I’ve Returned and So Apparently Are the Neck Multifidus Muscles after Exercise!

I’ve been out for six weeks sailing the Med. It was another great trip and a much-needed break for an old guy! Today, let’s cover a new study that shows that cervical multifidus muscle atrophy can be recovered with exercise.

Getting Back

If you recall, we are on a four-year journey to sail the Mediterranean, Adriatic, and Aegean seas. My wife and I do that in two 6-week clips on the shoulder seasons in the late spring and early fall each year. At first, this was drinking from a fire hose as there was an incredible amount to learn, but now we’re very comfortable.

On this trip, we left Valencia and sailed along the rest of southern Spain into the south of France, Monaco, and finally, northern Italy. Above are some of my favorite pics. If you’re interested in where we went and what we did, I have an Instagram account that I only use to document our sailing voyages; see https://www.instagram.com/chriscenteno541/.

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Multifidus Atrophy

The multifidus is the primary stabilizing muscle of the spine. It’s responsible for actively protecting the facet joints, discs, and nerves. The muscle can atrophy after neck or back trauma, and this can lead to active instability that can be the beginning of the degenerative cascade causing pain (4-12). While multifidus atrophy is easy to see on MRI and has been associated with headaches, neck, and back pain, regrettably, this finding is often not read by reading radiologists. So, to see if you have it, you must learn how to read your images for this finding.

Here are some videos I did that show you how to read your images for this abnormality:

I have also previously highlighted some exciting work showing that inflammatory cytokines are ramped up in these atrophied multifidus muscles (15). What’s not known is whether this is cause or effect.

Can Atrophy of the Multifidus Be Recovered with Physical Therapy?

The US healthcare system spends hundreds of billions annually treating back and neck pain. So, getting the multifidus muscle back is a multi-billion-dollar question. Is it possible?

A small 2019 study examined intensive exercise for patients with multifidus atrophy and low back pain (1). While the group of 14 patients as a whole didn’t show differences in their atrophy, the patients who did show improvements had better pain/functional results. A tiny retrospective pilot study also showed improvements with exercise in a handful of patients (2).

That’s about it; not much has been published on conservative exercise-based treatment for multifidus atrophy.

Restoring the Atrophied Cervical Multifidus with Exercise

I’ve highlighted the work of Jim Elliott, PT, Ph.D., on this blog. In this new research, five women with cervical multifidus atrophy had pre and post-MRIs and underwent ten weeks of neck strengthening. As a result, there was a mean improvement in multifidus atrophy as seen on MRI, measured by larger spinal stabilizers and less fatty infiltration in the multifidus. Those changes coincided with less pain and better physical function.

It’s important to note that while we have 100+ studies showing that multifidus atrophy is associated with headaches, neck and back pain, we have only small preliminary studies showing the effects of physical therapy on the condition. This severe discrepancy between knowing there is a problem and how best to fix it remains concerning.

There have been other approaches to helping this problematic atrophy. For example, a large case series out of the Middle East showed that injecting PRP into the atrophied multifidus also seemed to improve the MRI appearance of this fatty infiltration (16). Also, an RCT has recently been published using an implantable stimulator to help low back multifidus atrophy patients with excellent, durable pain/functional results but no tracking of MRI fatty infiltration (16).

The upshot? We are just beginning to see preliminary evidence that exercise can treat multifidus atrophy in selected patients. Hopefully, we’ll see better treatment research on this critical and ubiquitous clinical condition.



