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Abstract: The randomised clinical current study was planned to determine the comparative effects of isometric and isotonic global neck muscles strengthening exercises on pain, range of motion, strength, function and quality of life in patients with chronic mechanical neck pain. The study comprised 22 patients with chronic mechanical neck pain. The subjects were randomly divided into two interventional groups, with group A receiving isometric exercises and group B receiving isotonic exercises. Numeric Pain Rating Scale, Neck Disability Index, goniometer, dynamometer and Short Form-36 questionnaire were used for data collection. Isometric and isotonic exercise groups showed significant improvement (p<0.05) in terms of decreasing pain and functional disability, and increasing range of motion and strength. Intergroup comparison showed no significant differences (p>0.05), indicating similar efficacy of isometric and isotonic global neck muscles strengthening exercises., Trial Registration Number: This study was registered at ClinicalTrials.gov ID: NCT05865951.

Background: We analyzed cervical sagittal parameters and muscular function in different cervical kyphosis types., Methods: This cross-sectional study enrolled subjects with cervical spine lordosis (cervical curvature < -4°) or degenerative cervical kyphosis (cervical curvature > 4°), including C-, S-, and R-type kyphosis. We recorded patients' general information (gender, age, body mass index), visual analog scale (VAS) scores, and the Neck Disability Index (NDI). Cervical sagittal parameters including C2-C7 Cobb angle (Cobb), T1 slope (T1S), C2-C7 sagittal vertical axis (SVA), spino-cranial angle (SCA), range of motion (ROM), and muscular function (flexion-relaxation ratio (FRR) and co-contraction ratio (CCR) of neck/shoulder muscles on surface electromyography). Differences in cervical sagittal parameters and muscular function in subjects with different cervical spine alignments, and correlations between VAS scores, NDI, cervical sagittal parameters, and muscular function indices were statistically analyzed., Results: The FRR of the splenius capitis (SPL), upper trapezius (UTr), and sternocleidomastoid (SCM) were higher in subjects with cervical lordosis than in subjects with cervical kyphosis. FRR SPL was higher in subjects with C-type kyphosis than in subjects with R- and S-type kyphosis ( P < 0.05), and was correlated with VAS scores, Cobb angle, T1S, and SVA. FRR UTr was correlated with NDI, SCA, T1S, and SVA. FRR SCM was correlated with VAS scores and Cobb angle. CCR was correlated with SCA and SVA., Conclusion: Cervical sagittal parameters differed among different cervical kyphosis types. FRRs and CCRs were significantly worse in R-type kyphosis than other kyphosis types. Cervical muscular functions were correlated with cervical sagittal parameters and morphological alignment., Competing Interests: The authors declare that they have no competing interests., (© 2024 Wang et al.)

Background and Objectives : It has been seen that jaw opening is associated with neck extension and jaw closing is associated with neck flexion. This natural association between the jaw and neck can be used as a novel approach to treat chronic non-specific neck pain, although the effects of this concept have never been previously evaluated as a treatment strategy. This article intends to study the effects of integrating jaw opening and closing movements along with active neck exercises versus active neck exercises alone in the management of chronic non-specific neck pain. Materials and Methods : A total of 80 patients, aged 20 to 50, with chronic non-specific neck pain were included in a double-blind randomized controlled trial, conducted at the Sindh Institute of Physical Medicine and Rehabilitation, Karachi, Pakistan from 2018 to 2022. The patients were divided into two groups: Group A patients were assigned jaw movements with active neck exercises, while Group B patients were assigned only active neck exercises. Both groups were assigned isometric strengthening exercises and self-resisted strengthening exercises for cervical spine muscles as a home plan. The study used various outcome measures, including the numerical pain rating scale (NPRS), neck disability index (NDI), neck flexion endurance (NFE), neck extension endurance (NEE), the neck proprioception error (NPE): neck flexion proprioception error (NFPE), neck extension proprioception error (NEPE), neck right rotation proprioception error (NRRPE), and neck left rotation proprioception error (NLRPE), with measurements taken at week 1 and week 6, respectively; the mean differences between the groups were measured using a two-way repeated ANOVA. Results : The experimental group showed better improvements compared to the control group, NPRS (73%), NDI (57%), NFE (152%), NEE (83%), NFPE (58%), NEPE (65%), NRRPE (65%), and NLRPE (62%), with a significant difference ( p < 0.05). Conclusions : Active neck extension and flexion movements combined with jaw opening and closing are more effective in reducing pain and disability, improving neck muscles endurance and normalizing neck proprioception in patients with chronic neck pain.

Background: Dropped head syndrome (DHS) is followed by severe cervical extension muscle weakness that results in chin-on chest deformity. However, maintaining a neutral cervical position can be temporarily possible, and the diagnosis of DHS might sometimes be difficult. The purpose of the present study is to examine a novel clinical test (DHS test) as the diagnostic utility for objective evaluation that focuses on cervical extension condition in the prone position., Methods: One hundred subjects were diagnosed with isolated neck extensor myopathy (INEM)-DHS at our hospital (17 men and 83 women, mean age 75.0 ± 8.5 years), and 62 subjects were enrolled as age-matched controls. The DHS test consisted of three examinations; the first was "Ceiling gazing test" in standing position, the second was horizontal gazing in "Sphinx prone position test", and the third was horizontal gazing in "Hands and knees prone position test". We investigated the sensitivity and specificity of the DHS test for DHS., Results: The patients showing positive in the INEM-DHS group were 63/100 in Ceiling gaze test, 73/100 in the Sphinx prone position test, and 91/100 in the Hands and knees prone position test. In the control group, 0/62 patients presented positive in the Ceiling gaze test, 4/62 in the Sphinx prone position test, and 0/62 in the Hands and knees prone position test. Sensitivity and specificity of the DHS test were 63.0%/100%, 73.0%/93.5%, and 91.0%/100% in the Ceiling gaze test, Sphinx position prone position test, and Hands and knees prone position test, respectively., Conclusion: The prone position cervical extension test (DHS test) would be useful as a novel objective diagnostic tool for INEM-DHS., Competing Interests: Declaration of competing interest All authors declare that there are no personal or professional conflicts of interest related to the preparation and publication of this manuscript., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

The mobile phone is essential in daily life, especially during the pandemic. Prolonged use can cause postural issues, leading to common neck pain. This study aims to determine the correlation between mobile phone use duration, addiction, neck muscle endurance, and neck pain in university students. The study included 62 participants (30 female, 32 male) aged 18-35 years. Inclusion criteria required participants to have experienced neck pain at least twice in the past year and to have no other concomitant issues, as well as to volunteer for the study. Demographic information and daily mobile phone usage time were collected. Neck pain was assessed with the Visual Analogue Scale, smartphone addiction with the Smartphone Addiction Scale, and cervical muscle endurance was evaluated. Correlation analysis reveals a moderate relationship between neck pain severity (NPS) and cervical extensor muscle endurance (CEME), a strong relationship between NPS and cervical flexor muscle endurance (CFME), as well as a strong relationship among daily phone usage time (DPUT), CFME, and NPS, with a moderate relationship between DPUT and CEME. Participants were divided into two groups based on their DPUT, revealing that those who used their phone for four hours or more showed significantly higher levels of pain (p < 0.05) and reduced endurance in cervical flexor muscles. Our study found a strong correlation between neck pain, muscle endurance, and daily phone usage. Participants using their phones for more than four hours daily reported increased neck pain and decreased muscle endurance. We suggest integrating phone usage duration into neck pain assessments, promoting ergonomic practices, and offering detailed usage guidelines for users., (© 2024. The Author(s).)

A whiplash injury can alter neck muscle function, which remains years after the injury and may explain why symptoms such as persistent pain and disability occur. There is currently limited knowledge about dynamic neck muscle function in chronic whiplash-associated disorders (WAD), and about the extent to which altered muscle function can improve after rehabilitation. Ultrasound can detect mechanical neck muscle function by measuring real-time deformation and deformation rate in the muscles. This method was used for five dorsal neck muscles in participants with chronic WAD versus matched controls in resistant neck rotation. We obtained real-time, non-invasive ultrasound measurements using speckle tracking, multivariate analyses, and mixed-design ANOVA analyses. The results showed altered deformation in the three deepest neck muscle layers, with less deformation area in the WAD group compared to controls in rotation to the most painful side at baseline. Participants in the WAD group performed three months of neck-specific exercises, resulting in improved deformation in the deep neck muscles in WAD and with a similar deformation pattern to controls, and the significant group differences ceased. We reveal new and important insights into the capability of ultrasound to diagnose altered neck muscle function and evaluate an exercise intervention., (© 2024. The Author(s).)

