Craniocervical Flexion Research Articles

The Importance of Optimal Gaze Direction on Deep Neck Flexor Activation in Chronic Neck Pain.

Chronic neck pain (CNP) patients have weak deep neck flexors (DNF) and a hyperactive sternocleidomastoid (SCM). The cranio-cervical flexion test (CCFT) promotes activation of the DNF and decreases activity of the SCM, promoting pain recovery, but research suggests SCM activation increases with increasing gaze direction. We aimed to investigate how DNF and SCM activation varies according to gaze direction in the CCFT, and to prescribe the appropriate gaze direction for CNP. Twenty-eight CNP subjects had their maximum strength pressure level determined by CCFT for strength (20–~30 mmHg) and at each of the measured pressures, DNF and SCM thickness in each of four gaze directions (0°, 20°, 40°, and 60°) was measured by ultrasound imaging. The DNF to SCM ratio varied significantly according to gaze direction (p < 0.05), with gaze directions of 20° and 0° being significantly different from 40° (p < 0.05). Although there was no significant difference in DNF activation according to gaze direction, there was in SCM activation (p < 0.05), with SCM 60° significantly different from SCM 20° and SCM 40° (p < 0.05). In order to increase DNF activation efficiency during the CCFT, SCM activation should be controlled, and a gaze direction below 20° is the most efficient. This can inform DNF training of CNP patients in a clinical environment.

Immediate Effect of Cervico-thoracic Mobilization on Deep Neck Flexors Strength in Individuals with Forward Head Posture: A Randomized Controlled Trial

ABSTRACT Introduction Forward head posture is the most frequently observed postural deviations and is said to be associated with shortening of posterior cervical extensors and weakening of the anterior deep cervical flexors. Manual therapy has the potential to achieve reflexogenic changes in muscle and enhance the motor activity and strength. Purpose of the study To evaluate the immediate effect of grade IV cervicothoracic Maitland mobilization on deep neck flexors strength in individuals with forward head posture. Study design A Single-blinded randomized placebo-controlled trial. Method Sixty individuals were randomly divided into two groups. Placebo-controlled (PBO) group (n = 30) received the grade I and experimental (EXP) group (n = 30) received grade IV posteroanterior central and unilateral Maitland mobilization from the upper cervical to the upper thoracic spine. Outcome measure: Clinical Cranio-cervical flexion test (CCFT) was used to measure the motor activity and the strength of deep neck flexors. Results The strength of deep neck flexors effectively increased (p = <0.0001) after advocating grade IV mobilization. Conclusion This study concluded that grade IV central and unilateral posteroanterior Maitland mobilization demonstrated significant increase in the deep neck flexors strength in individuals with forward head posture.

Immediate effect of kinesio taping on deep cervical flexor endurance: A non-controlled, quasi-experimental pre-post quantitative study

ABSTRACT Objective Whether Kinesio taping® (KT) might change the endurance of the cervical deep flexor muscles.Methods: Healthy university students were assessed at baseline, immediately after the KT application over the posterior cervical muscles, and at a 24-h follow-up. The clinical assessment of the endurance of the deep cervical flexor muscles using the craniocervical flexion test (CCFT) was performed.Results: Sixty-two students (32 women) with a mean age of 20.4 ± 1.3 years completed the study protocol. Statistically significant pre- to post-taping differences in performance of the craniocervical flexion movement were found between baseline-immediate and baseline-24-h follow-up (p˂0.001). A statistically significant difference in the endurance of the cervical deepflexor muscles was found between baseline-immediate (for stage 2 result and cumulative endurance score), baseline-24-h follow-up (for stage 2result and cumulative endurance score), and immediate-24-h follow-up (for stage 2 result, for cumulative endurance score) p˂0.01.Conclusion: Cervical KT increased endurance for the short term.

Does the Addition of Manual Therapy Approach to a Cervical Exercise Program Improve Clinical Outcomes for Patients with Chronic Neck Pain in Short- and Mid-Term? A Randomized Controlled Trial.

