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Piano players, as well as other musicians, spend a long time training to achieve the best results, sometimes adopting unnatural body positions that may cause musculoskeletal pain. This paper presents the preliminary results of a study targeting the analysis of the head and cervical postures of 17 piano players during musical performance. It was found, as a common feature, that the players tilt the head to the right and forward towards the score and keyboard. Players who know the score by heart tend to move their heads more compared to the ones who have to keep their eyes on the score.

Background: Patients with cervical radiculopathy often have neck- and arm pain, neurological changes, activity limitations and difficulties in returning to work. Most patients are not candidates for surgery but are often treated with different conservative approaches and may be sick-listed for long periods. The purpose of the current study is to compare the effectiveness of neck-specific training versus prescribed physical activity., Methods/design: The current protocol is a two armed intervention randomised clinical trial comparing the outcomes of patients receiving neck specific training or prescribed physical activity. A total of 144 patients with cervical radiculopathy will be randomly allocated to either of the two interventions. The interventions will be delivered by experienced physiotherapists and last 14 weeks. The primary outcome variable is neck- and arm pain intensity measured with a Visual Analogue Scale accompanied with secondary outcome measures of impairments and subjective health measurements collected before intervention and at 3, 6, 12 and 24 months after base-line assessment., Discussion: We anticipate that the results of this study will provide evidence to support recommendations as to the effectiveness of conservative interventions for patients with cervical radiculopathy., Trial Registration: ClinicalTrials.gov identifier: NCT01831271.

The goal of this study was to obtain the limit of dysphagia and the average volume per swallow in patients with mild to moderate Parkinson's disease (PD) but without swallowing complaints and in normal subjects, and to investigate the relationship between them. We hypothesize there is a direct relationship between these two measurements. The study included 10 patients with idiopathic PD and 10 age-matched normal controls. Surface electromyography was recorded over the suprahyoid muscle group. The limit of dysphagia was obtained by offering increasing volumes of water until piecemeal deglutition occurred. The average volume per swallow was calculated by dividing the time taken by the number of swallows used to drink 100 ml of water. The PD group showed a significantly lower dysphagia limit and lower average volume per swallow. There was a significantly moderate direct correlation and association between the two measurements. About half of the PD patients had an abnormally low dysphagia limit and average volume per swallow, although none had spontaneously related swallowing problems. Both measurements may be used as a quick objective screening test for the early identification of swallowing alterations that may lead to dysphagia in PD patients, but the determination of the average volume per swallow is much quicker and simpler.

Head retraction exercises are one of several commonly used clinical tools that are used to assess and treat patients with head and neck pain and to aid in restoration of a normal neutral head posture. Retraction of the head results in flexion of the occipitoatlantal (OA) joint and stretching of rectus capitis posterior minor (RCPm) muscles. The role that retraction of the head might have in treating head and neck pain patients is currently unknown. RCPm muscles arise from the posterior tubercle of the posterior arch of C1 and insert into the occipital bone inferior to the inferior nuchal line and lateral to the midline. RCPm muscles are the only muscles that attach to the posterior arch of C1. The functional role of RCPm muscles has not been clearly defined. The goal of this project was to develop a three-dimensional, computer-based biomechanical model of the posterior aspect of the OA joint. This model should help clarify why voluntary head retraction exercises seem to contribute to the resolution of head and neck pain and restoration of a normal head posture in some patients. The model documents that length-tension properties of RCPm muscles are significantly affected by variations in the physical properties of the musculotendonous unit. The model suggests that variations in the cross sectional area of RCPm muscles due to pathologies that weaken the muscle, such as muscle atrophy, may reduce the ability of these muscles to generate levels of force that are necessary for the performance of normal, daily activities. The model suggests that the main benefit of the initial phase of head retraction exercises may be to strengthen RCPm muscles through eccentric contractions, and that the main benefit of the final phase of retraction may be to stretch the muscles as the final position is held., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Functional neck/shoulder stiffness is one of the most well-known indications for acupuncture treatment in Japan. There is little evidence for the effectiveness of acupuncture treatment for functional neck/shoulder stiffness. Research using two different placebos may allow an efficient method to tease apart the components of real acupuncture from various kinds of 'non-specific' effects such as ritual with touch or ritual alone. Herein, we describe a protocol of an ongoing, single-centre, randomised, placebo-controlled trial which aims to assess whether, in functional neck/shoulder stiffness, acupuncture treatment with skin piercing has a specific effect over two types of placebo: skin-touching plus ritual or ritual alone., Methods: Six acupuncturists and 400 patients with functional neck/shoulder stiffness are randomly assigned to four treatment groups: genuine acupuncture penetrating the skin, skin-touch placebo or no-touch placebo needles in a double-blind manner (practitioner-patient blinding) or no-treatment control group. Each acupuncturist applies a needle to each of four acupoints (Bladder10, Small Intestine14, Gallbladder21 and Bladder42) in the neck/shoulder to 50 patients. Before, immediately after and 24 hours after the treatment, patients are asked about the intensity of their neck/shoulder stiffness. After the treatment, practitioners and patients are asked to guess whether the treatment is "penetrating", "skin-touch" or "no-touch" or to record "cannot identify the treatment"., Discussion: In addition to intention-to-treat analysis, we will conduct subgroup analysis based on practitioners' or patients' guesses to discuss the efficacy and effectiveness of treatments with skin piercing and various placebo controls. The results of practitioner and patient blinding will be discussed. We believe this study will further distinguish the role of different components of acupuncture., Trial Registration: Current Controlled Trial ISRCTN76896018.

Background: Tension-type headaches (TTH) are common among children worldwide and mean a potential risk of disability and medication overuse headache. The associated mechanisms, however, remain unsolved. Our study investigated muscle strength in the neck-shoulder region, aerobic power and pericranial tenderness in girls with TTH compared with healthy controls., Methods: A blinded case-control study comprising 41 girls with TTH and 41 age-matched healthy controls. Standardised testing of isometric maximal voluntary contraction (MVC) and force steadiness of neck flexion and extension, as well as MVC and rate-of-force development of dominant shoulder, was conducted. VO2 max was recorded by a submaximal ergometer test and pericranial tenderness by standardised manual palpation. Logistic regression analyses were applied., Results: Girls with TTH demonstrated significantly higher pericranial tenderness than controls, in correlation with headache frequency (r = 0.66, p < 0.001). Results indicated that the odds ratio of girls having headache are 7.6 (95% CI 1.4-40.9) for weak to strong shoulder muscles; weak to average neck-shoulder strength OR 3.1 (95% CI 1.2-8.1); neck flexion strength OR 1.3 (95% CI 1.0-1.6) and 5.2 (95% CI: 1.4-19.6) for each unit of decrease in VO2 max., Conclusions: Reduced neck-shoulder strength and aerobic power together with increased pericranial tenderness are associated with TTH in girls. Future interventions should be directed towards health promoting patient educational programmes on enhanced physical exercising. Much more exact and detailed research in young girls and boys are needed., (© International Headache Society 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Head repositioning tasks have been used in different experimental and clinical contexts to quantitatively measure motor control performance. Effects of pain on sensorimotor control have often been described in various musculoskeletal conditions and may provide relevant information with regard to potential mechanisms underlying tension-type headaches. The purpose of the current study was to compare the performance of patients with tension-type headache and healthy participants in a cervical aiming task using the Fitts' task paradigm., Methods: Patients with tension-type headache and healthy controls were compared in a cervical aiming task. Participants were asked to move their head as quickly, and precisely as possible to a target under various experimental conditions. Dependent variables included movement time, variable error, constant error and absolute error., Results: As predicted by Fitts' law, decreasing target size and increasing head rotation amplitudes yielded longer movement times in both groups. Participants with tension-type headache, when compared to healthy participants showed a significant increase in both constant and absolute errors for each of the four conditions., Conclusion: Decreased motor performance was observed in participants with tension-type headache, likely due to altered motor control of the neck musculature. Future research is warranted to investigate the clinical aspect related to decrease in motor performance.