Objective: To evaluate neck muscle coactivation across different levels of mental workload during simulated flight tasks., Background: Neck pain (NP) is highly prevalent among military aviators. Given the complex nature within the flight environment, mental workload may be a risk factor for NP. This may induce higher levels of neck muscle coactivity, which over time may accelerate fatigue, increase neck discomfort, and affect flight task performance., Method: Three counterbalanced mental workload conditions represented by simulated flight tasks modulated by interstimulus frequency and complexity were investigated using the Modifiable Multitasking Environment (ModME). The primary measure was a neck coactivation index to describe the neuromuscular effort of the neck muscles as a system. Additional measures included perceived workload (NASA TLX), subjective discomfort, and task performance. Participants ( n = 60; 30M, 30F) performed three test conditions over 1 hr each while seated in a simulated seating environment., Results: Neck coactivation indices (CoA) and subjective neck discomfort corresponded with increasing level of mental workload. Average CoAs for low, medium, and high workloads were: .0278(SD = .0232), .0286(SD = .0231), and .0295(SD = .0228), respectively. NASA TLX mental, temporal, effort, and overall scores also increased with the level of mental workload assigned. For ModME task performance, the overall performance score, monitoring accuracy, and resource management accuracy decreased while reaction times increased with the increasing level of mental workload. Communication accuracy was lowest with the low mental workload but had higher reaction times relative to increasing workload., Conclusion: Mental workload affects neck muscle coactivation during combinations of simulated flight tasks within a simulated helicopter seating environment., Application: The results of this study provide insights into the physical response to mental workload. With increasing multisensory modalities within the work environment, these insights may assist the consideration of physical effects from cognitive factors.

Objective: To compare the effects of a neck-specific exercise programme with internet support and 4 physiotherapist sessions (NSEIT) and the same neck-specific exercises supervised by a physiotherapist (NSE) on neck muscle endurance and cervical range of motion., Design: Randomized controlled trial., Patients: A total of 140 participants with chronic whiplash-associated disorders grade II or grade III were randomly assigned to the NSEIT or NSE groups., Methods: Outcomes were changes in active cervical range of motion, cranio-cervical flexion test, neck muscle endurance, and neck pain, at 3- and 15-month follow-ups., Results: There were no significant differences between the NSEIT and NSE groups. There was a significant group-by-time inter-action effect in active cervical range of motion flexion/extension where the NSEIT group improved to 3-month follow-up, but the NSE group did not. Both groups were significantly improved over time in all other outcomes (p < 0.001) at 3- and 15-month follow-ups, with effect size between 0.64 and 1.35 in active cervical range of motion, cranio-cervical flexion test, dorsal neck muscle endurance, and neck pain, and effect size between 0.22 and 0.42 in ventral neck muscle endurance., Conclusion: Both NSE and NSEIT led to improved neck function. Depending on the patients' needs, either NSE or NSEIT could be used as treatment for patients with chronic whiplash-associated disorders.

Background: Text neck syndrome is an overuse condition that has become a global problem for all ages who use smartphones. Although therapeutic approaches are used to manage text neck syndrome, relatively little evidence exists on efficacy. This study aimed to investigate the effects of proprioceptive neuromuscular facilitation (PNF) techniques on individuals with text neck syndrome., Methods: Thirty-eight participants with text neck syndrome were randomly allocated to either the experimental or control group. Both groups performed the program including cervical range of motion, strengthening, and posture correction exercises for 6 weeks, 3 days a week, once a day for 10 repetitions. In the experimental group were included in a PNF program 3 days a week for 6 weeks. In the program, contract-relax and replication techniques were used. Pain intensity, cervical range of motion, cervical muscles' endurance, posture, and disability were assessed. Outcome measures were assessed at baseline and after 6 weeks., Results: Pain intensity, neck muscle endurance tests, posture, and disability scores significantly improved in both groups (P < .05). The cervical range of motion values in all directions were significantly increased only in the experimental group (P < .05). The improvements in pain intensity, neck muscle endurance tests, posture, and disability scores were greater in the experimental group compared with the control group (P < .05)., Conclusion: PNF could be used effectively to reduce neck pain and disability level and enhance cervical range of motion, cervical muscles' endurance, and posture in individuals with text neck syndrome., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To investigate whether a combination of dry-needling treatments and upper extremity neuromuscular reeducation exercises can significantly improve neck pain and/or headache-related disability, joint position error, cervical range of motion, and pain pressure threshold in individuals suffering from cervicogenic headache (CGH)., Methods: This study is a quasi-experimental design. Seven participants met the inclusion criteria and received dry needling to three muscles that reproduced the participant's headache symptoms and completed the Neck Disability Index (NDI), Headache Disability Inventory (HDI), Visual Analog Scale (VAS), and Numeric Pain Rating Scale (NPRS). Participants performed an exercise regimen designed to address strength and mobility of cervical and scapulothoracic musculature., Results: There were significant improvements seen in cervical range of motion and neck pain-related disability (NDI) during the 4-week treatment period., Conclusion: Dry needling and neuromuscular re-education (NMR) exercises could be effective components of treatment for individuals suffering from CGH to reduce disability and pain.

Background: Disorder of consciousness (DOC) is a state of prolonged altered consciousness due to severe acquired brain injury (ABI). DOC can be differentiated into coma, unresponsive wakefulness syndrome (UWS), or minimally conscious state (MCS) depending on the behavioral features observed and their relationship to the level of consciousness. Spasticity is one of the most frequently reported medical comorbidities in DOC patients. Since there is a critical lack of spasticity-focused studies and, in turn, of target treatment, we designed this pilot prospective study to evaluate cervical spine muscle spasticity and its effect on rehabilitation outcome in a large cohort of patients followed from the post-acute phase to 6 months after severe ABI., Aim: To evaluate neck muscle spasticity and investigate its impact on neurological and functional outcome in a large cohort of adult patients with DOC followed from post-acute to 6 months after severe ABI., Design: Single-center prospective pilot study., Setting: Highly specialized inpatient neurorehabilitation clinic., Population: Patients with severe ABI admitted within 3 months after the acute event to our Neurorehabilitation Unit between May 21 st , 2019 and April 23 rd , 2020 for treatment of DOC as a part of their rehabilitation program., Methods: In this single-center prospective pilot study demographic data, etiology of ABI (traumatic versus non-traumatic), DOC evaluated with the revised Coma Recovery Scale (CRS-R), and neurological and functional outcome assessed respectively with the Glasgow Coma Scale (GCS) and Functional Independence Measure (FIM) were considered. During cervical examination, we assessed spasticity with the Modified Ashworth Scale (MAS), deviation of head alignment with a goniometer, and pain with the Nociception Coma Scale-Revised (NCS-R)., Results: Of the 48 patients, 41.7% were diagnosed with UWS and 58.3% were in a minimally conscious state (MCS). We found spasticity of neck muscles in 91.7% of patients, with no difference in severity (assessed with MAS) between UWV and MCS. The NCS-R score at cervical spine examination was lower in UWS than MCS. Spasticity was severer in patients with traumatic brain injury (TBI) compared to non-traumatic. At multiple linear regression analysis, younger age, hemisyndrome, and tetraparesis were independent predictors of severity of neck muscle spasticity in MCS. More severe spasticity was a predictor of worse neurological and functional outcome at discharge in UWS patients, independently of the other confounding variables at admission (e.g., age, severity of brain injury, functional assessment, and pain)., Conclusions: Spasticity of neck muscles frequently develops in patients with DOC and is more severe in those after TBI. UWV and MCS have different spasticity profiles as regards risk factors and neurological and functional outcome. Severity of neck muscle spasticity in UWV patients may represent an early indicator of worse neurological and functional outcome after inpatient rehabilitation., Clinical Rehabilitation Impact: Our findings could prompt clinicians to redefine the rehabilitation aims regarding spasticity and to estimate the functional outcome in patients undergoing intensive rehabilitation after severe ABI.