Chronic neck pain is one of today’s most prevalent pathologies. The International Classification of Diseases categorizes four subgroups based on patients’ associated symptoms. However, this classification does not encompass upper cervical spine dysfunction. The aim is to compare the short- and mid-term effectiveness of adding a manual therapy approach to a cervical exercise protocol in patients with chronic neck pain and upper cervical spine dysfunction. Fifty-eight subjects with chronic neck pain and upper cervical spine dysfunction were recruited (29 = Manual therapy + Exercise; 29 = Exercise). Each group received four 20-min sessions, one per week during four consecutive weeks, and a home exercise regime. Upper flexion and flexion-rotation test range of motion, neck disability index, craniocervical flexion test, visual analogue scale, pressure pain threshold, global rating of change scale, and adherence to self-treatment were assessed at the beginning, end of the intervention and at 3- and 6-month follow-ups. The Manual therapy + Exercise group statistically improved short- and medium-term in all variables compared to the Exercise group. Four 20-min sessions of Manual therapy + Exercise along with a home-exercise program is more effective in the short- to mid-term than an exercise protocol and a home-exercise program for patients with chronic neck pain and upper cervical dysfunction.

Evaluation of a Cervical Stabilization Exercise Program for Pain, Disability, and Physical Impairments in University Violinists with Nonspecific Neck Pain.

Cervical stabilization exercises are frequently used to reduce pain, maximize function, and improve physical impairments for people with nonspecific neck pain. We conducted a single arm study to evaluate the effects of a home-based cervical stabilization exercise program for university violin players with nonspecific neck pain who frequently assume an asymmetrical neck posture and activate their superficial cervical flexors to stabilize the violin. Twenty violin players with nonspecific neck pain from university symphony orchestras participated in this study. All participants received assessments twice before the intervention and once immediately after a 6-week cervical stabilization exercise program. No significant differences were found between the two pretests before the intervention. After the intervention, the Numeric Rating Scale, the Neck Disability Index, the craniocervical flexion test, muscle endurance tests, cervical range of motion (all directions except flexion) tests, and cervicocephalic relocation tests (flexion and left rotation) showed improvements. The forward head posture indicated by the craniovertebral angle also slightly improved. The results of this single arm study suggest that cervical stabilization exercise is feasible and has the potential to improve physical health for collegiate violin players with nonspecific neck pain.

Effects of Neuromuscular Electrical Stimulation (NMES) Plus Upper Cervical Spine Mobilization on Forward Head Posture and Swallowing Function in Stroke Patients with Dysphagia.

After a stroke, forward head posture occurs, resulting in swallowing dysfunction. Neuromuscular electrical stimulation (NMES) combined with upper cervical spine mobilization has demonstrated enhanced recovery of the swallowing function in stroke patients. This study investigated the therapeutic effects of NMES in conjunction with upper cervical mobilization in stroke patients with dysphagia. Thirty-four stroke patients were recruited (in a randomized controlled clinical trial) and divided into an experimental group (n = 17; NMES plus upper cervical spine mobilization) and a control group (n = 17; NMES plus sham mobilization). Forward head posture was measured by craniocervical flexion test (CCFT) and craniovertebral angle (CVA). Swallowing function was measured by variations in video fluoroscopic dysphagia scale (VDS) and penetration–aspiration scale (PAS) scores using the video fluoroscopic swallowing study (VFSS). All measurements were done at baseline and after four weeks of NMES plus mobilization. A significant increase was observed in CCFT, CVA, VDS (total VDS score, oral stage score, pharyngeal stage score), and PAS score in all variations in the experimental group. The CCFT, CVA, pharyngeal stage score, total VDS, and PAS score were significantly higher in the experimental group when compared to the control group. NMES plus upper cervical spine mobilization can be regarded as a promising method to improve swallowing function and forward head posture changes in stroke patients with dysphagia.