Objective: The aim of this study was to investigate pain patterns and the distribution of myofascial trigger points (MTPs) in whiplash-associated disorders (WADs II and III) as compared with mechanical neck pain (MNP)., Methods: Manual examination of suboccipital, upper trapezius, elevator scapula, temporalis, supraspinatus, infraspinatus, deltoid, and sternocleidomastoid muscles, was done to search for the presence of both active or latent MTPs in 49 WAD patients and 56 MNP patients. Local pain and referred pain from each active MTP was recorded on an anatomical map., Results: The mean number of active MTPs was significantly greater in the WAD group (6.71 ± 0.79) than in the MNP group (3.26 ± 0.33) (P < 0.001), but this was not found for the latent MTPs (3.95 ± 0.57 vs. 2.82 ± 0.34; P > 0.05). In the WAD group, the current pain intensity (visual analogue scale) of the patients was significantly correlated with the number of active MTPs (rs  = 0.03, P = 0.03) and the spontaneous pain area (rs  = 0.25, P = 0.07), and the number of active MTPs was significantly correlated with the spontaneous pain area (rs  = 0.3, P = 0.03). In the MNP group, significant correlation was found only between pain duration and spontaneous pain area (rs  = 0.29, P = 0.02)., Conclusions: Active MTPs are more prominent in WAD than MNP and related to current pain intensity and size of the spontaneous pain distribution in whiplash patients. This may underlie a lower degree of sensitization in MNP than in WAD., (Wiley Periodicals, Inc.)

Objective: The purposes of this study were to examine whether any differences in function and health exist between patients with cervical radiculopathy (CR) due to disk disease scheduled for surgery and patients with chronic whiplash-associated disorders (WADs) and to compare measures of patients' physical function with those obtained from healthy volunteers., Methods: This is a cross-sectional study of patients with CR (n = 198) and patients with chronic WAD (n = 215). Patient data were compared with raw data previously obtained from healthy people. Physical measures included cervical active range of motion, neck muscle endurance, and hand grip strength. Self-rated measures included pain intensity (visual analog scale), neck disability (Neck Disability Index), self-efficacy (Self-Efficacy Scale), and health-related quality of life (EuroQol 5-dimensional self-classifier)., Results: Patient groups exhibited significantly lower performance than the healthy group in all physical measures (P < .0005) except for neck muscle endurance in flexion for women (P > .09). There was a general trend toward worse results in the CR group than the WAD group, with significant differences in neck active range of motion, left hand strength for women, pain intensity, Neck Disability Index, EuroQol 5-dimensional self-classifier, and Self-Efficacy Scale (P < .0001)., Conclusions: Patients had worse values than healthy individuals in almost all physical measures. There was a trend toward worse results for CR than WAD patients., (Copyright © 2014 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

Purpose: To determine the time-wise effect of specific resistance training on neck pain among industrial technicians with frequent neck pain symptoms., Methods: Secondary analysis of a parallel-group cluster randomized controlled trial of 20 weeks performed at two large industrial production units in Copenhagen, Denmark. Women with neck pain >30 mm VAS (N = 131) were included in the present analysis. The training group (N = 77) performed specific resistance training for the neck/shoulder muscles three times a week, and the control group (N = 54) received advice to stay active. Participants of both groups registered neck pain intensity (0-100 mm VAS) once a week., Results: Neck pain intensity was 55 mm (SD 23) at baseline. There was a significant group by time interaction for neck pain (F-value 2.61, P<0.001, DF = 19). Between-group differences in neck pain reached significance after 4 weeks (11 mm, 95% CI 2 to 20). The time-wise change in pain showed three phases; a rapid decrease in the training group compared with the control group during the initial 7 weeks, a slower decrease in pain during the following weeks (week 8-15), and a plateau during the last weeks (week 16-20). Adherence to training followed a two-phase pattern, i.e. weekly participation rate was between 70-86% during the initial 7 weeks, dropping towards 55-63% during the latter half of the training period., Conclusion: Four weeks of specific resistance training reduced neck pain significantly, but 15 weeks is required to achieve maximal pain reduction. The time-wise change in pain followed a three-phase pattern with a rapid effect during the initial 7 weeks followed by a slower but still positive effect, and finally a plateau from week 15 and onwards. Decreased participation rate may explain the decreased efficacy during the latter phase of the intervention.

Background: Neglected congenital muscular torticollis is rare in adults but may be associated with pain and cosmetic problems. The efficacy of surgical correction in these patients has not been well established in the literature., Questions/purposes: We sought to describe (1) the primary goals that influenced adults with neglected muscular torticollis to seek surgical correction, (2) improvements of patients' function (specifically ROM) and radiographic parameters associated with deformities, (3) patient-derived outcomes using a previously published scale that includes function, and cosmesis, and (4) complications associated with sternocleidomastoid release in one surgeon's series of patients., Methods: We retrospectively reviewed the records of all adult patients who had surgical release of the sternocleidomastoid muscle between 2003 and 2011 by one surgeon and who were followed up for more than 1 year after surgery; 42 of these procedures were performed, and complete followup was available for 37 of them (88%). The mean age of the patients was 27 years (range, 18-48 years), and the minimum followup was 1.5 years (mean, 2.4 years; range, 1.5-4.7 years). The primary goal of the operation for each patient was determined to assess if it was met. Functional outcomes were assessed in terms of motion deficit: lateral flexion and rotation. Radiographic outcomes were assessed for cervicomandibular angle, lateral translation of the head and neck, and Cobb's angle of the cervicothoracic spine. The overall clinical results of surgery were assessed with the modified Cheng and Tang scoring system, and complications were tallied from a chart review., Results: The primary goals of surgery were cosmesis in 17 (46%) patients, pain in 11 (30%) patients, and function in nine (24%) patients. Patients for whom pain was the primary goal of surgery were older than the other patients. ROM and radiographic parameters associated with deformity consistently improved in these patients (p < 0.001 in all planes), and the overall results according to the modified Cheng and Tang scoring system indicated that 21 (57%) patients had an excellent result, 12 (32%) had a good result, and four (11%) had a fair result. There were no serious complications and no reoperations in these patients., Conclusions: Sternocleidomastoid release was beneficial for the treatment of neglected congenital muscular torticollis in adults and was not associated with any serious complications. Surgical treatment led to cosmetic and functional improvements and relieved pain originating from the muscle imbalance brought about by the long-standing deformity., Level of Evidence: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Background: Cervical vestibular evoked myogenic potentials (cVEMPs) are electromyogram responses evoked by high-level acoustic stimuli recorded from the tonically contracting sternocleidomastoid (SCM) muscle, and have been accepted as a measure of saccular and inferior vestibular nerve function. As more laboratories are publishing cVEMP data, there is a wider range of recording methods and interpretation, which may be confusing and limit comparisons across laboratories., Objective: To recommend minimum requirements and guidelines for the recording and interpretation of cVEMPs in the clinic and for diagnostic purposes., Material and Methods: We have avoided proposing a single methodology, as clinical use of cVEMPs is evolving and questions still exist about its underlying physiology and its measurement. The development of guidelines by a panel of international experts may provide direction for accurate recording and interpretation., Results: cVEMPs can be evoked using air-conducted (AC) sound or bone conducted (BC) vibration. The technical demands of galvanic stimulation have limited its application. For AC stimulation, the most effective frequencies are between 400 and 800 Hz below safe peak intensity levels (e.g. 140 dB peak SPL). The highpass filter should be between 5 and 30 Hz, the lowpass filter between 1000 and 3000 Hz, and the amplifier gain between 2500 and 5000. The number of sweeps averaged should be between 100 and 250 per run. Raw amplitude correction by the level of background SCM activity narrows the range of normal values. There are few publications in children with consistent results., Conclusion: The present recommendations outline basic terminology and standard methods. Because research is ongoing, new methodologies may be included in future guidelines., (Copyright © 2014 International Federation of Clinical Neurophysiology. All rights reserved.)