Background and Objectives : Physiotherapy approaches are used to eliminate the problems caused by cervicogenic headache (CHA), known as secondary headache associated with the structures of the upper cervical region. This study aimed to investigate the effects of cervical mobilization (CM) with clinical Pilates exercises (CPE) on pain, muscle stiffness and head-neck blood flow in CGH. Materials and Methods : A total of 25 patients participated in this randomized controlled study and were randomized into either the CM group or the CM+CPE group. All treatment methods were applied 3 days a week for 6 weeks. The outcome measure was headache intensity and frequency, the number of analgesics, muscle stiffness and vertebral artery (VA) and internal carotid artery (ICA) blood flow. Headache intensity was measured by a visual analogue scale, muscle stiffness by a myotonometer and blood flow by Doppler US. Evaluations were repeated after 6 weeks of treatment. Within-group comparisons were made by the Wilcoxon signed rank test, and between-group comparisons were made by the Mann-Whitney U test. Results : After treatments in the two groups, headache intensity and frequency and the number of analgesics decreased, the muscle stiffness of the suboccipital, upper trapezius and sternocleidomastoid (SCM) muscles decreased, and the blood flow of the ICA and VA increased ( p < 0.05). There was a significant difference between the groups in terms of headache intensity ( p = 0.025) and muscle stiffness in SKM ( p = 0.044) in favor of the CM+CPE group. Conclusions : Non-pharmacological treatment approaches have an important role in CHA related to the upper cervical region. This study suggests that it would be beneficial to add CM in combination with CPE to the non-pharmacological treatment of patients with CHA.

Objective: Muscle dysfunction caused by repetitive work or strain in the neck region can interfere muscle responses. Muscle dysfunction can be an important factor in causing cervical spondylosis. However, there has been no research on how the biomechanical properties of the upper cervical spine change when the suboccipital muscle group experiences dysfunction. The objective of this study was to investigate the biomechanical evidence for cervical spondylosis by utilizing the finite element (FE) approach, thus and to provide guidance for clinicians performing acupoint therapy., Methods: By varying the elastic modulus of the suboccipital muscle, the four FE models of C0-C3 motion segments were reconstructed under the conditions of normal muscle function and muscle dysfunction. For the two normal condition FE models, the elastic modulus for suboccipital muscles on both sides of the C0-C3 motion segments was equal and within the normal range In one muscle dysfunction FE model, the elastic modulus on both sides was equal and greater than 37 kPa, which represented muscle hypertonia; in the other, the elastic modulus of the left and right suboccipital muscles was different, indicating muscle imbalance. The biomechanical behavior of the lateral atlantoaxial joint (LAAJ), atlanto-odontoid joint (ADJ), and intervertebral disc (IVD) was analyzed by simulations, which were carried out under the six loadings of flexion, extension, left and right lateral bending, left and right axial rotation., Results: Under flexion, the maximum stress in LAAJ with muscle imbalance was higher than that with normal muscle and hypertonia, while the maximum stress in IVD in the hypertonic model was higher than that in the normal and imbalance models. The maximum stress in ADJ was the largest under extension among all loadings for all models. Muscle imbalance and hypertonia did not cause overstress and stress distribution abnormalities in ADJ., Conclusion: Muscle dysfunction increases the stress in LAAJ and in IVD, but it does not affect ADJ., (© 2024. The Author(s).)

Neck muscle weakness due to amyotrophic lateral sclerosis (ALS) can result in dropped head syndrome, adversely impacting the quality of life of those affected. Static neck collars are currently prescribed to hold the head in a fixed upright position. However, these braces are uncomfortable and do not allow any voluntary head-neck movements. By contrast, powered neck exoskeletons have the potential to enable head-neck movements. Our group has recently improved the mechanical structure of a state-of-the-art neck exoskeleton through a weighted optimization. To evaluate the effect of the structural changes, we conducted an experiment in which patients with ALS were asked to perform head-neck tracking tasks while using the two versions of the neck exoskeleton. We found that the neck muscle activation was significantly reduced when assisted by the structurally enhanced design compared to no assistance provided. The improved structure also improved kinematics tracking performance, allowing users to better achieve the desired head poses. In comparison, the previous design did not help reduce the muscle effort required to perform these tasks and even slightly worsened the kinematic tracking performance. It was also found that biomechanical benefits gained from using the structurally improved design were consistent across participants with both mild and severe neck weakness. Furthermore, we observed that participants preferred to use the powered neck exoskeletons to voluntarily move their heads and make eye contact during a conversation task rather than remain in a fixed upright position. Each of these findings highlights the importance of the structural design of neck exoskeletons in achieving desired biomechanical benefits and suggests that neck exoskeletons can be a viable method to improve the daily life of patients with ALS.

Objectives: To verify the rates of heat effectiveness generated by Carbon Nanotubes (CNT) in the resolution of dizziness in individuals diagnosed with Cervical Dizziness (CD)., Methods: Randomized clinical trial was performed and samples from volunteers diagnosed with CD, divided into a Study Group (SG) and Control Group (CG). Patches containing CNT with thermotherapeutic effect were used in SG and inert patches in the CG. Treatment was performed over 30 days and measures of pain, dizziness and asymmetry of cervical muscle tension were evaluated over 60 days., Results: Pain, dizziness and asymmetry of cervical muscle tension were reduced in the SG. The variables analyzed in this study did not change in the CG., Conclusion: Our results show that the therapeutic effect of heat was effective in the treatment of patients diagnosed with CD. We could also observe a clear interrelationship between pain and dizziness symptoms with the asymmetry of cervical muscle tension., Level of Evidence: 1B., (Copyright © 2023 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier España S.L.U. All rights reserved.)

Background and Objectives: The main target of inspiratory muscle training (IMT) is to improve diaphragm function in patients with COPD who have inspiratory muscle weakness. Ventilatory demand is already increased during quiet breathing in patients with COPD, and whether threshold load imposed by IMT would active more accessory muscle remained to be determined. The purpose of this study was to examine diaphragm and sternocleidomastoid (SCM) activation during IMT with intensities of 30% and 50% maximal inspiratory pressure (P Imax )., Methods: Patients with COPD and a P Imax lower than 60 cmH 2 O were recruited for the study. Surface electromyography (EMG) was used to measure diaphragm and SCM activation, and group-based trajectory modeling (GBTM) was used to identify activation patterns during IMT. The generalized estimating equation (GEE) was then used to detect differences of variables between various breathing tasks. Statistical significance was established at p < 0.05., Results: A total of 30 patients with COPD participated in this study. All patients demonstrated significant increases in diaphragm and SCM activation during 30% and 50% P Imax of IMT than during quiet breathing (all p < 0.001). Diaphragm demonstrated two distinct patterns in response to IMT: low activation (n = 8) and high activation (n = 22) group using GBTM analysis., Conclusion: Diaphragm and SCM were substantially activated during IMT in patients with COPD who had inspiratory muscle weakness. Regardless of whether diaphragm activation was high or low, SCM was activated to a greater extent in response to IMT., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: To date, the histopathologic characteristics of dropped head syndrome (DHS) have not been reported sufficiently. The present study investigates the histopathology of biopsy specimens from the cervical paravertebral region in patients with DHS., Methods: Histopathological parameters were evaluated in biopsy specimens of the cervical paravertebral soft tissue from 15 patients with DHS., Results: Among the 15 cases of DHS examined, skeletal muscle was identified in 7 cases, all of which showed necrosis, microvessel proliferation and atrophy. The ligament was identified in 12 cases, 8 of which showed degeneration. The lag time between the onset of symptoms and the performance of a biopsy in all 8 cases, which showed degeneration was over 3 months. Microvessel proliferation in the ligament was observed in 1 of the 4 cases, in which the lag time between the onset of symptoms and the performance of a biopsy was less than 3 months (acute or subacute phase), and in 7 of the 8 cases, in which the lag time between the symptoms and the performance of a biopsy was over 3 months (chronic phase). Chronic inflammation in the ligament was identified in 1 of the 12 cases., Conclusions: The identification of necrosis, microvessel proliferation, and atrophy in the skeletal muscle of patients with DHS and the presence of ligament degeneration and microvessel proliferation in the chronic but not acute or subacute phases may suggest that persistent skeletal muscle damage of the cervical paravertebral region causes subsequent ligament damage in patients with DHS., (© 2021. The Author(s).)

