Cervical Endurance Research Articles

Applying Clinical Practice Guidelines on Chronic Headaches, Neck Pain, and Chest Symptoms: A Single Case Report

BACKGROUND: Neck pain and headaches are common conditions in physical therapy practice. Clinical practice guidelines (CPGs) are forms of evidence designed to decrease practice variability and guide care. CPG recommendations are general, with few specific tactics recommended, which could be a factor in their limited adoption and poor application. This case report demonstrates an example of implementing the Academy of Orthopedic Physical Therapy Neck Pain Revision CPG while also highlighting limitations and areas lacking specificity. CASE PRESENTATION: The patient was a 37-year-old female with neck pain, chest pain, and headaches. She was treated following the recommendations within the Academy of Orthopedic Physical Therapy CPG along with psychologically informed practice. The Neck Disability Index (NDI), Patient-Specific Functional Scale, Fear-Avoidance Beliefs Questionnaire, symptoms, and impairments were measured at evaluation, discharge, and 2 months post discharge. OUTCOMES: Clinically meaningful improvements in NDI and Patient-Specific Functional Scale scores, improved cervical endurance, scapular strength, and cervical motor control were observed at discharge. Additional improvements in NDI scores were seen at 2 months post discharge. DISCUSSION: While the CPG promotes the use of manual therapy, exercise, and general screening, the authors demonstrate specific techniques for identifying and managing fear-avoidance behavior with cognitive and graded exposure techniques. JOSPT Cases 2024;4(4):159-166. Epub 18 September 2024. doi:10.2519/josptcases.2024.0025

Performance Optimization and Injury Mitigation for Air Force Student Fighter Pilots.

Military fighter aircrew report high rates of cervical pain and injury. There is currently no consensus regarding the best training methods for this population. Eglin Air Force Base (AFB) and Luke AFB have multidisciplinary teams specializing in aircrew training, performance, and injury mitigation. All student pilots (SPs) completing Basic Course training at these locations engage in an 8-week Spine Training Program (STP). The STP originated at Luke AFB in 2020 and was expanded to Eglin AFB in 2022. The primary aim of this study was to assess whether the STP led to significant changes in the performance measure studied, Cervical Endurance Hold (CEH). Further, this study aimed to determine if the CEH training effect was independent of location of STP administration. We hypothesized that SPs would exhibit statistically significant CEH training adaptations irrespective of base location. Air Force F-16 and F-35 SPs from Luke AFB and Eglin AFB were actively enrolled in the Basic Course and participated in the standardized STP from 2020 to 2023. The CEH test was administered prior to (intake) and following (exit) the 8-week STP. SPSS for Windows version 29 software (IBM, Armonk, NY) was used to retrospectively analyze the data from this study. Participants were excluded if they were unable to perform the CEH test at intake or exit. The study was approved by the Air Force Research Laboratory Institutional Review Board and was performed in accordance with the ethical standards of the Declaration of Helsinki. One hundred and ninety-eight SPs (Luke AFB, males n = 170, females n = 12; Eglin AFB, males n = 16) completed the STP program. There was no significant difference between intake and exit concerning age, height, weight, % body fat, and fat-free mass at Luke AFB or Eglin AFB (P < 0.05). Statistically significant improvements in CEH were observed within all groups from intake to exit (P < 0.001). When considering all participants collectively, there was a notable33.6% increase in CEH from intake to exit (P < 0.001) with an overall effect size of d = 1.14. When analyzing specific subgroups, females from Luke AFB experienced a significant 20.4% increase in CEH (P < 0.001, d = 1.14), males from Luke AFB exhibited a significant 34.5% increase (P < 0.001, d = 1.09), and males from Eglin AFB demonstrated a significant increase of 55.7% in CEH (P < 0.001, d = 1.97). This retrospective analysis showed significant improvements in the CEH across all groups following the completion of the STP. Furthermore, CEH results from both bases exhibited a large effect size indicating a meaningful change was found between intake and exit regardless of training location. These preliminary study results should be interpreted with caution as a control group was unable to be established. In the future, a randomized control trial should be performed to test the STP used in this study against other STP programs. This may better inform experts on the best spine training methods for fighter aircrew.