Women with mechanical neck pain exhibit increased activation of their superficial neck extensors when performing the cranio-cervical flexion test

BackgroundSeveral studies have analysed the activity of superficial neck flexors, but the activity of neck extensors has been less investigated in patients with neck pain Objectives1, to investigate the differences in the activation of superficial neck flexor and extensor musculature during the cranio-cervical flexion test (CCFT) in women with mechanical chronic neck pain when compared to asymptomatic women; 2, to investigate the correlation between neck muscle activity and the clinical features of neck pain DesignCross-sectional MethodsSurface electromyography was recorded bilaterally from the sternocleidomastoid, anterior scalene, splenius capitis, and upper trapezius muscles of 30 women with mechanical chronic neck pain and 30 asymptomatic women as they performed the CCFT. Comparisons of the normalized root mean square between both groups were conducted with 2x5 ANCOVA with task level as the within-subjects variable, group as the between-subjects variable, and pain related-disability as a co-variate ResultsWomen with mechanical neck pain exhibited increased activity of superficial neck flexors (sternocleidomastoid: F = 14.448, P < 0.001; anterior scalene: F = 21.693, P < 0.001) and superficial neck extensors (splenius capitis: F = 4.692, P < 0.001; upper trapezius: F = 4.245, P < 0.001) as compared to asymptomatic women. Higher pain related-disability was associated with more electrical activity of the anterior scalene and upper trapezius muscles during the CCFT ConclusionsWomen with mechanical chronic neck pain exhibit an increased activity of their superficial neck flexors and superficial neck extensors during a low-load task such as CCFT when compared to asymptomatic pain-free women. Our results should be considered when designing therapeutic exercise programs for this population.

Relationship between specific temporomandibular disorders and impaired upper neck performance.

Upper neck impairments are more prevalent in patients with temporomandibular disorders (TMDs) but the differences between specific types of TMDs are unclear. This study evaluated the distribution of such impairments among different forms of TMD. In total, 116 participants (86 women and 30 men, age range 21-75yr) were investigated. Forty-two individuals had no TMDs and were assigned to the control group. The remaining 74 patients were assigned to one of three groups based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) findings: pain-related (n=37); intra-articular (n=17); or mixed (combined pain-related and intra-articular) (n=20). Analyses of impairments included between-group comparisons of key parameters of upper neck performance (active/passive mobility and muscular capabilities) and pain (subjective neck disability and pain sensitivity). Patients in the pain-related and mixed TMD groups were found to have decreased upper neck mobility in the cervical flexion-rotation test compared with patients in intra-articular and control groups, as well as poorer capabilities of the deep neck flexor muscles in the cranio-cervical flexion test compared to the control group. It was concluded that patients with pain-related TMD diagnoses are more likely to experience significant upper-neck hypomobility and poor muscular capabilities than patients with intra-articular diagnoses of TMD.

Reliability and discriminative validity of a screening tool for the assessment of neuromuscular control and movement control in patients with neck pain and healthy individuals

Background To evaluate the reliability and discriminative validity of a proposed adapted tool for the assessment of movement control in patients with and without neck pain. Method A cross-sectional study at a University hospital center involving 25 pain-free healthy controls and 25 patients suffering from neck pain. Participants were assessed by two raters for inter-rater reliability and 1 week afterwards by a same rater for intra-rater reliability. The assessment involved a test for the axioscapular (adapted scapular holding test; SHT) and craniocervical (adapted craniocervical flexion test; CCFT) region for which intra-class correlation coefficients (ICCs) were computed to define the reliability. Discriminative validity to distinguish patients from controls was assessed by cross-validated computation of sensitivity, specificity, positive and negative likelihood ratios, overall accuracy, and area under the curve. Results The proposed tool was able to reliably assess sensorimotor impairment in participants at the craniocervical region (ICCintra = [0.52–0.82]; ICCinter = [0.60–0.85]), left axioscapular region (ICCintra = [0.43–0.77]; ICCinter = 0.71–0.90), and right axioscapular region (ICCintra = [0.47–0.79]; ICCinter = [0.42–0.77]). Furthermore, the tool yielded a sensitivity of 0.86, a specificity of 0.57, and accuracy of 0.71 (based on cross-validation). Conclusion The proposed tool is able to reliably evaluate patients based on their sensorimotor performance in the craniocervical and axioscapular region. Implications for rehabilitation Neck pain is related to sensorimotor impairment including neuromuscular differences and atypical sensormimotor control strategies. Clinicians should not avoid the challenging task of screening for sensorimotor impairment in patients reporting neck pain. The proposed tool supplemented with other tools might guide clinicians in the evaluation of sensorimotor impairment.