There is evidence to implicate the role of the cervical spine in influencing postural control, however the underlying mechanisms are unknown. The aim of this study was to explore standing postural control mechanisms in older adults with neck pain (NP) using measures of signal frequency (wavelet analysis) and complexity (entropy). This cross-sectional study compared balance performance of twenty older adults with (age=70.3±4.0 years) and without (age=71.4±5.1 years) NP when standing on a force platform with eyes open and closed. Anterior-posterior centre-of-pressure data were processed using wavelet analysis and sample entropy. Performance-based balance was assessed using the Timed Up-and-Go (TUG) and Dynamic Gait Index (DGI). The NP group demonstrated poorer functional performance (TUG and DGI, p<0.01) than the healthy controls. Wavelet analysis revealed that standing postural sway in the NP group was positively skewed towards the lower frequency movement (very-low [0.10-0.39Hz] frequency content, p<0.01) and negatively skewed towards moderate frequency movement (moderate [1.56-6.25Hz] frequency content, p=0.012). Sample entropy showed no significant differences between groups (p>0.05). Our results demonstrate that older adults with NP have poorer balance than controls. Furthermore, wavelet analysis may reveal unique insights into postural control mechanisms. Given that centre-of-pressure signal movements in the very-low and moderate frequencies are postulated to be associated with vestibular and muscular proprioceptive input respectively, we speculated that, because NP demonstrate a diminished ability to recruit the muscular proprioceptive system compared to controls, they rely more on the vestibular system for postural stability., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Many congenital and acquired diseases, including trauma, may result in cervical spine instability. Given that airway management is closely related to the movement of the cervical spine, it is important that the anesthesiologist has detailed knowledge of the anatomy, the mechanisms of cervical spine instability, and of the effects that the different airway maneuvers have on the cervical spine. We first review the normal anatomy and biomechanics of the cervical spine in the context of airway management and the concept of cervical spine instability. In the second part, we review the protocols for the management of cervical spine instability in trauma victims and some of the airway management options for these patients., (Copyright © 2013 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. All rights reserved.)

Purpose: The aim of the study was to compare myoelectric manifestation in neck muscle endurance and fatigue characteristics during sub-maximal isometric endurance test in patients with cervical radiculopathy and asymptomatic subjects. An additional aim was to explore associations between primary neck muscle endurance, myoelectric fatigability, and self-rated levels of fatigue, pain and subjective health measurements in patients with cervical radiculopathy., Methods: Muscle fatigue in the ventral and dorsal neck muscles was assessed in patients with cervical radiculopathy and in an asymptomatic group during an isometric neck muscle endurance test in prone and supine. 46 patients and 34 asymptomatic subjects participated. Surface electromyography signals were recorded from the sternocleidomastoid, cervical paraspinal muscles and upper and middle trapezius bilaterally during the endurance test. Subjective health measurements were assessed with questionnaires., Results: The results showed altered neck muscle endurance in several of the muscles investigated with greater negative median frequency slope, greater variability, side imbalance, lower endurance time and higher experience of fatigue among the cervical radiculopathy patients compared with healthy subjects. Endurance times were significantly lower in both prone and in supine positions between the patients compared to asymptomatic subjects. During the neck muscle endurance test, fatigues in the upper trapezius muscles during the prone test and in the sternocleidomastoid muscles during the supine test were of more importance than self-perceived pain, fatigue, disability and kinesiophobia in predicting neck muscle endurance (NME)., Conclusion: NME testing in the primary neck muscles seems to be an important factor to take into consideration in rehabilitation.

Aims: To compare the masticatory and cervical muscle tenderness and pain sensitivity in the hand (remote region) between patients with temporomandibular disorders (TMD) and healthy controls., Methods: Twenty female subjects were diagnosed with chronic TMD, and 20 were considered healthy. Subjects completed the Neck Disability Index and Limitations of Daily Functions in a TMD questionnaire. Tenderness of the masticatory and cervical muscles and pain sensitivity in the hand were measured using an algometer. Three-way mixed analysis of variance (ANOVA) evaluated differences in muscle tenderness between groups. One-way ANOVA compared pain sensitivity in the hand between groups. Effect sizes were assessed using Cohen guidelines., Results: Significantly increased masticatory and cervical muscle tenderness and pain sensitivity in the hand were found in subjects with TMD when compared with healthy subjects. Moderate to high effect sizes showed the clinical relevance of the findings., Conclusion: The results of this study have highlighted the importance of assessing TMD patients not only in the craniofacial region but also in the neck and other parts of the body. Future studies should focus on testing the effectiveness of treatments addressing the neck and the pain sensitivity in the hand in patients with TMD.