Reliability and construct validity of the Craniocervical Flexion Test in patients with migraine

BackgroundMigraine may be accompanied by several cervical musculoskeletal dysfunctions, for example an altered performance on the Craniocervical Flexion Test (CCFT). However, CCFT measurement properties are still unclear in patients with migraine. ObjectivesTo determine intra- and inter-examiner reliability, construct validity, standard measurement error (SEM), and minimal detectable change (MDC) of the CCFT in patients with migraine. MethodsWomen diagnosed with migraine were considered eligible for this study. Participants were assessed by two examiners for the inter-examiner reliability, and with 7–10 days interval for the intra-examiner reliability. Construct validity was assessed considering headache and neck pain frequency and intensity, and self-reported questionnaires, including the Headache Impact Test – 6 items (HIT-6), the 12-item Allodynia Symptom Checklist/Brazil (ASC-12), and the Neck Disability Index (NDI). In addition, participants performed cervical endurance and maximal voluntary isometric contraction of the cervical flexors. ResultsA total of 103 women with migraine were recruited. The intra-examiner reliability was rated as good (ICC= 0.81, 95% CI: 0.73, 0.87), while the inter-examiner reliability was rated as moderate (ICC= 0.55, 95% CI: 0.40, 0.67). The intra and inter-examiner SEM were 1.31 and 1.36 mmHg respectively, and MDC were 3.63 and 3.77 mmHg. The HIT-6 and the cervical endurance flexion test were associated with the CCFT in a multiple linear regression model (p = 0.004, R = 0.35). ConclusionThe CCFT presents adequate intra- and inter-examiner reliability. Better performance on the CCFT test was associated with better HIT-6 scores and greater cervical endurance time, which was not influenced by the presence of neck pain.

A Profile of Isometric Cervical Strength in Elite Professional Male Rugby Players.

OBJECTIVES: To (1) provide position-specific normative data for isometric cervical muscle strength and endurance in professional, male rugby players and (2) assess the relationship between age, height, weight, and playing position with cervical muscle strength and endurance. DESIGN: Cross-sectional study. METHODS: Professional rugby players completed peak isometric cervical strength testing followed by a test of cervical muscle endurance. Descriptive statistics for continuous variables with strength normalized to body weight were performed. Multiple linear regression was used to estimate associations between strength measurements. RESULTS: In total, 136 players participated including front-row forwards (27%), other forwards (28%), and backs (45%). Front-row forwards had significantly greater peak isometric cervical muscle strength than other position groups, with backs having the lowest strength. Extension produced the highest force for all 3 position groups (429 N ± 104 N), whereas flexion produced the least (275 N ± 65 N). Age was associated with increased isometric cervical muscle strength. There was a statistically significant relationship between peak flexion strength and flexion endurance (P = .003). The average time for the endurance tests were 55.7 (±17.1) seconds and 52.9 (±20.1) seconds for extension and flexion, respectively. Other forwards had lower cervical extension muscle endurance than backs and front-row forwards. CONCLUSIONS: Normative values for peak and endurance isometric strength in professional rugby players illustrate significant differences between playing position. Consider age, body weight, and intraindividual variability when interpreting cervical strength and endurance results. J Orthop Sports Phys Ther 2024;54(3):1-8. Epub 29 January 2024. doi:10.2519/jospt.2024.11830.

An investigation of the relationship between cervical flexion strength, upper extremity vibration senses, cervical endurance, and cervical incline in patients with Parkinson's disease

An investigation of the relationship between cervical flexion strength, upper extremity vibration senses, cervical endurance, and cervical incline in patients with Parkinson's disease

The effects of myofascial induction therapy in survivors of head and neck cancer: a randomized, controlled clinical trial