Effects of Cervical Mobilization and Craniocervical Flexion Exercise on the Dynamic Balance and Gait Variability in Chronic Neck Pain Patients: Randomized Controlled Trial

Effects of Cervical Mobilization and Craniocervical Flexion Exercise on the Dynamic Balance and Gait Variability in Chronic Neck Pain Patients: Randomized Controlled Trial

Effect of Core Stability Exercise in Patients with Neckpain

Background: Pain is the most common symptom of which the human kind complaints. Neck pain is thesecond common condition cause of time off work after low back pain. According to 18% of the responders,the cause of their symptoms was unknown. The most frequently reported causes were ascribed to workingconditions (29%), tension: stress (29%) and a poor posture (21%). Sitting at work for more than 95% of theworking time seems to be a risk factor for neck pain.Aims and Objectives: To study the effectiveness of conventional physical therapy in patients with neckpain and to study the additive effect of core stability exercises on conventional physical therapy in patientswith neck pain.Materials and Methods: Study included 30 (Thirty) patients with chronic case of non-specific neck painbetween age group of 18-40 years. They were divided into 2 groups: Group A (Conventional therapy +Core stability exercises group) included 15 patients and Group B (Conventional therapy group) included 15patients by random sampling. The patients were treated for a period of 1 month. Pain was assessed by VisualAnalogue Scale, neck function was measured by Neck Disability Index and deep neck flexor strength wasmeasured by craniocervical flexion test.Results: Results showed that there was significant difference in VAS (P< 0.0001), NDI (P=0.002) and deepneck flexor strength (p< 0.0001) between Group A and B.Conclusion: Core stability exercise along with conventional physiotherapy was found to be more effectivein patients with chronic non-specific neck pain. So, these interventions can be applied in clinical setup incombination with conventional treatment for the better and long term improvements.

Measurement Properties of the Craniocervical Flexion Test: A Systematic Review.

Patients with neck pain commonly have altered activity of the neck muscles. The craniocervical flexion test (CCFT) is used to assess the function of the deep neck flexor muscles in patients with musculoskeletal neck disorders. Systematic reviews summarizing the measurement properties of the CCFT are outdated. The objective of this study was to systematically review the measurement properties of the CCFT for assessing the deep neck flexor muscles. The data sources MEDLINE, EMBASE, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Trials, Scopus, and Science Direct were searched in April 2019. Studies of any design that reported at least 1 measurement property of the CCFT for assessing the deep neck flexor muscles were selected. Two reviewers independently extracted data and rated the risk of bias of individual studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk-of-bias checklist. The overall rating for each measurement property was classified as "positive," "indeterminate," or "negative." The overall rating was accompanied with a level of evidence. Fourteen studies were included in the data synthesis. The ratings were positive, and the level of evidence was moderate for interrater and intrarater reliability and convergent validity. There was conflicting rating and level of evidence for discriminative validity. Measurement error was indeterminate, with an unknown level of evidence. Responsiveness was negative, with a limited level of evidence. A limitation of this study was that only papers published in English were included. The CCFT is a valid and reliable test that can be used in clinical practice as an assessment test. Because of the conflicting and low-quality evidence, caution is advised when using the CCFT as a discriminative test and as an outcome measure. Future better-designed studies are warranted.

Widespread impairment of tactile spatial acuity and sensory-motor control in patients with chronic nonspecific neck pain with neuropathic features