Objective: The aim of this study is to investigate the diagnostic accuracy of muscle-to-nodule strain ratio (MNSR) in the differentiation of benign and malignant thyroid nodules and to see if there was a difference between MNSR and parenchyma-to-nodule strain ratios (PNSR) in diagnosis., Methods: A total of 106 consecutive patients (88 women and 18 men; age range 19-79 years) with thyroid nodules were prospectively examined using ultrasound and sonoelastography before the fine-needle aspiration biopsy. The mean MNSR and PNSR were calculated for each nodule and the elasticity score was determined according to four-point scoring system., Results: According to the four-point scoring system, 44 of the 83 benign nodules had a score of one or two while 22 of the 23 malignant nodules had a score of three or four (p<0.001). Using ROC analysis, the best cutoff point for MNSR 1.85 and for PNSR 3.14 was calculated. The sensitivity and specificity for the MNSR were 95.6%, 92.8%, respectively; for the PNSR were 95.6%, 93.4%, respectively, when the best cutoff points were used (p<0.001). The κ value for the PNSR and MNSR methods was 0.87, which indicated an almost perfect agreement (p<0.001)., Conclusions: Sonoelastography has a high diagnostic accuracy in the differentiation of benign and malignant thyroid nodules. There was no significant difference between MNSR and PNSR in the differentiation of benign and malignant thyroid nodules. Therefore, we think that MNSR could safely be used in situations where PNSR could not be used., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: The purpose of this study was to evaluate neck-related physical function in individuals 11 to 14 years after anterior cervical decompression and fusion (ACDF) surgery for degenerative cervical disk disease and to compare the long-term outcome of 2 surgical techniques, including the Cloward procedure and cervical intervertebral fusion cage., Methods: In this cross-sectional study, 51 individuals, 11 years or more after ACDF, underwent testing of cervical active range of motion, hand-grip strength, static and dynamic balance, neck muscle endurance, and completed pain ratings. The participants' values were compared with values of age- and sex-matched healthy individuals to evaluate impairments. Correlations between different test scores and pain were performed. Group differences were analyzed between the 2 surgical techniques., Results: Sixty-five percent and 82% exhibited impairment in ventral and dorsal neck muscle endurance, respectively. Impairment rates of 18% to 39% for cervical active range of motion, 27% to 43% for hand-grip strength, 37% for standing balance, and 35% for dynamic balance were recorded. Twenty-nine percent of the participants had impairment (>30 mm visual analog scale) in pain. There were no significant differences in physical function between the 2 surgical treatment groups (Cloward procedure or cervical intervertebral fusion cage) (P = .10-.92)., Conclusions: In those studied, a large percentage of patients who had anterior cervical decompression and fusion surgery have impairments in neck-related physical function when compared 11 to 14 years after surgery with age- and sex-matched healthy reference individuals. Neck-specific function, but not balance, was statistically correlated to pain. Neck muscle endurance was most affected, and balance impairments were also present in one-third of the individuals. There were no differences in long-term physical function between the 2 surgical techniques., (Copyright © 2014 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

Vestibular-evoked myogenic potentials (VEMP), short-latency electromyographic responses elicited by acoustic stimuli, evaluate the function of vestibulocollic reflex and may give information about brainstem function. The aim of the present study is to evaluate the potential contribution of VEMP to the diagnosis of multiple sclerosis (MS). Fifty patients with MS and 30 healthy control subjects were included in this study. The frequency of VEMP p1-n1 and n2-p2 waves; mean p1, n1, n2, and p2 latency; and mean p1-n1 and n2-p2 amplitude were determined. The relation between clinical and imaging findings and VEMP parameters was evaluated. The p1-n1 and n2-p2 waves were more frequently absent in MS than in control subjects [p1-n1 wave absent: MS, 25 (25 %) ears; control, 6 (10 %) ears; P ≤ 0.02] [n2-p2 wave absent: MS, 44 (44 %) ears; control, 7 (12 %) ears; P ≤ 0.001]. The mean p1-n1 amplitude was lower in MS than in control subjects (MS, 19.1 ± 7.2 μV; control, 23.3 ± 7.4 μV; P ≤ 0.002). A total of 24/50 (48 %) MS patients had VEMP abnormalities (absent responses and/or prolonged latencies). VEMP abnormalities were more frequent in patients with than without vestibular symptoms (P ≤ 0.02) and with brainstem functional system score (FSS) ≥ 1 than FSS = 0 (P ≤ 0.02). In patients with MS, absence of p1-n1 wave was more frequent in patients with than without vestibular symptoms [absence of p1-n1 wave: vestibular symptoms, 9 (45 %) ears; no vestibular symptoms, 16 (20 %) ears; P ≤ 0.03] and patients with Expanded Disability Status Scale (EDSS) score ≥ 5.5 [absence of p1-n1 wave: EDSS ≥ 5.5, 7 (70 %) ears; EDSS <5.5, 18 (20 %) ears; P ≤ 0.001]. Abnormal VEMP may be noted in MS patients, especially those with vestibular symptoms and greater disability. The VEMP test may complement other studies for diagnosis and follow-up of patients with MS.

Background: Different types of exercises can help manage chronic neck pain. Supervised exercise interventions are widely used, but these protocols require substantial resources. The aim of this trial, which focused on adherence, was to evaluate two home exercise interventions., Methods: This parallel group randomized controlled trial included 57 women randomly allocated into two groups - a strength training group (STRENGTH, 34 subjects) and a stretching group (STRETCH, 23 subjects). The interventions focused on the neck and shoulder muscles and lasted for 12 months. The STRENGTH group performed weight training and ended each session with stretching exercises. These stretching exercises constituted the entirety of the STRETCH group's training session. Both groups were instructed to exercise three times per week. All the participants kept an exercise diary. In addition, all participants were offered support via phone and e-mail. The primary outcomes were pain intensity and function. The trial included a four- to six-month and a twelve-month follow-up. A completer in this study exercised at least 1,5 times per week during eight unbroken weeks. A responder in this study reported clinically significant improvements on pain and function. The statistical analyses used the Mann Whitney U-test, Wilcoxon signed-rank test, and X2 test., Results: At four- to six-months, the numbers of completers were 19 in the STRENGTH group and 17 in the STRETCH group. At twelve months, the corresponding numbers were 11 (STRENGTH) and 10 (STRETCH). At four- to six-months, the proportions of subjects reporting clinically important changes (STRENGTH and STRETCH) were for neck pain: 47% and 41%, shoulder pain: 47% and 47%, function: 37% and 29%. At twelve months, the corresponding numbers were for neck pain: 45% and 40%, shoulder pain: 55% and 50%, function: 55% and 20%., Conclusions: No differences in the two primary outcomes between the two interventions were found, a finding that may be due to the insufficient statistical power of the study. Both interventions based on home exercises improved the two primary outcomes, but the adherences were relatively low. Future studies should investigate ways to improve adherence to home exercise treatments., Trial Registration: ClinicalTrials.gov Id: NCT01876680.

Objective: For the evaluation of neck injury the relative distance was observed between a marker placed on the forehead and a marker placed on the shoulder and also by change of the angle. To compare the severity of head injury a value of maximum head acceleration was used, HIC and a 3 ms criterion. All criteria were related to the activity of musculus sternocleidomastoideus and musculus trapezius in a situation of expected or unexpected contact impact., Materials and Methods: The situation was recorded using a Qualisys system, head acceleration of probands in three axes was recorded using the accelerometer, activity of neck muscles was monitored by a mobile EMG., Results: Maximum head acceleration was 5.61 g for non-visual and 5.03 g for visual. HIC36 was 6.65 non visual and 5.97 for visual. 3-ms criterion was 5.37 g for non-visual and 4.89 g for visual and max. force was 291 N for non-visual and 314 N for visual. The average time of muscle activation of the observed group without visual perception is 0.355 s after hitting an obstacle, with visual perception 0.085 s before the crash., Conclusions: Kinematic values indicate more favourable parameters for neck injuries for visual. Head injury criteria show an average decrease of about 10% for visual. We can conclude that the visual perception means a significant increase in pre-activation of the observed muscle group of almost 745% and lower activation in following phase of approximately 90%.