PurposeWe aim to evaluate the effects of myofascial induction therapy (MIT) on the sequelae suffered by the survivors of HNC (sHNC).MethodsWe enrolled 46 sHNC in a randomized controlled trial (RCT), of whom 20 received a MIT protocol and 23 were placed on a waitlist while receiving the recommended treatment for 6 weeks. The MIT protocol included a total of 18 sessions, 3 days a week on alternate days for 6 weeks. Maximal mouth opening, the presence of temporomandibular dysfunction, cervical endurance, active range of motion (AROM), shoulder AROM, handgrip strength, and perceived physical fitness were assessed.ResultsMaximal mouth opening, temporomandibular dysfunction, cervical endurance, and AROM, affected shoulder abduction and unaffected shoulder flexion and external rotation significantly improved (p < .05) after an MIT protocol, but only cervical AROM and affected shoulder abduction changes were clinically meaningful. No statistically significant changes were observed in the other shoulder AROM, handgrip strength, or physical fitness perception (p > .05).ConclusionA 6-week MIT protocol improves mouth opening, TMD, cervical function (endurance and AROM), affected shoulder abduction and unaffected shoulder flexion, and external rotation AROM in the sHNC. However, no changes were observed in most of the shoulder AROM, muscular strength, or perceived physical fitness. Future studies should perform longer follow-up designs, increase the sample size, and include multimodal treatments to address these sequelae in the sHNC.

Correlation between kinesiophobia, muscle strength and neck endurance in patients with migraine

IntroductionMigraine is a highly disabling primary headache that can be accompanied by pain and musculoskeletal dysfunction in the cervical region. These individuals with cervical musculoskeletal dysfunction present a greater tendency toward fear and catastrophic thoughts and a greater risk of migraine chronification, developing behaviors such as hypervigilance in order to avoid further injury presenting the fear of movement which can be characterized as kinesiophobia. Kinesiophobia is defined as an "irrational and devastating fear of movement, arising from a belief in the fragility of injury or a fear of re-injury." In addition, kinesiophobia can also be characterized as a fear of symptoms of fatigue or exhaustion, physical or mental discomfort. Individuals with cervical musculoskeletal dysfunctions are more prone to fear and catastrophic thoughts, and have a higher risk of migraine chronification, as well as an overreaction to actual or potential threats, developing behaviors such as hypervigilance in order to avoid further injury. The Kinesiophobia is a prevalent condition in individuals with migraine and the association between the presence of migraine and kinesiophobia has recently been investigated. However, it is not yet known whether there is a correlation between muscle strength and cervical endurance with kinesiophobia. ObjectiveTo evaluate the correlation between muscle strength and neck muscle endurance with kinesiophobia in patients with migraine. Methods Were included 70 women aged between 18 and 55 years, with a mean age of 31 years (SD=9.35; CI=2.19), and a mean body mass index of 23.5 (SD=3.63; CI= 0.85), diagnosed according to the 3rd edition of the ICHD-3. Regarding the clinical characteristics of these patients, they presented headache onset at 14.5 years (SD=9.57; CI=2.24), a frequency of 12 days in the month (SD=9.74; CI=2.28), the intensity of 8/10 on the Numerical Pain Rating Scale (NPRS) (SD=1.60; CI=0.37). (To see the complete abstract, please, check out the PDF).

How does pain influence cervical endurance test performance in migraine patients?

Introduction Migraine sufferers frequently complain of cervical pain during and in-between migraine attacks and studies suggest that chronic neck pain is a risk factor for high-frequency migraine, including chronic migraine. Increased headache frequency and chronic neck pain are, in turn, independently associated with cephalic cutaneous allodynia, a known risk factor for increased headache frequency. Objective To verify the influence that pain in migraine patients has on muscle performace during the cervical endurance test and whether the change in performance is due to pain during the test, neck muscle dysfunction or both. Methods Were evaluate 100 women stratified by diagnosis (migraine, cervical pain, both and none) and self-reported pain during the cervical muscle endurance test in flexion and extension (with or without headache and / or cervical pain during the endurance test). Pain during the test by numerical rate scale (NPRS, 0-10) and pain pressure threshold were collected for all groups. Migraine patients answered 12-item Allodynia Symptom. We used one-way analysis of variance with the Tukey’s HSD post hoc test analysis to contrast pressure pain threshold and endurance across groups. Differences in flexion and extension times were compared using the Welch T-test and the McNemar Test was used to compare differences in headache and neck pain incidence per study group during flexion and extension endurance tests. Results There are significantly differences in mean endurance during flexion between migraine and neck pain [34.4s (25)] relative to neck pain alone [45.2 (18)], migraine [40.2s (29)] and controls [57.5.4s (40)] (p = 0.04). On average, those who experienced headache during the flexion test sustained for significantly less time than those without headache during the test (27.80 versus 46.18 seconds, p&lt;0.01); (To see the complete abstract, please, check out the PDF).