  1. Berry DB, Padwal J, Johnson S, Englund EK, Ward SR, Shahidi B. The effect of high-intensity resistance exercise on lumbar musculature in patients with low back pain: a preliminary study. BMC Musculoskelet Disord. 2019 Jun 18;20(1):290. doi: 10.1186/s12891-019-2658-1. PMID: 31208400; PMCID: PMC6580468.
  2. Woodham M, Woodham A, Skeate JG, Freeman M. Long-term lumbar multifidus muscle atrophy changes documented with magnetic resonance imaging: a case series. J Radiol Case Rep. 2014 May 31;8(5):27-34. doi: 10.3941/jrcr.v8i5.1401. PMID: 25426227; PMCID: PMC4242062.
  3. O’leary S, Jull G, Van Wyk L, Pedler A, Elliott J. Morphological changes in the cervical muscles of women with chronic whiplash can be modified with exercise-A pilot study. Muscle Nerve. 2015 Nov;52(5):772-9. doi: 10.1002/mus.24612. Epub 2015 Sep 3. PMID: 25702919; PMCID: PMC4545448.
  4. Seyedhoseinpoor T, Taghipour M, Dadgoo M, Sanjari MA, Takamjani IE, Kazemnejad A, Khoshamooz Y, Hides J. Alteration of lumbar muscle morphology and composition in relation to low back pain: a systematic review and meta-analysis. Spine J. 2022 Apr;22(4):660-676. doi: 10.1016/j.spinee.2021.10.018. Epub 2021 Oct 27. PMID: 34718177.
  5. Kader DF, Wardlaw D, Smith FW. Correlation between the MRI changes in the lumbar multifidus muscles and leg pain. Clin Radiol. 2000 Feb;55(2):145-9. doi: 10.1053/crad.1999.0340. PMID: 10657162.
  6. Goubert D, De Pauw R, Meeus M, Willems T, Cagnie B, Schouppe S, Van Oosterwijck J, Dhondt E, Danneels L. Lumbar muscle structure and function in chronic versus recurrent low back pain: a cross-sectional study. Spine J. 2017 Sep;17(9):1285-1296. doi: 10.1016/j.spinee.2017.04.025. Epub 2017 Apr 26. PMID: 28456669.
  7. Fernández-de-Las-Peñas C, Bueno A, Ferrando J, Elliott JM, Cuadrado ML, Pareja JA. Magnetic resonance imaging study of the morphometry of cervical extensor muscles in chronic tension-type headache. Cephalalgia. 2007 Apr;27(4):355-62. doi: 10.1111/j.1468-2982.2007.01293.x. PMID: 17376113.
  8. Elliott JM, Pedler AR, Jull GA, Van Wyk L, Galloway GG, OʼLeary SP. Differential changes in muscle composition exist in traumatic and nontraumatic neck pain. Spine (Phila Pa 1976). 2014 Jan 1;39(1):39-47. doi: 10.1097/BRS.0000000000000033. PMID: 24270932.
  9. Uthaikhup S, Assapun J, Kothan S, Watcharasaksilp K, Elliott JM. Structural changes of the cervical muscles in elder women with cervicogenic headache. Musculoskelet Sci Pract. 2017 Jun;29:1-6. doi: 10.1016/j.msksp.2017.02.002. Epub 2017 Feb 22. PMID: 28259769.
  10. Higgins JP, Elliott JM, Parrish TB. Brain Network Disruption in Whiplash. AJNR Am J Neuroradiol. 2020 Jun;41(6):994-1000. doi: 10.3174/ajnr.A6569. Epub 2020 Jun 4. PMID: 32499250; PMCID: PMC7342774.
  11. Paliwal M, Weber KA 2nd, Smith AC, Elliott JM, Muhammad F, Dahdaleh NS, Bodurka J, Dhaher Y, Parrish TB, Mackey S, Smith ZA. Fatty infiltration in cervical flexors and extensors in patients with degenerative cervical myelopathy using a multi-muscle segmentation model. PLoS One. 2021 Jun 25;16(6):e0253863. doi: 10.1371/journal.pone.0253863. PMID: 34170961; PMCID: PMC8232539.
  12. Elliott JM, Courtney DM, Rademaker A, Pinto D, Sterling MM, Parrish TB. The Rapid and Progressive Degeneration of the Cervical Multifidus in Whiplash: An MRI Study of Fatty Infiltration. Spine (Phila Pa 1976). 2015 Jun 15;40(12):E694-700. doi: 10.1097/BRS.0000000000000891. PMID: 25785961; PMCID: PMC4466088.
  13. Elliott JM, O’Leary S, Sterling M, Hendrikz J, Pedler A, Jull G. Magnetic resonance imaging findings of fatty infiltrate in the cervical flexors in chronic whiplash. Spine (Phila Pa 1976). 2010 Apr 20;35(9):948-54. doi: 10.1097/BRS.0b013e3181bb0e55. PMID: 20118837.
  14. Elliott JM, Galloway GJ, Jull GA, Noteboom JT, Centeno CJ, Gibbon WW. Magnetic resonance imaging analysis of the upper cervical spine extensor musculature in an asymptomatic cohort: an index of fat within muscle. Clin Radiol. 2005 Mar;60(3):355-63. doi: 10.1016/j.crad.2004.08.013. PMID: 15710139.
  15. James, G., Chen, X., Diwan, A. et al. Fat infiltration in the multifidus muscle is related to inflammatory cytokine expression in the muscle and epidural adipose tissue in individuals undergoing surgery for intervertebral disc herniation. Eur Spine J 30, 837–845 (2021). https://doi.org/10.1007/s00586-020-06514-4
  16. Gilligan C, Volschenk W, Russo M, Green M, Gilmore C, Mehta V, Deckers K, De Smedt K, Latif U, Sayed D, Georgius P, Gentile J, Mitchell B, Langhorst M, Huygen F, Baranidharan G, Patel V, Mironer E, Ross E, Carayannopoulos A, Hayek S, Gulve A, Van Buyten JP, Tohmeh A, Fischgrund J, Lad S, Ahadian F, Deer T, Klemme W, Rauck R, Rathmell J, Schwab F, Maislin G, Heemels JP, Eldabe S. Three-Year Durability of Restorative Neurostimulation Effectiveness in Patients With Chronic Low Back Pain and Multifidus Muscle Dysfunction. Neuromodulation. 2023 Jan;26(1):98-108. doi: 10.1016/j.neurom.2022.08.457. Epub 2022 Sep 27. Erratum in: Neuromodulation. 2023 Aug;26(6):1272-1273. PMID: 36175320.
Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile

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