Few studies have described physical therapy approaches to provide functional independence and reduce pain in individuals with dystonia. This report describes the physical therapy treatment of a 46-year-old woman diagnosed with idiopathic segmental axial dystonia. For two years, the patient was treated with kinesiotherapy (active and resisted movements and stretching of neck and trunk muscles), abdominal taping (kinesiotaping techniques), functional training, and sensory tricks. She was assessed with parts I, II and III of Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS-I, TWSTRS-II and TWSTRS-III), Berg Balance Scale (BBS), Six-Minute Walk Test (6-MWT), and the motor domain of Functional Independence Measure (FIM-motor) before and after the two-year treatment and after the one year follow-up. Postural control and symmetry improved (TWSTRS-I: from 30 to 18), functional independence increased (TWSTRS-II: from 27 to 15; BBS: from 36 to 46; 6-MWT: from 0 to 480 meters (m); FIM-motor: from 59 to 81), and the pain diminished (TWSTRS-III: from 12 to 5). The functional improvement was retained after one year (TWSTRS-I: 14/35; TWRTRS-II: 12/30; TWRTRS-III: 5/20; BBS: 48/56; 6-MWT: 450 m; FIM-motor: 81/91). This program showed efficacy on providing a better control of the dystonic muscles and thus the doses of botulinum toxin needed to treat them could be reduced. Outcomes support the therapeutic strategies used to deal with this type of dystonia.

Objective: This study aims to determine if cervical medial branch radiofrequency neurotomy reduces psychophysical indicators of augmented central pain processing and improves motor function in individuals with chronic whiplash symptoms., Design: Prospective observational study of consecutive patients with healthy control comparison., Setting: Tertiary spinal intervention centre in Calgary, Alberta, Canada., Subjects: Fifty-three individuals with chronic whiplash associated disorder symptoms (Grade 2); 30 healthy controls., Methods: Measures were made at four time points: two prior to radiofrequency neurotomy, and 1- and 3-months post-radiofrequency neurotomy. Measures included: comprehensive quantitative sensory testing (including brachial plexus provocation test), nociceptive flexion reflex, and motor function (cervical range of movement, superficial neck flexor activity during the craniocervical flexion test). Self-report pain and disability measures were also collected. One-way repeated measures analysis of variance and Friedman's tests were performed to investigate the effect of time on the earlier measures. Differences between the whiplash and healthy control groups were investigated with two-tailed independent samples t-test or Mann-Whitney tests., Results: Following cervical radiofrequency neurotomy, there were significant early (within 1 month) and sustained (3 months) improvements in pain, disability, local and widespread hyperalgesia to pressure and thermal stimuli, nociceptive flexor reflex threshold, and brachial plexus provocation test responses as well as increased neck range of motion (all P < 0.0001). A nonsignificant trend for reduced muscle activity with the craniocervical flexion test (P > 0.13) was measured., Conclusions: Attenuation of psychophysical measures of augmented central pain processing and improved cervical movement imply that these processes are maintained by peripheral nociceptive input., (Wiley Periodicals, Inc.)

Background: Iranian vibrato (tahrir) is a common feature of traditional Iranian singing. A unique feature of tahrir is a modulated voice quality perceived as a rhythmic falsetto voice break associated with upward pitch inflections. Laryngeal discomfort and impaired voice quality can occur in singers when they perform Iranian tahrir using an improper technique., Aim: A case series research design was used to explore voice treatment outcomes using laryngeal manual therapy (LMT) for treating voice problems associated with tahrir singing., Method: Four professional Iranian singers of the traditional style (3 men and 1 woman) were studied. All subjects reported difficulty executing tahrir during performances. They were assessed by a speech-language pathologist (SLP) specializing in the administration of LMT for voice disorders. Multidimensional assessments were made of the participants' vocal function using acoustic and auditory-perceptual evaluation, self-reports of the singers, and LMT assessments by the SLP before and after treatment. The therapeutic program implemented LMT techniques to release laryngeal joints and reduce muscular tension., Results: Pretreatment examination of the larynx and anterior neck musculature using palpation showed that the difficulties in producing tahrir vibrato were associated with a decreased thyrohyoid space and tension in the submental complex and sternocleidomastoid. Posttreatment examination showed an increased thyrohyoid space and reduced tension in the submental complex and sternocleidomastoid, associated with the singers' perception of reduced effort producing tahrir vibrato during singing., Conclusion: Tahrir vibrato requires specific training to prevent excessive tension in laryngeal and neck muscles. In the absence of such training, or in the context of excessive singing associated with fatigue, LMT may facilitate more efficient vocal production in tahrir singers., (© 2015 S. Karger AG, Basel.)

Background: This study investigates the reliability of muscle performance tests using cost- and time-effective methods similar to those used in clinical practice. When conducting reliability studies, great effort goes into standardising test procedures to facilitate a stable outcome. Therefore, several test trials are often performed. However, when muscle performance tests are applied in the clinical setting, clinicians often only conduct a muscle performance test once as repeated testing may produce fatigue and pain, thus variation in test results. We aimed to investigate whether cervical muscle performance tests, which have shown promising psychometric properties, would remain reliable when examined under conditions similar to those of daily clinical practice., Methods: The intra-rater (between-day) and inter-rater (within-day) reliability was assessed for five cervical muscle performance tests in patients with (n = 33) and without neck pain (n = 30). The five tests were joint position error, the cranio-cervical flexion test, the neck flexor muscle endurance test performed in supine and in a 45°-upright position and a new neck extensor test., Results: Intra-rater reliability ranged from moderate to almost perfect agreement for joint position error (ICC ≥ 0.48-0.82), the cranio-cervical flexion test (ICC ≥ 0.69), the neck flexor muscle endurance test performed in supine (ICC ≥ 0.68) and in a 45°-upright position (ICC ≥ 0.41) with the exception of a new test (neck extensor test), which ranged from slight to moderate agreement (ICC = 0.14-0.41). Likewise, inter-rater reliability ranged from moderate to almost perfect agreement for joint position error (ICC ≥ 0.51-0.75), the cranio-cervical flexion test (ICC ≥ 0.85), the neck flexor muscle endurance test performed in supine (ICC ≥ 0.70) and in a 45°-upright position (ICC ≥ 0.56). However, only slight to fair agreement was found for the neck extensor test (ICC = 0.19-0.25)., Conclusions: Intra- and inter-rater reliability ranged from moderate to almost perfect agreement with the exception of a new test (neck extensor test), which ranged from slight to moderate agreement. The significant variability observed suggests that tests like the neck extensor test and the neck flexor muscle endurance test performed in a 45°-upright position are too unstable to be used when evaluating neck muscle performance.