Evaluation of Cervical Endurance by Craniocervical Flexion Test in Patients with Subacromial Impingement Syndrome: A Preliminary Study

Aim: The aim of the study is to evaluate deep cervical flexor endurance in patients with subacromial impingement syndrome (SIS) and compare it with norm values proven in the literature in asymptomatic individuals. &#x0D; Materials and Methods: The patients’ age, weight, height, duration of complaints and dominant side information were recorded. 35 patients (25 female, 10 male) diagnosed with SIS by physicians participated in the study. Pain intensity was evaluated by numerical rating scale at rest, during elevation and at night. Craniocervical flexion test (CFT) is used for evaluating cervical endurance. “Stabilizer Pressure Biofeedback” device is used for this test. Two types of points are obtained as a result of this test. One is the CFT activation score, which expresses the activation level of the deep cervical muscles, and the other is the CFT performance index, which expresses the endurance of the deep cervical muscles. &#x0D; Results: Both the activation score (3.9±1.9) and the performance index (31.4±14.2) of CFT were significantly different in patients with SIS when compared with those of asymptomatic individuals.&#x0D; Conclusion: Cervical endurance is reduced in patients with SIS. Treatments including cervical stabilization should be planned in these patients.

Craniocervical and Cervical Spine Features of Patients with Temporomandibular Disorders: A Systematic Review and Meta-Analysis of Observational Studies.

To assess neck disability with respect to jaw disability, craniocervical position, cervical alignment, and sensorimotor impairments in patients with temporomandibular disorders (TMD), a systematic review and meta-analysis of observational studies trials were conducted. The meta-analysis showed statistically significant differences in the association between neck disability and jaw disability (standardized mean difference (SMD), 0.72 (0.56–0.82)). However, results showed no significant differences for cervical alignment (SMD, 0.02 (−0.31–0.36)) or for the craniocervical position (SMD, −0.09 (−0.27–0.09)). There was moderate evidence for lower pressure pain thresholds (PPT) and for limited cervical range of motion (ROM). There was limited evidence for equal values for maximal strength between the patients with TMD and controls. There was also limited evidence for reduced cervical endurance and conflicting evidence for abnormal electromyographic (EMG) activity and motor control in TMD patients. Results showed a clinically relevant association between cervical and mandibular disability in patients with TMD. Regarding sensory-motor alterations, the most conclusive findings were observed in the reduction of PPT and cervical ROM, with moderate evidence of their presence in the patients with TMD. Lastly, the evidence on impaired motor control and cervical EMG activity in patients with TMD was conflicting.

Effect of MaRhyThe versus myofascial mobility tool in female individuals with or without neck pain having forward head posture and buffalo hump – A randomized clinical trial

Background and Objectives: Prolonged forward head posture (FHP) leads to the development of buffalo hump (BH) at the base of the posterior neck, predominantly seen in females. MaRhyThe (MRT) and myofascial mobility tool (M2T) are novel physiotherapy methods applied in various soft-tissue disorders. A dearth of literature exists about using these methods for the treatment of BH and FHP. Hence, the aim of the present study was to compare the effects of MRT and M2T in female individuals having FHP and BH. Materials and Methods: The study was a randomized clinical trial. Twenty female were randomly allocated to Group A (n = 10) and Group B (n = 10) who received MRT and M2T, respectively. The primary outcomes assessed included craniovertebral angle (CVA), neck circumference (NC), and skinfold measure. The secondary outcomes were cervical endurance and range of motion that were assessed on day 1 (pre) and day 10 (post). Exercise and study intervention (MRT/M2T) were given alternately for 10 days. Results: All the primary and secondary outcome parameters analyzed at days 1 and 10 showed statistically significant results for both the study groups (P Conclusion: Both MRT and M2T interventions were effective in reducing the BH and correction of FHP in addition to improving cervical mobility and endurance. However, MRT proved to be superior to M2T in terms of correction of FHP and reduction of the BH.

