.
31. Barrett MD, McLoughlin TF, Gallagher KR, et al. Effectiveness of 44. Duma SM, Manoogian SJ, Bussone WR, et al. Analysis of real-time
a tailored neck training program on neck strength, movement, head accelerations in collegiate football players. Clin J Sport Med.
and fatigue in under-19 male rugby players: a randomized con­ 2005;15(1):3–8. .
trolled pilot study. J Sports Med. 2015;6:137–147. 45. Tierney RT, Sitler MR, Swanik CB, et al. Gender differences in
32. Davies M, Moore IS, Moran P, et al. Cervical range of motion, head-neck segment dynamic stabilization during head
cervical and shoulder strength in senior versus age-grade Rugby acceleration. Med Sci Sports Exerc. 2005;37(2):272–279.
Union International front-row forwards. Physical Therapy in Sport. 46. Queen RM, Weinhold PS, Kirkendall DT, et al. Theoretical study of
2016;19:36–42. the effect of ball properties on impact force in soccer heading. Med
33. Hamilton DF, Gatherer D, Jenkins PJ, et al. Age-related differences Sci Sports Exerc. 2003;35(12):2069–2076.
in the neck strength of adolescent rugby players: a cross-sectional 47. Dezman ZD, Ledet EH, Kerr HA. Neck strength imbalance correlates
cohort study of Scottish schoolchildren. Bone Joint Res. 2012;1 with increased head acceleration in soccer heading. Sports Health.
(7):152–157. 2013;5(4):320–326.
34. Hamilton DF, Gatherer D, Robson J, et al. Comparative cervical 48. Croisier JL, Ganteaume S, Binet J, et al. Strength imbalances
profiles of adult and under-18 front-row rugby players: implications and prevention of hamstring injury in professional soccer
for playing policy. Br Med J. 2014;4(5):e004975. players: a prospective study. Am J Sports Med. 2008;36
35. Naish R, Burnett A, Burrows S, et al. Can a specific neck strengthen­ (8):1469–1475.
ing program decrease cervical spine injuries in a men’s professional 49. Rezasoltani A, Ahmadi A, Nehzate-Khoshroh M, et al. Cervical mus­
Rugby union team? J Sports Sci Med. 2013;12(3):542. cle strength measurement in two groups of elite Greco-Roman and
A retrospective analysis.(Research article)(Report). free style wrestlers and a group of non-athletic subjects. Br J Sports
36. Salmon DM, Sullivan SJ, Handcock P, et al. Neck strength and Med. 2005;39(7):440–443.
self-reported neck dysfunction: what is the impact of a season of 50. Ratamess NA. ACSM’s foundations of strength training and condi­
Rugby Union? J Sports Med Physiotherapy Fitness. 2018;58 tioning. American College of Sports Medicine Wolters Kluwer
(7–8):1078–1089. Health/Lippincott Williams & Wilkins; 2013.
37. Snodgrass SJ, Osmotherly PG, Reid SA, et al. Physical characteristics 51. Lisman P, Signorile JF, Del Rossi G, et al. Investigation of the effects of
associated with neck pain and injury in rugby union players. cervical strength training on neck strength, EMG, and head kinematics
J Sports Med Phys Fitness. 2018;58(10):1474–1481. during a football tackle. Int J Sports Sci Eng. 2012;6(3):131–140.
38. Olivier PE, Du Toit DE. Isokinetic neck strength profile of senior elite 52. Schmidt JD, Guskiewicz KM, Blackburn JT, et al. The influence of
rugby union players. J Sci Med Sport. 2008;11(2):96–105. cervical muscle characteristics on head impact biomechanics in
39. Maconi F, Venturelli M, Limonta E, et al. Effects of a 12-week neck football. Am J Sports Med. 2014;42(9):2056–2066.
muscles training on muscle function and perceived level of muscle 53. Mortensen JD, Vasavada AN, Merryweather AS. Sensitivity analysis
soreness in amateur rugby players. Sport Sci Health. 2016;12 of muscle properties and impact parameters on head injury risk in
(443–452):3. American football. J Biomechanics. 2020;100:109411.
40. Konrath J, Appleby B. An investigation of cervical strength and 54. Lark SD, McCarthy PW. Cervical range of motion and propriocep­
anthropometry in professional rugby union players. J Aus tion in rugby players versus non-rugby players. J Sports Sci.
Strength Conditioning Ass. 2012;21:11. 2007;25(8):887–894.
41. Geary GBS, Delahunt E, Delahunt E. Intrarater reliability of neck 55. Fuller C, Taylor A, Douglas M, et al. Rugby world cup 2019 injury
strength measurement of rugby union players using surveillance study. S Afr J Sports Med. 2020;32(1):1.
a handheld dynamometer. J Manipulative Physiol Ther. 56. Le Flao E, Brughelli M, Hume PA, et al. Assessing head/neck
2013;36(7):444–449. dynamic response to head perturbation: a systematic review.
42. Hamilton DF, Gatherer D. Cervical isometric strength and range of Sports Med. 2018;48(11):2641–2658.
motion of elite rugby union players: a cohort study. BioMed Central 57. Neck Muscular HC. Strength, training, performance and sport injury
Sports Sci Med Rehab. 2014;6(1):32. risk: a review. Sports Med. 2016;46(8):1111–1124.