Whiplash associated disorder (WAD) represents an enormous economic, social and personal burden. Five out of 10 people with WAD never fully recover and up to 25% continue to have moderate to severe pain-related disability. Unfortunately, clear and definitive reasons as to why half of individuals with WAD recover uneventfully and the other half do not, remain elusive. Identifying the factors that can reliably predict outcome holds considerable importance for not only WAD, but arguably for other acute musculoskeletal traumas. The precise pathology present in WAD has been controversial and often biased by outdated models. Fortunately, a combination of new measurement technology that illuminates pain processing, physical and social functioning and post-traumatic stress responses (and possibly markers of altered muscle size/shape/physiology) is providing a clearer picture of the multisystem pathophysiology in individuals with persistent WAD. The aim of this professional issues paper is to illuminate the clinical and research communities with regards to the growing body of knowledge for determining the trajectory of a patient with whiplash., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The purpose of this study was to assess the effect of repeated sessions of electrical stimulation therapy (EST) on the neck muscles with respect to the stimulation site by using quantitative kinematic analysis of videofluoroscopic swallowing studies (VFSS) in dysphagia patients with acquired brain injury. We analyzed 50 patients in a tertiary hospital who were randomly assigned into two different treatment groups. One group received EST on the suprahyoid muscle only (SM), and the other group received stimulation with one pair of electrodes on the suprahyoid muscle and the other pair on the infrahyoid muscle (SI). All patients received 10-15 sessions of EST over 2-3 weeks. The VFSS was carried out before and after the treatment. Temporal and spatial parameters of the hyoid excursion and laryngeal elevation during swallowing were analyzed by two-dimensional motion analysis. The SM group (n = 25) revealed a significant increase in maximal anterior hyoid excursion distance (mean ± SEM = 1.56 ± 0.52 mm, p = 0.008) and velocity (8.76 ± 3.42 mm/s, p = 0.017), but there was no significant increase laryngeal elevation. The SI group (n = 25), however, showed a significant increase in maximal superior excursion distance (2.09 ± 0.78 mm, p = 0.013) and maximal absolute excursion distance (2.20 ± 0.82 mm, p = 0.013) of laryngeal elevation, but no significant increase in hyoid excursion. There were no significant differences between the two groups with respect to changes in maximal anterior hyoid excursion distance (p = 0.130) and velocity (p = 0.254), and maximal distance of superior laryngeal elevation (p = 0.525). EST on the suprahyoid muscle induced an increase in anterior hyoid excursion, and infrahyoid stimulation caused an increase in superior laryngeal elevation. Hyolaryngeal structural movements were increased in different aspects according to the stimulation sites. Targeted electrical stimulation based on pathophysiology is necessary.

Background: The craniocervical flexion test (CCFT) is generally undertaken using a pressure biofeedback unit. However, the high costs of the device limits its availability in poorly resourced healthcare settings. The use of alternate measures such as the aneroid sphygmomanometer to undertake CCFT need to be investigated., Objective: The objective of this study was to establish the concurrent validity, intra- and inter-rater reliability of the aneroid sphygmomanometer using a paediatric size cuff for CCFT in asymptomatic adults., Methods: This cross-sectional observational study involved 300 asymptomatic participants randomly allocated to either validity (n = 100), intra-rater (n = 100) or inter-rater (n = 100) testing. Participants were asked to perform CCFT to assess craniocervical flexors performance using the pressure biofeedback unit and the aneroid sphygmomanometer with a paediatric cuff. Inter-rater reliability test was performed by two different raters on the same day with rest of 30 min between tests. An independent observer checked and recorded the pressures noted on the pressure dial thus ensuring blinded outcome measurement. Correlation between the two instruments was determined by computing the stability coefficient (Pearson product moment correlation) and associated P-values for statistical significance. Intra-class correlation coefficients and its 95% confidence intervals (CIs) were calculated to determine the intra- and inter-rater reliability., Results: The concurrent validity of aneroid sphygmomanometer as per Pearson's product moment correlation was r = 0.856 for activation score. The intra-class correlation coefficients for intra-rater reliability was 0.92 (95% CI 0.89-0.94), and inter-rater reliability was 0.87 (95% CI 0.80-0.91)., Conclusion: This study has confirmed high concurrent validity, intra- and inter-rater reliability of the aneroid sphygmomanometer using a paediatric cuff for CCFT in asymptomatic adults. Its use in people with neck pain warrants investigation., (© 2013 The Authors. International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute.)

AIM. To analyse the effectiveness of therapeutic exercise on migraines and tension-type headaches (TTH). MATERIALS AND METHODS. Electronic databases were used to search the literature for relevant articles. Eligibility criteria were: controlled randomised clinical trials (RCT), conducted on patients with migraine or TTH, in which the therapeutic intervention was based on therapeutic exercise, and the papers had been published in English and Spanish. Two independent reviewers performed the analysis of the methodological quality using the Delphi scale. RESULTS. Ten RCT were selected, seven of which offered good methodological quality. According to all the studies analysed, the intensity and frequency of pain diminished in comparison to the situation prior to establishing therapeutic exercise, and in five studies the effect was higher than in the control group. The qualitative analysis showed strong evidence of the absence of adverse events following the application of therapeutic exercise. Furthermore, strong evidence was also found of the effect of physiotherapeutic treatment, including therapeutic exercise, in lowering the intensity, frequency and duration of pain in patients with TTH. Limited evidence was also found of the effectiveness of aerobic exercise in patients with migraine, although it was not better than the effects derived from other forms of treatment. CONCLUSIONS. Results show that therapeutic exercise is a safe treatment that provides beneficial effects on migraines or TTH. Further RCT are required in the future with appropriate methodological designs to confirm these results.

Background: Chronic neck pain after whiplash associated disorders (WAD) may lead to reduced displacement and peak velocity of neck movements. Dynamic neck movements in people with chronic WAD are also reported to display altered movement patterns such as increased irregularity, which is suggested to signify impaired motor control. As movement irregularity is strongly related to the velocity and displacement of movement, we wanted to examine whether the increased irregularity in chronic WAD could be accounted for by these factors., Methods: Head movements were completed in four directions in the sagittal plane at three speeds; slow (S), preferred (P) and maximum (M) in 15 men and women with chronic WAD and 15 healthy, sex and age-matched control participants. Head kinematics and measures of movement smoothness and symmetry were calculated from position data. Surface electromyography (EMG) was recorded bilaterally from the sternocleidomastoid and splenius muscles and the root mean square (rms) EMG amplitude for the accelerative and decelerative phases of movement were analyzed., Results: The groups differed significantly with regard to movement velocity, acceleration, displacement, smoothness and rmsEMG amplitude in agonist and antagonist muscles for a series of comparisons across the test conditions (range 17-121%, all p-values < 0.05). The group differences in peak movement velocity and acceleration persisted after controlling for movement displacement. Controlling for differences between the groups in displacement and velocity abolished the difference in measures of movement smoothness and rmsEMG amplitude., Conclusions: Simple, unconstrained head movements in participants with chronic WAD are accomplished with reduced velocity and displacement, but with normal muscle activation levels and movement patterns for a given velocity and displacement. We suggest that while reductions in movement velocity and displacement are robust changes and may be of clinical importance in chronic WAD, movement smoothness of unconstrained head movements is not.