This study aimed to verify if migraine frequency or migraine-associated neck pain were associated with a reduction of normalized force and altered electromyographic activity during maximal cervical muscle isometric contractions. Additionally, it aimed to assess the correlation of normalized isometric force with years with migraine, headache frequency, headache intensity, migraine-related disability, and severity of cutaneous allodynia. The sample comprises 71 women with migraine (40/31 episodic/chronic, 42/18 with/without neck pain) and 32 women without headache. Cervical muscle isometric force in flexion, extension, and lateral flexion was assessed synchronized with the acquisition of superficial electromyography from the cervical muscles. Women with episodic migraine presented lower normalized isometric force in extension, flexion, and right and left lateral flexions than controls (P < 0.05). Women with migraine and neck pain exhibited lower cervical extension and right/left lateral-flexions normalized isometric force than controls (P < 0.05). No significant differences were observed in antagonist activity. Normalized isometric force in all directions showed weak to moderate correlations with the severity of self-reported symptoms of cutaneous allodynia (- 0.25 ≥ r ≥ - 0.39). No additional linear correlation with clinical migraine features was observed. In conclusion, cervical muscle weakness may be associated with episodic migraine and neck pain concurrent with migraine attacks without altered antagonist activity. Additionally, it may also be related to the severity of cutaneous allodynia., (© 2021. The Author(s).)

Chronic neck pain (CNP) incidence in the general population is high and contributes to a significant health problem. Kinesiophobia (fear of pain to movement or re-injury) combined with emotions and physical variables may play a vital role in assessing and managing individuals with CNP. The study's objectives are 1) to evaluate the relationship between kinesiophobia, neck pain intensity, proprioception, and functional performance; 2) to determine if kinesiophobia predicts pain intensity, proprioception, and functional performance among CNP individuals. Sixty-four participants with CNP (mean age 54.31 ± 9.41) were recruited for this cross-sectional study. The following outcome measures were evaluated: Kinesiophobia using the Tampa Scale of Kinesiophobia (TSK), neck pain intensity using the visual analog scale (VAS), cervical proprioceptive joint position errors (in flexion, extension, and rotation directions) using cervical range of motion (CROM) device and handgrip strength as a measure of functional performance using the Baseline® hydraulic hand dynamometer. Kinesiophobia showed a strong positive correlation with neck pain intensity (r = 0.81, p<0.001), a mild to a moderate positive correlation with proprioception joint position errors (JPE) in extension, rotation left and right directions (p<0.05), but no correlation in flexion direction (p = 0.127). Also, there was a moderate negative correlation with handgrip strength (r = -0.65, p<0.001). Regression analysis proved that kinesiophobia was a significant predictor of pain intensity, proprioception, and functional performance (p<0.05). This study infers that kinesiophobia in individuals with CNP predicts pain, proprioception, and functional performance. Kinesiophobia assessment should be considered in regular clinical practice to understand the barriers that can influence rehabilitation outcomes in CNP individuals., Competing Interests: No authors have competing interests.

Neuromuscular impairments are frequently observed in patients with chronic neck pain (CNP). This study uniquely investigates whether changes in neck muscle synergies detected during gait are sensitive enough to differentiate between people with and without CNP. Surface electromyography (EMG) was recorded from the sternocleidomastoid, splenius capitis, and upper trapezius muscles bilaterally from 20 asymptomatic individuals and 20 people with CNP as they performed rectilinear and curvilinear gait. Intermuscular coherence was computed to generate the functional inter-muscle connectivity network, the topology of which is quantified based on a set of graph measures. Besides the functional network, spectrotemporal analysis of each EMG was used to form the feature set. With the use of Neighbourhood Component Analysis (NCA), we identified the most significant features and muscles for the classification/differentiation task conducted using K-Nearest Neighbourhood (K-NN), Support Vector Machine (SVM), and Linear Discriminant Analysis (LDA) algorithms. The NCA algorithm selected features from muscle network topology as one of the most relevant feature sets, which further emphasize the presence of major differences in muscle network topology between people with and without CNP. Curvilinear gait achieved the best classification performance through NCA-SVM based on only 16 features (accuracy: 85.00%, specificity: 81.81%, and sensitivity: 88.88%). Intermuscular muscle networks can be considered as a new sensitive tool for the classification of people with CNP. These findings further our understanding of how fundamental muscle networks are altered in people with CNP., Competing Interests: The authors have declared that no competing interests exist.

There is a lack of studies comparing the effects of different exercise types in patients with thoracic hyperkyphosis. Twenty-four subjects were divided into three groups: corrective exercise, resistance exercise, and physical therapy. The groups performed their respective interventions, two times per week for three months. Clinical outcomes, including the value of Cobb's angle, cervical muscle strength and endurance, and the cross-sectional area of the cervical deep muscles were measured pre- and post-intervention. There was a significant difference in the changes in the thoracic Cobb's angle between the groups (P < 0.001). The corrective exercise group revealed a significantly superior increase in muscle strength and endurance between pre- and post-intervention (P < 0.012). There was a significant difference in the cross-sectional area of the cervical deep muscles included longus capitis and multifidus between the groups (P < 0.036 and 0.007, respectively). The corrective exercise group showed the most significant increase in cross-sectional area between pre- and post-intervention (P < 0.012). A corrective exercise program is a more effective intervention than traditional resistance exercise and physical therapy for improving the thoracic Cobb's angle, cervical muscle strength and endurance, and the cross-sectional area of the deep muscles in patients with thoracic hyperkyphosis.Trial registration: KCT0005292.

Background: Neck pain (NP) is a common work-related disorder, with high prevalence in the profession of teaching. The daily duties of a school teacher involve head-down postures while reading and writing, which expose them to the risk of developing NP. Deep cervical flexor (DCF) muscles have been reported to have lower endurance in patients with cervical impairment, which has additionally been associated with disability. There is limited evidence regarding the efficacy of training of DCF muscles in occupational NP. The objective of this study was to investigate the effects of DCF muscle training on pain, muscle endurance, and functional disability using pressure biofeedback in school teachers with NP., Methods: Sixty-five teachers (age, 25-45 years) with more than 5 years of teaching experience participated in this study. They were randomly divided into two groups: the experimental (E) and control (C) groups. In the E group, the subjects underwent DCF muscle training using pressure biofeedback in addition to conventional exercises for neck pain, while those in the C group underwent conventional exercises only. Pain, muscle endurance, and disability were measured at day 0 (before the treatment) and days 14 and 42 after the treatment. Endurance of DCF muscles was measured by the craniocervical flexion test using pressure biofeedback, pain intensity was measured using the numeric pain rating scale, and functional disability was assessed using the neck disability index questionnaire. This study was performed in accordance with CONSORT guidelines., Results: On day 0, there were no significant differences in the age, pain, muscle endurance, and disability levels between the groups. After initiating the intervention, although there were improvements in both groups, there was a statistically significant improvement in muscle endurance, pain, and disability in subjects who received additional training with pressure biofeedback., Conclusions: Besides increasing muscle endurance, specific training of DCF muscles in addition to conventional exercises can improve neck pain and functional disability. These results should be further correlated clinically. A dedicated time for exercises at school could help prevent the development of NP in teachers. This trial is registered with ClinicalTrials.gov NCT03537300 May 24, 2018 (retrospectively registered)., Competing Interests: The authors declare that they have no conflict of interest., (Copyright © 2021 Zaheen A. Iqbal et al.)

Understanding the interactions between neural and musculoskeletal systems is key to identifying mechanisms of functional failure. Mammalian swallowing is a complex, poorly understood motor process. Lesion of the recurrent laryngeal nerve, a sensory and motor nerve of the upper airway, results in airway protection failure (liquid entry into the airway) during swallowing through an unknown mechanism. We examined how muscle and kinematic changes after recurrent laryngeal nerve lesion relate to airway protection in eight infant pigs. We tested two hypotheses: 1 ) kinematics and muscle function will both change in response to lesion in swallows with and without airway protection failure, and 2 ) differences in both kinematics and muscle function will predict whether airway protection failure occurs in lesion and intact pigs. We recorded swallowing with high-speed videofluoroscopy and simultaneous electromyography of oropharyngeal muscles pre- and postrecurrent laryngeal nerve lesion. Lesion changed the relationship between airway protection and timing of tongue and hyoid movements. Changes in onset and duration of hyolaryngeal muscles postlesion were less associated with airway protection outcomes. The tongue and hyoid kinematics all predicted airway protection outcomes differently pre- and postlesion. Onset and duration of activity in only one infrahyoid and one suprahyoid muscle showed a change in predictive relationship pre- and postlesion. Kinematics of the tongue and hyoid more directly reflect changes in airway protections pre- and postlesion than muscle activation patterns. Identifying mechanisms of airway protection failure requires specific functional hypotheses that link neural motor outputs to muscle activation to specific movements. NEW & NOTEWORTHY Kinematic and muscle activity patterns of oropharyngeal structures used in swallowing show different patterns of response to lesion of the recurrent laryngeal nerve. Understanding how muscles act on structures to produce behavior is necessary to understand neural control.