Exploring the role of cervical spine endurance as a predictor of concussion risk and recovery following sports related concussion

BackgroundConcussions have become a significant public health concern with rising incidence rates. Concussions have been shown to occur concurrently with neck injuries, such as whiplash-associated-disorder, therefore, understanding the role of the neck in concussions is important. ObjectivesTo determine if there is a relationship between cervical muscle endurance and either concussion incidence, or concussion recovery in university athletes. Specifically, the primary aim was to investigate a relationship between pre-season deep neck flexor endurance test (DNFET) time in those who sustained an in-season injury versus those who did not. The secondary aim is to determine correlation in DNFET times and concussion recovery. DesignLongitudinal observational study. MethodsPre-season DNFET was performed on university athletes. In the event of a concussion, cervical endurance and neuromuscular adaptation was re-assessed with the DNFET. Rehabilitative exercises were prescribed, as required, and DNFET was measured at subsequent treatments. ResultsThere was no significant difference between pre-season DNFET times and concussion incidence (p = 0.55). However, there was a moderate correlation between DNFET times and concussion recovery (R = 0.47, p = 0.001) whereby DNFET times improved predictively throughout rehabilitation. ConclusionsWhile no statistically significant relationship was found between DNFET and concussion incidence, a significant clinical relationship was present with recovery. The validity of the DNFET test as a means for assessing risk or measuring recovery requires additional research.

Effects of deep cervical flexor training on impaired physiological functions associated with chronic neck pain: a systematic review

BackgroundNeck pain is a major health issue with high rates of recurrence. It presents with a variety of altered sensorimotor functions. Exercise is a cornerstone of rehabilitation and many training methods are used. Exercise is evaluated in most randomized controlled trials on its pain relieving effects. No review has assessed the effect of exercise on the altered physiological functions or determined if there are differential effects of particular training methods. This review investigated the effects of deep cervical flexor (DCF) training, a training method commonly used for patients with neck pain, and compared it to other training methods or no training on outcomes of cervical neuromuscular function, muscle size, kinematics and kinetics.MethodsWeb of Science, Scopus, CINAHL, PubMed were searched from inception until January 2018. Twelve randomized controlled trials were included that compared DCF training as sole intervention to other training or no interventions in persons with neck pain. The Cochrane Risk of Bias tool was used to assess the method quality. All outcome measures were analysed descriptively and meta-analyses were performed for measures evaluated in three or more studies.ResultsDCF training was compared to cervical endurance, strength, proprioception and mobility training, muscle stretching, and no intervention control groups. Physiological outcome measures included neuromuscular co-ordination (craniocervical flexion test), functional tasks, muscle fatigability, muscle size, kinematics (joint position sense, posture and range of motion) and kinetics (strength, endurance and contraction accuracy). Strong evidence was found for effectiveness of DCF training on neuromuscular coordination, but it had no or small effects on strength and endurance at higher loads. DCF training improved head and cervical posture, while evidence was limited or contradictory for other measures.ConclusionsDCF training can successfully address impaired neuromuscular coordination, but not cervical flexor strength and endurance at higher contraction intensities. A multimodal training regime is proposed when the aim is to specifically address various impaired physiological functions associated with neck pain.

Is forward head posture relevant to cervical muscles performance and neck pain? A case–control study