ObjectiveTo assess differences in tactile spatial acuity and in sensory-motor control between patients with chronic nonspecific neck pain (CNSNP) with and without neuropathic features (NF), as well as asymptomatic. Methods183 participants were included, 135 had CNSNP classified by the Self-report version of Leeds Assessment of Neuropathic Symptoms and Signs scale in order to identify pain with NF: (1) CNSNP with NF (n = 67), (2) CNSNP with No-NF (n = 68), and (3) asymptomatic subjects (n = 48).The following tests in the following order were assessed after determining the participants’ clinical characteristics: 1) two-point discrimination, 2) joint position error, and 3) craniocervical flexion test. ResultsBoth neck pain groups showed a significant reduction in their ability to discriminate two points in the trapezium and masseter, as well as a significant deficit of a moderate to large magnitude in craniocervical motor control compared with the asymptomatic group. However, only the CNSNP with NF group showed a significant impairment of the two-point discrimination in the tibia (d = 0.57) and a significant impairment of the kinesthetic sense (neck rotation, d = 0.73; neck lateroflexion, d = 0.69), compared with the asymptomatic group. Significant differences in pain intensity, disability and psychological factors between the CNSNP groups were also found, observing the poorest results in the NF group. ConclusionsPatients with CNSNP with NF have a greater sensory, motor and psychological impairment than those without NF, more pain intensity, disability and negative psychological factors, as well as more impaired tactile spatial acuity in areas remote to the pain and impaired cervical kinesthetic sense.

Relation between endurance of deep cervical flexor muscles and physical activity level, perceived stress, sleep quality, and smartphone addiction

ABSTRACT Objective: To determine the reference values of deep cervical flexor muscle endurance and its relationship with associated parameters. Methods: The International Physical Activity Questionnaire, Perceived Stress Scale, Pittsburgh Sleep Quality Index, and Smartphone Addiction Scale-Short Version were used in the study. The craniocervical flexion test was performed to measure the endurance. Results: Endurance (mmHg) values were determined as 24.23 ± 2.39 (women), 24.15 ± 2.65 (men), and 24.19 ± 2.51 (students). The cumulative endurance (mmHg) scores were determined as 27.50 ± 21.29 (women), 27.65 ± 25.42 (men), and 27.57 ± 23.33 (students). There was no correlation between the endurance of the muscles and age, gender, body mass index, physical activity level (except walking score), perceived stress, sleep quality (except sleep latency component), and smartphone addiction (p ˃ 0.05). Conclusion: Defining the reference values of Stage 2 and cumulative endurance would be of great value for preventing, diagnosing, and managing cervical area problems.

What is the minimal important difference of pain intensity, mandibular function, and headache impact in patients with temporomandibular disorders? Clinical significance analysis of a randomized controlled trial

BackgroundThere are insufficient studies providing Minimal Clinically Important Difference (MCID) for outcomes related to temporomandibular disorders (TMD). Objectives(1) To provide the MCID of outcomes related to TMD using the Global Rating of Change Scale (GRCS) as an anchor. (2) To verify which outcomes can predict a moderate or large response to the treatment. Study designSecondary analysis of a randomized controlled trial in subjects with TMD. MethodsSixty-one women with TMD were divided into intervention and control groups. Visual Analogue Scale (VAS), Headache Impact Test (HIT-6), pressure pain thresholds (PPTs) of masticatory muscles, Mandibular Function Impairment Questionnaire (MFIQ), and Craniocervical Flexion Test (CCFT) were collected at baseline and 5-weeks follow-up. ResultsParticipants were divided based on their response to the treatment, according to the GRCS. MCID values were provided for subjects that moderately or largely improved to the treatment. MCID was between 0 and 1.90 for orofacial pain, around 2 points for the MFIQ, between 3 and 6.26 points for the HIT-6, around 0.2 kg/cm2 for the PPTs on masticatory muscles, around 2.5 mm for MMO and between 60 and 68 points for CCFT. Orofacial pain and HIT-6 were the most discriminative variables at determining whether patients would largely/moderately improve or would not improve after treatment. ConclusionsThe values of MCID could be used as guidance for both clinical practice and research. Pain intensity and headache impact were the most predictive outcomes for improvement of the general health status of women with TMD.

Effectiveness of Craniocervical Flexion Exercise on Pain, Disability, and Cervical Range of Motion in Patients with Neck Pain

Effectiveness of Craniocervical Flexion Exercise on Pain, Disability, and Cervical Range of Motion in Patients with Neck Pain

Effect of self- care exercises in forward head posture on craniovertebral angle and craniocervical flexion endurance: A pilot study