In contemporary societies, computer use by children is a necessity and thus highly prevalent. Using computers for long hours is related to a higher risk of computer-related muscular disorders like forward head posture (FHP) and neck pain (NP). Deep cervical flexor (DCF) muscles are important head-on-neck posture stabilizers; thus, their training may lead to an improvement in FHP and NP. The aim of this study was to determine if 4 weeks of DCF training is effective in alleviating NP, improving FHP, and functional status in adolescent children using computers regularly, a pretest-posttest experimental group design was used. Subjects were randomly assigned into the experimental group (receiving DCF training and postural education) and the control group (receiving postural education only). 30 subjects with a mean age of 15.7 ± 1.725 years with NP and FHP using computers regularly participated in the study. Dependent variables were measured on day 1 (at baseline) and after 4 weeks of training. Photographic analysis was used for measuring FHP, visual analog scale for NP intensity, and neck disability index for functional status. Data analysis showed that in both groups, no significant improvement occurred in FHP. In both groups, there was a significant improvement in functional status and NP. There was no significant difference between both groups for FHP and NP. There was a significant improvement in functional status in the experimental group in comparison to the control group. Four weeks of DCF training does not cause a significant improvement in FHP in 13 to 18 years old adolescent children using computers regularly., Competing Interests: The authors declare that there is no conflict of interest regarding the publication of this paper., (Copyright © 2020 Isha Sikka et al.)

Objective: 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., Methods: 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., Results: 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., Conclusions: 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., (© The Author(s) 2020. Published by Oxford University Press on behalf of American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Tremor is an important phenotypic feature of dystonia. Using the new concept (Col-Cap) of classification we examined the frequency of tremor in cervical dystonia (CD) patients, their main subtypes and muscles injected., Methods: In this large study conducted at multiple movement disorder centres in Europe and India, between January and June 2019, we examined 293 patients with idiopathic CD who were all treated with botulinum toxin (BTX)., Results: The dystonic head tremor (DHT+) was present in 57.6 % of CD patients and they had a significantly longer duration of symptoms than patients without head tremor (DHT-). In DHT+ patients torticaput was the most common subtype and the majority (63.3%) had one or two subtypes only. There was no significant difference between the number of unilateral injections for any of the muscles in the DHT+ and DHT- groups, while the number of patients receiving bilateral injections in splenius capitis (78 vs 25; p = 0.00001), sternocleidomastoid (31 vs 6; p = 0.0005), trapezius (28 vs 9; p = 0.01), and obliquus capitis inferior (15 vs 2; p = 0.008) were significantly more in the DHT+ group. The mean doses of all three types of BTX/A were not significantly different between the two groups., Conclusions: The frequency of head tremor was 57.6% in our CD patients and torticaput was the most common dystonic subtype associated with tremor. Simple forms of CD seemed more likely associated with head tremor, than complex forms of CD. Most of the DHT+ patients received bilateral injections. The use of 'Col-Cap' classification was helpful in the identification of muscles likely to be involved in tremor in CD patients., Competing Interests: Dr. Sanjay Pandey and Dr. Christian Altmann have no conflict of interest. All other authors were speakers and consultants for Allergan, Merz/Desitin and Ipsen, but none relevant to this study (and had no financial or other support)., (Copyright: © 2020 The Author(s).)

Migraine is a burdensome disease with an especially high prevalence in women between the age of 15 and 49 years. Non-pharmacological, non-invasive therapeutic methods to control symptoms are increasingly in demand to complement a multimodal intervention approach in migraine. Thirty-seven subjects (age: 25.0 ± 4.1 years; 36 females) diagnosed with high-frequency episodic migraine who presented at least one active myofascial trigger point (mTrP) in the trapezius muscles and at least one latent mTrP in the deltoid muscles bilaterally prospectively underwent six sessions of repetitive peripheral magnetic stimulation (rPMS) over two weeks. Patients were randomly assigned to receive rPMS applied to the mTrPs of the trapezius (n = 19) or deltoid muscles (n = 18). Whereas the trapezius muscle is supposed to be part of the trigemino-cervical complex (TCC) and, thus, involved in the pathophysiology of migraine, the deltoid muscle was not expected to interfere with the TCC and was therefore chosen as a control stimulation site. The headache calendar of the German Migraine and Headache Society (DMKG) as well as the Migraine Disability Assessment (MIDAS) questionnaire were used to evaluate stimulation-related effects. Frequency of headache days decreased significantly in both the trapezius and the deltoid group after six sessions of rPMS (trapezius group: p = 0.005; deltoid group: p = 0.003). The MIDAS score decreased significantly from 29 to 13 points (p = 0.0004) in the trapezius and from 31 to 15 points (p = 0.002) in the deltoid group. Thus, rPMS applied to mTrPs of neck and shoulder muscles offers a promising approach to alleviate headache frequency and symptom burden. Future clinical trials are needed to examine more profoundly these effects, preferably using a sham-controlled setting.

Background: Upper crossed syndrome (UCS) refers to specific altered muscle activation and changed movement patterns along with some postural deviations in the upper quarter of the body. This syndrome might contribute to the dysfunction of the cervicothoracic and glenohumeral joints., Objectives: The present study will aim to investigate the effectiveness of a comprehensive corrective exercises program (CCEP) and subsequent detraining on alignment, muscle activation and movement pattern in men with UCS., Methods/design: This is a parallel-group randomized controlled trial. Participants will be 22 men aged 18 to 28 years who are suffering from UCS. Participants in the intervention group will conduct CCEP (three times a week for 8 weeks), followed by 4 weeks of detraining. The control group will do their daily activities. Participants will be randomized (1:1) into the intervention or the control group. The primary outcome will be upper trapezius activations. Secondary outcomes consist of electromyography of middle and lower trapezius and serratus anterior muscles, scapular dyskinesis test, forward head and shoulder angles, thoracic kyphosis angle, and neck flexion pattern test., Discussion: We propose to evaluate the effectiveness of a randomized controlled trial of a CCEP in men with UCS on their alignment, selected muscle activations, and relevant movement patterns. Results from our trial may provide new insights into the effects of exercise not only on the alignment but also on muscle activation and movement patterns that are important outcomes for people with postural malalignments and, if successful, could assist therapists in evidence-based clinical decision-making., Trial Registration: Iranian Registry of Clinical Trials, IRCT20181004041232N1. Registered on 26 October 2018.

Objective: To describe the clinical, serologic and histologic features of a cohort of patients with brachio-cervical inflammatory myopathy (BCIM) associated with systemic sclerosis (SSc) and unravel disease-specific pathophysiologic mechanisms occurring in these patients., Methods: We reviewed clinical, immunologic, muscle MRI, nailfold videocapillaroscopy, muscle biopsy, and response to treatment data from 8 patients with BCIM-SSc. We compared cytokine profiles between patients with BCIM-SSc and SSc without muscle involvement and controls. We analyzed the effect of the deregulated cytokines in vitro (fibroblasts, endothelial cells, and muscle cells) and in vivo., Results: All patients with BCIM-SSc presented with muscle weakness involving cervical and proximal muscles of the upper limbs plus Raynaud syndrome, telangiectasia and/or sclerodactilia, hypotonia of the esophagus, and interstitial lung disease. Immunosuppressive treatment stopped the progression of the disease. Muscle biopsy showed pathologic changes including the presence of necrotic fibers, fibrosis, and reduced capillary number and size. Cytokines involved in inflammation, angiogenesis, and fibrosis were deregulated. Thrombospondin-1 (TSP-1), which participates in all these 3 processes, was upregulated in patients with BCIM-SSc. In vitro, TSP-1 and serum of patients with BCIM-SSc promoted proliferation and upregulation of collagen, fibronectin, and transforming growth factor beta in fibroblasts. TSP-1 disrupted vascular network, decreased muscle differentiation, and promoted hypotrophic myotubes. In vivo, TSP-1 increased fibrotic tissue and profibrotic macrophage infiltration in the muscle., Conclusions: Patients with SSc may present with a clinically and pathologically distinct myopathy. A prompt and correct diagnosis has important implications for treatment. Finally, TSP-1 may participate in the pathologic changes observed in muscle., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

Competing Interests: Funding: None. Conflicts of Interest: The authors report no conflicts of interest. Ethics Statement: All patients who appear on the video have provided written informed consent and authorization for videotaping and publication of the videotape.