BackgroundForward head posture (FHP) and muscular dysfunction are likely contributing factors to chronic neck pain (CNP) but there are inconsistent findings on the relevance of these factors to clinical CNP characteristics. ObjectiveTo compare FHP, cervical muscles size and endurance between CNP and asymptomatic participants and to investigate their association with pain and disability and relative involvement of deep/superficial and flexor/extensor muscles. MethodsThirty-two patients with CNP and 35 asymptomatic participants were included in this case–control study. FHP in standing, extensor and flexor muscles endurance and dimensions were assessed using digital photography, clinical tests and ultrasonographic imaging, respectively. The visual analog scale and neck disability index were also used to evaluate CNP patients’ clinical characteristics. ResultsDeep flexor (mean difference=0.06, 95% CI=0.02–0.11) and extensor muscles size (mean difference=0.07, 95% CI=0.01–0.12) were found to be significantly smaller in CNP patients. CNP patients also demonstrated lower levels of flexor (mean difference=14.68, 95% CI=3.65–25.72) and global extensor endurance capacity. FHP was neither different between the groups nor correlated with any of the dependent variables. Neither FHP nor endurance was correlated with pain/disability. Extensor endurance in both groups and flexor endurance in the asymptomatic group showed significant correlations with muscles size. ConclusionsFHP was found neither different between groups nor correlated with muscle performance or CNP clinical characteristics. While cervical endurance was found lower in CNP patients, it did not show any association with pain/disability. The muscular size–endurance relationship seems to become more complex in the presence of NP. While deep muscles seem to be differentially affected in the presence of CNP, the alterations do not seem to be uniform in the flexor and extensor groups.

EFFECT OF THE CERVICAL ENDURANCE TRAINING PROGRAMME IN MECHANICAL NECK PAIN

Background:&nbsp;Mechanical neck pain commonly arises insidiously and is generally multifactorial in origin. Regardless of the primary source of pain, the prognosis for individual experiencing chronic neck pain is poor. Exercise interventions are important for effective management of patients with neck pain.the objective of the study is to compare the efficacy of cervical endurance training programme with cervical isometric exercise in alleviating symptoms of mechanical neck pain.Methods: 40 subjects were assessed and identified with Mechanical Neck Pain and recruited for the study and were randomly divided into two groups. In one group endurance training for cervical muscles and in another group resisted isometric had been given for 3 weeks. The post treatment scores regarding endurance, pain intensity, disability, Range of motion and muscle power were compared with the pre treatment scores.Results:&nbsp;Paired‘t’ test was done to compare the pretreatment scores with the post treatment scores .Unpaired ‘t’ test was done to compare the post treatment scores of both the groups. The pain intensity, disability were found to be significantly decreased in experimental group than the control group (p&lt;0.001). While the endurance was found to be significantly increased in experimental group than the control group (p &lt; 0.001). The muscle power was found to be slightly increased in the control group than the experimental group .The post treatment cervical range of motion does not have significant difference in between the groups (Flexion- p=0.35 and Extension-p=0.40).Conclusion:&nbsp;This study showed that the progressive endurance exercise is beneficial in alleviating mechanical neck pain and should be incorporated along with the conventional physiotherapy treatment for mechanical neck pain.

ARE CLINICAL MEASURES OF CERVICAL SPINE STRENGTH AND CERVICAL FLEXOR ENDURANCE RISK FACTORS FOR CONCUSSION IN ELITE YOUTH ICE HOCKEY PLAYERS?

BackgroundSymptoms of dizziness, neck pain and headaches have previously been identified as risk factors for concussion. Clinical measures associated with these symptoms have not previously been evaluated as risk factors...

The relationship between cervical flexor endurance, cervical extensor endurance, VAS, and disability in subjects with neck pain

BackgroundSeveral tests have been suggested to assess the isometric endurance of the cervical flexor (NFME) and extensors (NEE) muscles. This study proposes to determine whether neck flexors endurance is related to extensor endurance, and whether cervical muscle endurance is related to disability, pain amount and pain stage in subjects with neck pain.MethodsThirty subjects (18 women, 12 men, mean ± SD age: 43 ± 12 years) complaining of neck pain filled out the Visual Analogue Scale (VAS) and the Neck Pain and Disability Scale-Italian version (NPDS-I). They also completed the timed endurance tests for the cervical muscles.ResultsThe mean endurance was 246.7 ± 150 seconds for the NEE test, and 44.9 ± 25.3 seconds for the NMFE test. A significant correlation was found between the results of these two tests (r = 0.52, p = 0.003). A positive relationship was also found between VAS and NPDS-I (r = 0.549, p = 0.002). The endurance rates were similar for acute/subacute and chronic subjects, whereas males demonstrated significantly higher values compared to females in NFME test.ConclusionsThese findings suggest that neck flexors and extensors endurance are correlated and that the cervical endurance is not significantly altered by the duration of symptoms in subjects with neck pain.