Background: Forward head posture (FHP) is the most frequently attained attitude of the head associated with rounded-shoulder posture (RSP) that leads to muscle imbalances. This needs to be corrected to prevent neck pain. Self-care exercises are home exercises that work positively for the prevention of the secondary effects of RSP. Aims: The aim of this study is to determine the effects of two self-care exercises, namely Bruegger's postural relief position and quadruped track cervical brace exercise in the management of asymptomatic FHP in terms of craniovertebral angle (CVA) and craniocervical flexion endurance (CCFE). Settings and Design: A single-group pre–post study design was conducted on physiotherapy volunteer student population of the Health Science University, Belagavi. Materials and Methods: Fifteen participants with asymptomatic FHP ( Results: The mean age of the participants was 23.00 years (standard deviation = 1.56). The comparison of pre- and postintervention scores for CVA and CCFE outcomes demonstrated a statistically significant improvement (P Conclusions: The two self-care exercises showed an effective reduction of CVA and increased deep cervical flexor strength in FHP. Once learned by the patients, the exercises can be self-administered and can be performed independently by the patients.

Immediate Effects of Posteroanterior Cervical Mobilization on Pressure Pain Threshold and Gait Parameters in Patients with Chronic Neck Pain: A Pilot Study

Background: Mobilization and cranio-cervical flexion exercise has been reported in reducing pain from cervical part and improving its motor function; also, has been represented that alleviate of neck pain and recover of neck muscles improve the normal gait performance. However, few studies have identified the effects of mobilization and exercise on pain and gait parameters with preceding issues. Objective: To examine the effects or changes of pressure pain threshold (PPT) and gait parameters in patients with chronic neck pain. Design: Cross-Sectional Clinical Trials Methods: Twenty patients with the history of neck pain (>3 months) performed the cervical mobilization and cranio-cervical flexion exercise. Gait parameters were assessed with wireless device and collected data were transmitted to the personal computer via Bluetooth. The PPT was measured posteroanterior direction at the prone position and the mean of subsequent three PPT meas­urements was used for the final analysis. Results: Both cervical central posteroanterior mobilization (CCPAM) (p<.000) and sling-based cranio-cervical flexion exercise (SBCCFE) (p<.000) group showed a significant increase in the PPT and the gait parameters, cadence (p<.023), was significantly increased in the CCPAM group, however slightly increased in the SBCCFE group. The comparison between the CCPAM and the SBCCFE groups after treatment did not show significant differences for the score on the PPT and gait parameters. Conclusions: This study suggests that CCPAM and SBCCFE increase PPT, cadence, and gait speed.

머리-목 굽힘 기반 몸통 안정화 운동이 경직성 뇌성마비 아동의 대동작기능과 앉은 자세정렬에 미치는 효과

머리-목 굽힘 기반 몸통 안정화 운동이 경직성 뇌성마비 아동의 대동작기능과 앉은 자세정렬에 미치는 효과

Extensor/flexor ratio of neck muscle strength and electromyographic activity of individuals with migraine: a cross-sectional study.

Neck pain is considered a common characteristic of migraine attacks. The relationship between neck pain and migraine can be explained by central sensitization of the trigeminocervical complex, where superior cervical afferents and the trigeminal nerve converge. However, few studies have evaluated motor control of cervical muscles in individuals with migraine. Thus, the purpose of the present study was to determine the extensor/flexor ratio of neck muscle strength and electromyographic activity during a test of maximal voluntary isometric contraction and craniocervical flexion in individuals with migraine and individuals without history of migraine or other headaches. Fifty-two women with the disease and 52 women with neither a history of migraine nor neck pain, between 18 and 55years old, were included in the study. The electromyographic activities of the sternocleidomastoid, anterior scalene, splenius capitis, and upper trapezius muscles were evaluated during a test of maximal voluntary isometric contraction and craniocervical flexion. The migraine group presented lower flexor muscle strength and a higher extensor/flexor muscle strength ratio than the control group. In addition, the migraine group showed a reduced electromyographic extensor/flexor muscle ratio during maximal voluntary isometric contraction in flexion. The results demonstrated worse performance in the craniocervical flexion test of the migraine group and a lower electromyographic ratio of extensor/flexor neck muscles in the last stage of the test. Altogether, the migraine group presented an imbalance in cervical muscles verified not only during force production, but also during muscle activity. These slides can be retrieved under Electronic Supplementary Material.