The objective of this investigation was to evaluate the activity of the suprahyoid musculature during swallowing and to correlate the findings with the degree of megaesophagus, oral and pharyngeal videofluoroscopy and esophageal manometry in patients with achalasia caused by Chagas' disease. Twenty-nine patients with positive serology for Trypanosoma cruzi and dysphagia (Chagas' disease group) and 29 individuals matched by sex and age (control group) participated in the study. Surface electromyography of the suprahyoid musculature and videofluoroscopy during swallowing of paste and liquid consistencies were performed. Canonical correlation analysis of the MANOVA test results showed that the Chagas' disease group had lower electromyographic activity when compared with controls. Overlapping circles of radiological findings were found for megaesophagus. The Spearman test showed a positive correlation between the electromyographic activity in the maximum voluntary isometric contraction and the time of pharyngeal transit for both liquid (p = 0.014) and paste (p = 0.047). The logistic regression test showed no association between electromyographic activity of the suprahyoid muscles and esophageal manometry results (p > 0.05). In conclusion, individuals with chagasic megaesophagus have reduced electromyographic activity of the suprahyoid muscles during swallowing, in addition to a greater recruitment of the suprahyoid musculature with increased pharyngeal transit time.

Motor development in infants is dependent upon the function of the inner ear balance organ (vestibular organ). Vestibular failure causes motor delays in early infancy and suboptimal motor skills later on. A vestibular test for newborns and infants that is applicable on a large scale, safe and cost effective is in demand in various contexts: in the differential diagnosis of early onset hearing loss to determine forms associated with vestibular failure; in early hearing habilitation with cochlear implant, indicating the vestibular predominant side; and in the habilitation of children affected by motor skill disorders, revealing the contribution of a vestibular failure. This work explored the feasibility of cervical vestibular evoked myogenic potentials (VEMP) in conjunction with newborn universal hearing screening program. VEMP was measured after the hearing tests and was evoked by bone-conducted stimuli. Moreover, stimulus delivery was regulated by neck muscle activity, with infants rested unconstrained in their parents´ arms and with the head supported by the operator´s hand. This VEMP protocol showed a high level of feasibility in terms of test viability and result reproducibility. VEMP integrated into the newborn hearing screening program may represent a practical method for large-scale assessment of balance function in infants.

Background: Altered thickness, cross-sectional area and activity of deep neck muscles have frequently been reported in patients with chronic non-specific neck pain (CNNP). It is claimed that these muscles do not recover spontaneously. These muscles provide a considerable amount of cervical stability. Therefore, various therapeutic exercises have been recommended to recover from resulting complications. However, most exercise protocols do not target deep neck muscles directly. Thus, this might be a reason for long-lasting complications. Accordingly, the purpose of the present study is to discuss a randomized controlled trial (RCT) protocol in which we aim to investigate and compare the effects of neck-specific exercise programmes versus general exercise programmes in patients with CNNP., Methods: A 2*2 factorial RCT with before-after design. Sixty-four participants with CNNP will be recruited into the study. They will be randomly divided into two groups, including specific neck exercise and general exercise. Each exercise programme will be carried out three times a week and will last for 8 weeks. Primarily, dorsal and ventral neck muscle thickness, pain and disability and secondarily, muscle strength, quality of life, sleep quality, fear avoidance and neck range of motion will be assessed at the baseline and immediately at the end of the exercise protocol., Discussion: The results of this study will inform clinicians on which type of exercise is more beneficial for patients with CNNP., Trial Registration: IRCT2017091620787N2, Sep 16 2017.

Background: Dropped head syndrome (DHS) is a low prevalence and the clinical features remain unclear. The purpose of the present study was to clarify the general overview of DHS., Methods: The subjects were 67 consecutive DHS patients (17 men and 50 women; average age 72.9 ± 10.2 years) presenting difficulty of horizontal gaze in up-right position. The patients' background, global spinal alignment, clinical findings and treatment were analyzed., Results: The peak population of DHS was 75-79-year-old females. The comorbidities included Parkinson's disease in 9 cases, minor trauma in 9 cases, post-cervical operation in 3 cases, mental depression in 3 cases, malignant tumor in 3 cases, diabetes mellitus in 2 cases and rheumatoid arthritis in 2 cases. The C2-C7 cervical coronal vertical axis was distributed more to the right side (2.6 ± 12.8 mm). Regarding sagittal alignment, 24 cases (35.8%) showed negative balanced DHS (N-DHS) and 43 cases (64.2%) showed positive balanced DHS (P-DHS). There were significant differences in C2-C7 angle, T1S, LL and PI-LL between the two groups. Cervical or back pain was present in 62 cases (92.5%), and average numerical rating scale was 3.0 ± 2.6. Fourteen cases (20.9%) recovered (average 11.3 months), but 29 cases (43.3%) did not recover without surgery. Twenty-four cases (35.8%) underwent surgery, 20 for cervical spine and 4 for thoraco-lumbar spine, and horizontal gaze difficulty was improved in all patients post-surgery., Conclusion: DHS was mainly observed in elderly women. About 20% of DHS patients recovered without surgical treatment. DHS was accompanied by scoliosis in 37.3% of the cases., (Copyright © 2019. Published by Elsevier B.V.)

Objectives : The purpose of this study was to describe the reliability and validity of measurements of cervical retraction strength obtained with a hand held dynamometer (HHD) from healthy adults. Background : Impaired neck muscle strength is related to neck pain, abnormal posture, and various cervical pathologies. While sophisticated devices to objectively measure neck strength exist, many are not practicable in typical orthopedic practices or have questionable validity and reliability. Methods : Forty participants were included in the analysis of neck strength using isometric testing with an HHD fixed in a cradle on a table top. The highest neck retraction force recorded in Newtons (N) for each participant, was used for data analysis. Results : Both intratester and intertester reliability were excellent as judged by intraclass correlation coefficients (ICCs) (.885 - .974) and minimal detectable change (MDC) (21.1 to 47.6 N). Validity was confirmed on the basis of expected gender and age differences (ie, men were stronger than women and younger participants were stronger than older participants). Conclusion : Fixed HHD is a reliable and valid tool for measuring isometric neck retraction strength in ostensibly healthy adults. Its value in the assessment of individuals with neck pathology awaits further examination.

Objective: This paper presents the first study where a dynamic neck brace was used to characterize the head motion of ALS patients while concurrently recording the surface electromyography (EMG) of the neck muscles., Methods: Eleven ALS patients and 10 age-matched healthy controls consented and participated in an experiment. Each participant was asked to perform three single-plane motions of the head-neck that included flexion-extension in the sagittal plane, lateral bending in the coronal plane, and axial rotation in the transverse plane. Each motion was performed in a cycle and was repeated five times at self-selected speeds., Results: During single-plane flexion-extension under gravity, compared to healthy peers, ALS patients showed a shorter duration to reach the maximum flexion and an earlier EMG onset in the neck extensors starting from the neutral. The brace measures in activation of the neck muscles in ALS patients were well correlated with clinically measured scores, such as the ALSFRS-r and the FVC. The activation duration of sternocleidomastoid, used to rotate the head, correlated well with the ALSFRS-r and FVC in ALS patients during axial rotation., Interpretation: The ability to synchronously activate a pair of muscles to execute single-plane motions in ALS patients seems to have been compromised due to the disease and potentially results in head drop. The neck brace measures can be adapted in the clinic to complement self-reporting in ALS patients and used to assess the head drop and progress of the disease., (© 2019 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals, Inc. on behalf of American Neurological Association.)

Objectives : Headaches can be associated with rhinosinusitis and may present a diagnostic challenge because of symptomatic overlap with other recurring headaches. Neck pain has received extensive attention in migraine, tension-type and cervicogenic headache but not as a comorbid feature of headache in those with rhinosinusitis. This study investigated the occurrence of neck pain and cervical musculoskeletal dysfunction in individuals with self-reported sinus headaches (SRSH). Methods : Participants with and without SRSH attended a single data collection session. Participants completed the Headache Impact Test (HIT)-6 and the Sino-Nasal Outcome Test (SNOT)-22. Cervical range of motion (ROM), segmental examination, muscle endurance and pressure-pain threshold (PPT) were measured . Results : Participants included 31 with SRSH (77.4% female; age 43.7 (9.9) years) and 30 without headache. Average symptom duration was 89.7 (±85.6) months. Mean SNOT-22 and HIT-6 scores were 36.2 (15.3) and 56.7 (7.1), respectively. In the SRSH group, 83.9% ( n = 26) reported neck pain. There was a significant difference between groups for cervical sagittal (14.3° [5.3°, 23.3°], p = 0.002) and transverse plane ROM (21.5° [12.4°, 30.6°], p < 0.001), but no difference in frontal plane motion ( p = 0.017). There were significant between groups difference in neck flexor endurance (19.5 s [10.1 s, 28.9 s], <0.001), segmental dysfunction O-C4 ( p < 0.001) but not in PPT ( p = 0.04). Discussion : Neck pain and cervical musculoskeletal dysfunction are common among persons with SRSH and may be a comorbid feature or contributing factor to headaches attributed to rhinosinusitis. Further research is needed to understand these associations.