Context: Clinical manifestations and outcome of cholinergic insecticide poisoning is well studied. There are limited data on neuroparalytic features, predictors, and impact on mortality of intermediate syndrome., Methods: Patients admitted with history of insecticide exposure and cholinergic signs in a tertiary care center between April 2011 and March 2012 were followed up till recovery or death. While on standard care, development of intermediate syndrome was noted by neck and proximal muscle weakness, and/or signs of respiratory failure in the absence of cholinergic signs., Results: In 176 patients studied, incidence of intermediate syndrome was 17.6% (n = 31) with mean time of appearance of 44.5 ± 22.1 h after exposure (range 26 h- 5 days). Intermediate syndrome occurred in organophosphorus and carbamate poisoning (38.7% and 41.9%) and lasted for 1-7 days. All patients with intermediate syndrome developed weakness of neck and proximal muscles during the course; neck muscle weakness was the initial feature in majority of patients with respiratory failure (20/26). Age ≥ 45 (RR 2.23, 95% CI 1.14-4.38, p = 0.02), and dimethyl organophosphorus compounds (RR 4.87, 95% CI 1.82-13.04, p = 0.01) were found to be associated with development of intermediate syndrome while multiple gastric lavage was protective (RR 0.44, 95% CI 0.22-0.87, p = 0.001). Receiver operating characteristic curves were plotted for International Program on Chemical Safety Poison Severity Score (IPCS PSS) and Glasgow coma scale (GCS) on admission (AUC/sensitivity/specificity 0.77/0.94/0.6 for IPCS PSS > 2 and 0.64/0.71/0.65 for GCS ≤ 10). Overall mortality was 28.4% (n = 50); 40% (n = 20/50) occurred among intermediate syndrome patients with respiratory failure., Conclusion: As with exposure to organophosphorus, carbamate also result in intermediate syndrome; risk may be high with age ≥ 45, admission score of PSS > 2, and GCS ≤ 10. It can be detected early by identifying neck muscle weakness which aids in anticipating respiratory failure. Multiple gastric lavages may be protective; needs larger studies for clarification.

Objective: The purpose of this study was to assess the effects of a low-load training program for the deep cervical flexors (DCFs) on pain, disability, and pressure pain threshold (PPT) over cervical myofascial trigger points (MTrPs) in patients with chronic neck pain., Methods: Thirty patients with chronic idiopathic neck pain participated in a 6-week program of specific training for the DCF, which consisted of active craniocervical flexion performed twice per day (10-20 minutes) for the duration of the trial. Perceived pain and disability (Neck Disability Index, 0-50) and PPT over MTrPs of the upper trapezius, levator scapulae, and splenius capitis muscles were measured at the beginning and end of the training period., Results: After completion of training, there was a significant reduction in Neck Disability Index values (before, 18.2 ± 12.1; after, 13.5 ± 10.6; P < .01). However, no significant changes in PPT were observed over the MTrPs., Conclusion: Patients performing DCF training for 6 weeks demonstrated reductions in pain and disability but did not show changes in pressure pain sensitivity over MTrPs in the splenius capitis, levator scapulae, or upper trapezius muscles., (© 2013. Published by National University of Health Sciences All rights reserved.)

Background: Although exercise can be effective for relief of neck pain, little is known about the effect of exercise on the neural control of neck muscles., Methods: A randomized controlled trial was conducted on 46 women with chronic neck pain to investigate the immediate effectiveness of an 8-week exercise programme on pain and directional specificity of neck muscle activity. At baseline, the patients completed questionnaires including the neck disability index (NDI) and performed a circular contraction of their head in the horizontal plane at 15 N force, with continuous change in force direction in the range 0-360°. Electromyography (EMG) was recorded from the sternocleidomastoid (SCM) and splenius capitis (SCap) muscles. Tuning curves of the EMG amplitude were computed, which depicts muscle activity over a range of force directions. The mean point of the tuning curves defined a directional vector, which determined the specificity of muscle activity. Patients were randomly assigned either to a training or control group., Results: A significant between-group difference in the change in NDI was observed. A reduction in NDI was observed following training (pre: 18.2 ± 7.4; post: 14.1 ± 6.5; p < 0.01) but not for the control group (pre: 17.5 ± 6.3; post: 16.6 ± 7.4). The training group showed higher specificity of muscle activity post-intervention (pre: 18.6 ± 9.8%, post: 24.7 ± 14.3%; p < 0.05), whereas no change occurred for the control group (pre: 19.4 ± 11.9%, post: 18.2 ± 10.1%)., Conclusion: An exercise programme that aims to enhance motor control of the cervical spine improves the specificity of neck muscle activity and reduces pain and disability in patients with neck pain., (© 2013 European Federation of International Association for the Study of Pain Chapters.)

Introduction: Pain in the neck region among skydivers can be related to repeated parachute opening shocks (POS), but empirical data on ramair POS biomechanics is lacking in the literature. The aim of this study was to develop and evaluate a methodology for assessment of multidirectional accelerations and neck muscle activity during parachuting, and to describe preliminary data., Methods: In an experimental design, four experienced skydivers made two consecutive skydives. Deceleration was recorded with two triaxial accelerometers, one placed on the skydiver's cervicothoracic junction (acc-neck) and the other on the harness (acc-rig). Surface electromyography (EMG) was sampled from four sites bilaterally: anterior-neck, posterior upper and lower neck, and upper shoulder muscles. EMG activity was normalized against a premeasured maximum voluntarily produced electrical signal (MVE)., Results: The measuring equipment did not interfere with the parachute jumps. High-quality signals were recorded. The median peak POS deceleration for the acc-neck vs. acc-rig indicated differences (4.0 G vs. 5.1 G), in addition to significant differences emerging for medians of average and maximum onset rates of deceleration (avg: 1.2 G x s(-1) vs. 19.5 G x s(-1); max: 23.0 G x s(-1) vs. 80.0 G x s(-1)). The median of overall muscleactivity was as high as 87% MVE, but no differences in peak activity were found between muscles. Temporal activations of the posterior upper neck occurred less than 50 ms after deceleration initiation, indicating feedforward control of the neck., Conclusion: All instruments recorded data of good quality without impeding the skydiving activity. Triaxial accelerometry on the neck vs. the harness yielded dissimilar results, underlining the importance of correct accelerometer placement. Muscle activity was high during POS and neck muscles showed anticipatory tendencies.

Study Design: Prospective longitudinal study., Objective: To explore the working mechanism of manual therapy, we investigated whether 3 cervical spine variables were mediators of the effect of manual therapy on headache frequency. Background Manual therapy has been shown to reduce headache frequency in participants with chronic tension-type headache (CTTH). To what extent specific elements of treatment contribute to the effectiveness of manual therapy in CTTH is unknown., Methods: One hundred eighty-two participants with CTTH participated in a prospective longitudinal study: 142 underwent manual therapy and 40 participants received usual care by their general practitioner. Regression analysis was performed according to the steps described by Baron and Kenny, and the proportion of mediated effect was estimated for 3 potential mediators: (1) cervical range of motion, (2) neck flexor endurance, and (3) forward head posture. Outcome was defined as a 50% or greater reduction in headache days., Results: Neck flexor endurance mediated 24.5% of the effect of manual therapy. Cervical range of motion and forward head posture showed no mediated effect., Conclusions: Increased neck flexor endurance appears to be a working mechanism of manual therapy. This finding supports isometric training of neck flexors in participants with CTTH. Trial registered with Netherlands Trial Register (TR 1074).