Objectives : To compare the performance of cervical stabilizer muscles using the craniocervical flexion test (CCFT) among individuals with subacute, chronic, and asymptomatic low back pain (LBP) conditions. Methods : Individuals with subacute ( N = 23) and chronic LBP ( N = 23) with their age- and gender-matched controls ( N = 30) participated in this study. All recruited participants were required to perform the CCFT. The activation score (AS) and the performance index (PI) were recorded by an assessor who was blinded to the group of participants. Results : Approximately, 74% of subacute LBP participants and 60-65% of chronic LBP participants obtained abnormal AS and PI. AS was significantly lower in participants with subacute ( P = 0.0002) and chronic LBP ( P = 0.0009) than the control group. Likewise, the PI was significantly lower in participants with subacute ( P = 0.0002) and chronic LBP ( P = 0.0036) than the control group. Participants in the subacute LBP group showed significantly greater percentages of abnormal responses on the AS ( P < 0.0001) and the PI ( P = 0.0001) than the control. Discussion : Abnormal performance of cervical stabilizer muscles using the CCFT was demonstrated in a high proportion of participants with LBP. The findings highlight the plausible association in muscle control between cervical and lumbar stabilizers. Level of Evidence : 2b.

Sensorimotor control of neck muscles differs between individuals with and without pain. Differences in the primary motor cortex (M1) maps of these muscles may be involved. This study compared M1 representations of deep (DNF) and superficial (SNF) neck flexor muscles between 10 individuals with neck pain (NP) and 10 painfree controls. M1 organisation was studied using transcranial magnetic stimulation (TMS) applied to a grid over the skull and surface electromyography of DNF (pharyngeal electrode) and SNF. Three-dimensional maps of M1 representation of each muscle were generated. Peaks in the SNF map that represented the sternocleidomastoid (SCM) and platysma muscles were identified. Unique centre of gravity (CoG)/map peaks were identified for the three muscles. In comparison to painfree controls, NP participants had more medial location of the CoG/peak of DNF, SCM, and platysma, greater mediolateral variation in DNF CoG (p = 0.02), fewer SNF and DNF map peaks (p = 0.01). These data show that neck flexor muscle M1 maps relate to trunk, neck, and face areas of the motor homunculus. Differences in M1 representation in NP have some similarities and some differences with observations for other musculoskeletal pain conditions. Despite the small sample size, our data did reveal differences and is comparable to other similar studies. The results of this study should be interpreted with consideration of methodological issues., (© 2019 Wiley Periodicals, Inc.)

It has been suggested that neck muscle strength and anticipatory cocontraction can decrease head motions during head impacts. Here, we quantify the relative angular impulse contributions of neck soft tissue to head stabilization using an OpenSim musculoskeletal model with Hill-type muscles and rate-dependent ligaments. We simulated sagittal extension and lateral flexion mild experimental head impacts performed on 10 subjects with relaxed or cocontracted muscles, and median American football head impacts. We estimated angular impulses from active muscle, passive muscle and ligaments during head impact acceleration and deceleration phases. During the acceleration phase, active musculature produced resistive angular impulses that were 30% of the impact angular impulse in experimental impacts with cocontracted muscles. This was reduced below 20% in football impacts. During the deceleration phase, active musculature stabilized the head with 50% of the impact angular impulse in experimental impacts with cocontracted muscles. However, passive ligaments provided greater stabilizing angular impulses in football impacts. The redistribution of stabilizing angular impulses results from ligament and muscle dependence on lengthening rate, where ligaments stiffen substantially compared to active muscle at high lengthening rates. Thus, ligaments provide relatively greater deceleration impulses in these impacts, which limit the effectiveness of muscle strengthening or anticipated activations.

Aim: To further the understanding of the pathophysiological mechanisms underlying tension-type headache (TTH) by comparing the endurance and strength of neck extensor muscles under acute muscle fatigue in participants with TTH and asymptomatic participants., Methods: We conducted a cross-sectional analysis of neck extensor muscle performance. Asymptomatic participants and participants with TTH were recruited via social media platforms and from the Université du Québec à Trois-Rivières community and employees. A total of 44 participants with TTH and 40 asymptomatic participants took part in an isometric neck extensor endurance task performed at 60% of their maximum voluntary contraction. Inclusion criteria for the headache group were to be older than 18 years old and to fulfil the International Headache Society classification's criteria for either frequent episodic or chronic TTH. Clinical (self-efficacy, anxiety, neck disability and kinesiophobia) and physical parameters (neck extensors maximum voluntary contraction, endurance time, muscle fatigue) as well as characteristics of headache episodes (intensity, frequency and associated disability) were collected for all participants. Surface electromyography was used to document upper trapezius, splenius capitis and sternocleidomastoids muscle activity and muscle fatigue., Results: Both groups displayed similar neck extensor muscle endurance capacity with a mean difference of 6.2 s (p>0.05) in favour of the control group (control=68.1±32.3; TTH=61.9±20.1). Similarly, participants in the headache group showed comparable neck extensor muscle strength (95.9±30.4 N) to the control group (111.3±38.7 N). Among participants with TTH, those scoring as severely incapacitated by headaches were the ones with higher neck-related disability (F[1,44]=10.77; p=0.002), the more frequent headache episodes (F[1,44]=6.70; p=0.01) and higher maximum headache intensity (F[1,44]=10.81; p=0.002)., Conclusion: A fatigue task consisting of isometric neck extension cannot efficiently differentiate participants with TTH from asymptomatic participants., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Whiplash associated disorders remain a major health problem in terms of impact on health care and on societal costs. Aetiology remains controversial including the old supposition that the cervical muscles do not play a significant role. This study examined the muscle activity from relevant muscles during rear-end impacts in an effort to gauge their influence on the aetiology of whiplash associated disorders., Methods: Volunteers were subjected to a sub-injury level of rear impact. Surface electromyography (EMG) was used to record cervical muscle activity before, during and after impact. Muscle response time and EMG signal amplitude were analysed. Head, pelvis, and T1 acceleration data were recorded., Results: The activities of the cervical muscles were found to be significant. The sternocleidomastoideus, trapezius and erector spinae were activated on average 59 ms, 73 ms and 84 ms after the impact stimulus, respectively, prior to peak head acceleration (113 ms)., Conclusion: The cervical muscles reacted prior to peak head acceleration, thus in time to influence whiplash biomechanics and possibly injury mechanisms. It is recommended therefore, that muscular influences be incorporated into the development of the new rear-impact crash test dummy in order to make the dummy as biofidelic as possible., (Copyright © 2019 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.)

Purpose: Producing tongue pressure (TP) by pushing the tongue against the palate consists of lifting the tongue muscles and elevating the floor of the mouth via suprahyoid muscle contraction. Though studies have shown that tongue-pressure resistance training (TPRT) increases tongue function, none have focused on suprahyoid muscle function enhancements. Our study aimed to verify whether TPRT improves both tongue function and hyoid movement during swallowing., Materials and Methods: Eighteen patients (mean age: 76.8±6.2 years) with presbyphagia presenting with symptoms such as coughing and choking were enrolled. All patients performed daily living activities independently. None of the participants had diseases causing dysphagia or previous oral or pharyngeal surgery. Participants were instructed to push their tongues against the palate as hard as possible with their mouths closed for 10 seconds, and then resting for 10 seconds. A set consisted of five consecutive exercise and resting periods; two sets per day were performed for a month. TP and the oral diadochokinetic rate (ODKR), measured by repetitions of the syllables /ta/ and /ka/, assessed tongue function. The extent of anterior and superior hyoid movement and parameters related to swallowing, including the penetration aspiration scale (PAS) and the normalized residue ratio scale (NRRS) in the valleculae (NRRSv) and piriform sinus (NRRSp), were evaluated based on videofluoroscopic data., Results: The anterior ( P =0.031) and superior hyoid movement ( P =0.012), TP ( P =0.002), ODKR/ta/ ( P =0.034), ODKR/ka/ ( P =0.009), and the width of the upper esophageal sphincter ( P =0.001) were larger at follow-up than at baseline. NRRSp ( P =0.022), PAS ( P =0.016), and pharyngeal transit times ( P =0.004) were smaller at follow-up than at baseline., Conclusion: TPRT improved tongue strength, dexterity, both anterior and superior hyoid elevation, and swallowing functions. Therefore, TPRT could improve tongue function and suprahyoid muscle function simultaneously and contribute to prevention of sarcopenic dysphagia., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Computers are used as a means of social communication, for work and other purposes. However, patients with spinal cord injuries may have a higher risk than normal individuals with musculoskeletal problems when using computers owing to their inability to control respective postures due to problems in motor and sensory functioning., Objectives: This study is aimed at identifying the effect of computer desk heights on musculoskeletal discomforts of the neck and upper extremities and EMG activities in patients with spinal cord (C6) and upper thoracic spinal cord injuries., Methods: Participants of the present study were the patients diagnosed with ASIA A or B. The patients were divided into two groups according to their spinal cord injuries: C6 group and T2-T6 group. The level of the desk was set at 5 cm below the elbow, at the elbow level, and 5 cm above the elbow level. Electromyography was used to measure the duration of typing task EMG(%RVC) of the cervical erector spinae, upper trapezius, anterior deltoid, and wrist extensor. Subjective musculoskeletal discomfort (Borg-RPE) was measured at the end of the experiment., Results: The two groups showed differences in terms of RPE corresponding to each level of the computer desk ( p < .05). Postanalysis revealed the C6 group had decreased RPE as the level of computer desk increased, whereas the subjects in the T2-T6 group had decreased RPE values in accordance with the decreasing level of computer desk ( p < .05). In EMG, both groups had no significant differences ( p > .05). However, in terms of the interaction between the muscles and the level of computer desk in both groups, the differences in the interactions of the upper trapezius and wrist extensor with each level of the desk were found ( p < .05)., Conclusion: This study is meaningful in that it confirms computer work posture and preference of spinal cord-injured individuals.

Background: There is insufficient knowledge of pathophysiological parameters to understand the mechanism behind prolonged whiplash associated disorders (WAD), and it is not known whether or not changes can be restored by rehabilitation. The aims of the projects are to investigate imaging and molecular biomarkers, cervical kinaesthesia, postural sway and the association with pain, disability and other outcomes in individuals with longstanding WAD, before and after a neck-specific exercise intervention. Another aim is to compare individuals with WAD with healthy controls., Methods: Participants are a sub-group (n = 30) of individuals recruited from an ongoing randomized controlled study (RCT). Measurements in this experimental prospective study will be carried out at baseline (before intervention) and at a three month follow-up (end of physiotherapy intervention), and will include muscle structure and inflammation using magnetic resonance imaging (MRI), brain structure and function related to pain using functional MRI (fMRI), muscle function using ultrasonography, biomarkers using samples of blood and saliva, cervical kinaesthesia using the "butterfly test" and static balance test using an iPhone app. Association with other measures (self-reported and clinical measures) obtained in the RCT (e.g. background data, pain, disability, satisfaction with care, work ability, quality of life) may be investigated. Healthy volunteers matched for age and gender will be recruited as controls (n = 30)., Discussion: The study results may contribute to the development of improved diagnostics and improved rehabilitation methods for WAD., Trial Registration: Clinicaltrial.gov Protocol ID: NCT03664934, initial release 09/11/2018.

Objective: The aim of this study is to compare the effectiveness of dry needling therapy combined with exercise and exercise treatment alone for alleviating the dizziness caused by cervical myofascial pain syndrome., Design: This was a prospective randomized clinical study that included 61 women who had dizziness and myofascial trigger points on the neck muscles. The patients were randomized into a dry needling + exercise group (N = 31) and an exercise only group (N = 30)., Results: The mean age of the patients (±SD) was 38.4 ± 8.3 years. The intragroup comparisons of the severity of neck pain, algometric measurement, number of dizziness attacks per week, severity of the dizziness, fall index, and the Dizziness Handicap Inventory were improved in both groups at the first and fourth months (P < 0.05). The intergroup comparisons of the severity of neck pain, algometric measurement, number of dizziness attacks per week, the severity of the dizziness, and the Dizziness Handicap Inventory were more improved in the dry needling + exercise group at the first or fourth month compared with their inital assessments (P < 0.05). There was no diffence in fall index scores between the groups (P > 0.05)., Conclusions: Both dry needling + exercise therapy and exercise therapy alone were effective in treating dizziness caused by cervical myofascial pain syndrome. However, dry needling + exercise treatment was superior to exercise treatment alone.

Dropped head syndrome (DHS) is a rare condition, characterised by weakness of the cervical paraspinal muscles with sagging of the head. It is usually seen in association with neurological disorders and rarely can follow radiotherapy. We report a case of a 54-year-old man survivor of Hodgkin lymphoma (HL), who developed DHS 28 years after radiotherapy. He was referred to our department due to progressive weakness and atrophy of cervical paraspinal and shoulder girdle musculature. Physical and neurophysiological examination, electromyography and MRI confirmed the diagnosis of DHS. In the following years, there was no progression of symptoms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: An abnormal sternocleidomastoid muscle in congenital muscular torticollis can be classified into one of the four types via sonography. However, this categorization lacks quantitative measurements. The purpose of the study was to determine quantitative measurements of the sonograms via image analysis., Methods: Infants younger than 12 months of age suspected of having congenital muscular torticollis were included. Intraclass correlation coefficient estimates for interobserver reliability and a simple regression analysis for criterion validity were calculated. Spearman correlation analysis was then performed. The analyzed parameters included cervical passive range of motion for lateral flexion and rotation, area, brightness, max/min Feret's diameters, and muscular width/thickness., Results: Of the 29 (4.0 ± 2.6 months) screened infants, 13 (1.9 ± 1.7 months) were included. Nine were male, and 4 were female. Seven infants with mass were ultrasonographically classified into type I, and the other six infants were classified into type II. The affected/unaffected side ratios of cervical passive range of motion for lateral flexion and rotation were 0.92 ± 0.13 and 0.88 ± 0.16, respectively. The parameters measured on the sonograms were reliable, and the max/min Feret's diameters were valid measurements. The affected/unaffected side ratio of cervical passive range of motion for rotation significantly correlated with the affected/unaffected side ratios of the sternocleidomastoid muscle sonogram on area (r = -0.62, p = 0.03) and min Feret's diameter (r = -0.69, p = 0.01)., Conclusions: The area and min Feret's diameter were efficacious parameters for image analysis on sternocleidomastoid sonograms, and the min Feret's diameter would be more suitable than thickness for measuring the thickening SCM in transverse view. A healthy control group, more data and follow-up would be needed to confirm the changes on the SCM sonograms for clinical decision., (Copyright © 2018 Chang Gung University. Published by Elsevier B.V. All rights reserved.)

Background: Neck 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., Methods: Web 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., Results: DCF 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., Conclusions: DCF 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.

Objectives: To determine whether two independent examiners can agree on a diagnosis of myofascial pain syndrome (MPS). To evaluate interexaminer reliability in identifying myofascial trigger points in upper quarter muscles. To evaluate the reliability of clinical diagnostic criteria for the diagnosis of MPS. To evaluate the validity of clinical diagnostic criteria for the diagnosis of MPS., Design: Validity and reliability study., Setting: Provincial Hospital. Toledo, Spain., Participants: Twenty myofascial pain syndrome patients and 20 healthy, normal control subjects, enrolled by a trained and experienced examiner., Methods: Ten bilateral muscles from the upper quarter were evaluated by two experienced examiners. The second examiner was blinded to the diagnosis group. The MPS diagnosis required at least one muscle to have an active myofascial trigger point. Three to four days separated the two examinations. The primary outcome measure was the frequency with which the two examiners agreed on the classification of the subjects as patients or as healthy controls. The kappa statistic (K) was used to determine the level of agreement between both examinations, interpreted as very good (0.81-1.00), good (0.61-0.80), moderate (0.41-0.60), fair (0.21-0.40), or poor (≤0.20)., Results: Interexaminer reliability for identifying subjects with MPS was very good (K = 1.0). Interexaminer reliability for identifying muscles leading to a diagnosis of MPS was also very good (K = 0.81). Sensitivity and specificity showed high values for most examination tests in all muscles, which confirms the validity of clinical diagnostic criteria in the diagnosis of MPS., Conclusions: Interrater reliability between two expert examiners identifying subjects with MPS involving upper quarter muscles exhibited substantial agreement. These results suggest that clinical criteria can be valid and reliable in the diagnosis of this condition.