Poor visual ergonomics is associated with visual and neck/shoulder discomfort, but the relation between visual demands and neck/shoulder muscle activity is unclear. The aims of this study were to investigate whether trapezius muscle activity was affected by: (i) eye-lens accommodation; (ii) incongruence between accommodation and convergence; and (iii) presence of neck/shoulder discomfort. Sixty-six participants (33 controls and 33 with neck pain) performed visually demanding near work under four different trial-lens conditions. Results showed that eye-lens accommodation per se did not affect trapezius muscle activity significantly. However, when incongruence between accommodation and convergence was present, a significant positive relationship between eye-lens accommodation and trapezius muscle activity was found. There were no significant group-differences. It was concluded that incongruence between accommodation and convergence is an important factor in the relation between visually demanding near work and trapezius muscle activity. The relatively low demands on accommodation and convergence in the present study imply that visually demanding near work may contribute to increased muscle activity, and over time to the development of near work related neck/shoulder discomfort., (Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Pediatric headache is an increasingly reported phenomenon. Cervicogenic headache (CGH) is a subgroup of headache, but there is limited information about cervical spine physical examination signs in children with CGH. Therefore, a cross-sectional study was designed to investigate cervical spine physical examination signs including active range of motion (ROM), posture determined by the craniovertebral angle (CVA), and upper cervical ROM determined by the flexion-rotation test (FRT) in children aged between 6 and 12 years. An additional purpose was to determine the degree of pain provoked by the FRT. Thirty children (mean age 120.70 months [SD 15.14]) with features of CGH and 34 (mean age 125.38 months [13.14]) age-matched asymptomatic controls participated in the study. When compared to asymptomatic controls, symptomatic children had a significantly smaller CVA (p < 0.001), significantly less active ROM in all cardinal planes (p < 0.001), and significantly less ROM during the FRT (p < 0.001), especially towards the dominant headache side (p < 0.001). In addition, symptomatic subjects reported more pain during the FRT (p < 0.001) and there was a significant negative correlation (r = -0.758, p < 0.001) between the range recorded during the FRT towards the dominant headache side and FRT pain intensity score. This study found evidence of impaired function of the upper cervical spine in children with CGH and provides evidence of the clinical utility of the FRT when examining children with CGH.

Objective: To investigate the relation between localized pressure pain sensitivity and the amplitude and specificity of semispinalis cervicis muscle activity in patients with chronic neck pain., Materials and Methods: Pressure pain detection thresholds (PPDTs) were measured over the C2-C3 and C5-C6 cervical zygapophyseal joints in 10 women with chronic neck pain and 9 healthy age-matched and sex-matched controls. Intramuscular electromyography (EMG) was acquired from the semispinalis cervicis at the levels of C2 and C5 during isometric circular contractions in the horizontal plane at 15 and 30 N, with continuous change in force direction in the range 0 to 360 degrees. The average rectified value and directional specificity of semispinalis cervicis muscle activity were computed and regression analyses were performed between measures of EMG and PPDT., Results: Patients showed significantly lower PPDT compared with controls (P<0.01). Patients also displayed lower EMG amplitude of the semispinalis cervicis at both spinal levels during the circular contractions (average across spinal levels, mean±SD: 129.01±58.99 and 126.83±58.78 µV for the 15- and 30-N contractions, respectively) compared with controls (158.69±66.27 and 187.64±87.82 µV; P<0.05). Furthermore, the directional specificity of semispinalis cervicis muscle was lower for the patients during the circular contractions (P<0.05). The PPDT (C2 and C5 pooled) was positively correlated to both, directional specificity (R=0.22, P<0.05) and amplitude (R=0.15, P<0.05) of the EMG., Discussion: In contrast to asymptomatic individuals, the semispinalis cervicis muscle displays reduced and less-defined EMG activity during a multidirectional isometric contraction in patients with chronic neck pain. The altered behavior of the semispinalis cervicis is weakly associated to pressure pain sensitivity.

The deep cervical extensors are anatomically able to control segmental movements of the cervical spine in concert with the deep cervical flexors. Several investigations have confirmed changes in cervical flexor muscle control in patients with neck pain and as a result, effective evidence-based therapeutic exercises have been developed to address such dysfunctions. However, knowledge on how the deep extensor muscles behave in patients with neck pain disorders is scare. Structural changes such as higher concentration of fat within the muscle, variable cross-sectional area and higher proportions of type II fibres have been observed in the deep cervical extensors of patients with neck pain compared to healthy controls. These findings suggest that the behaviour of the deep extensors may be altered in patients with neck pain. Consistent with this hypothesis, a recent series of studies confirm that patients display reduced activation of the deep cervical extensors as well as less defined activation patterns. This article provides an overview of the various different structural and functional changes in the deep neck extensor muscles documented in patients with neck pain. Relevant recommendations for the management of muscle dysfunction in patients with neck pain are presented., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: To address the high prevalence of neck dysfunction in helicopter aircrew, a 12-wk training program was designed to examine the effects on neck muscular strength and endurance., Methods: Subjects were recruited from Canadian Forces (CF) helicopter aircrew and randomized into either a neck coordination training program (CTP; N = 10), an endurance training program (ETP; N = 11), or a nontreatment control (CON; N = 8). Baseline assessments determined maximal voluntary contraction (MVC) strength and endurance capacity using a submaximal contraction to fatigue at 70% of their MVC for extension, flexion, and left (Ltflx) and right (Rtflx) lateral flexion. The ETP subjects performed dynamic contractions at 30% of their MVC in the four testing directions using a head harness and Thera-band tubing. The CTP consisted of exercises that focused on strengthening the deep cervical musculature using the mass of the head as resistance and progressing to exercises that incorporated the superficial cervical muscles., Results: Post-intervention, the ETP achieved the only statistically significant increase in maximal force when compared to the CON (14.4%). Improved times to fatigue were achieved by the CTP for flexion (26.34 +/- 20.72 s), Ltflx (23.54 +/- 13.94 s), and Rtflx (28.72 +/- 4.88 s)., Conclusion: The provision of an ETP and CTP resulted in a positive trend toward improved maximal force and muscular endurance. The greatest improvements in endurance and strength were found for those subjects assigned to the CTP treatment. Our research demonstrates the importance of including a designed and supervised training program into the daily routine of helicopter aviators.

Physical and psychosocial stressors in the workplace have been independently associated with the development of neck pain, yet interactions among these risk factors remain unclear. The purpose of this study was to compare the effects of mentally challenging computer work performed with and without exposure to a psychosocial stressor on cervical muscle activity and posture. Changes in cervical posture and electromyography of upper trapezius, cervical extensor, and sternocleidomastoid muscles were compared between a resting seated posture at baseline, a low stress condition with mental concentration, and a high stress condition with mental concentration and psychosocial stress in sixty healthy office workers. Forward head posture significantly increased with mental concentration compared to baseline, but did not change with further introduction of the stressor. Muscle activity significantly increased from the low stress to high stress condition for both the dominant and non-dominant upper trapezius, with no corresponding change in activity of the cervical extensors or flexors between stress conditions. These findings suggest that upper trapezius muscles are selectively activated by psychosocial stress independent of changes in concentration or posture, which may have implications for the prevention of stress-related trapezius myalgia in the workplace., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: The aim of this study was to investigate whether patients with chronic neck pain have changes in their transcutaneous partial pressure of arterial carbon dioxide (PtcCO2) and whether other physical and psychologic parameters are associated., Design: In this cross-sectional study, 45 patients with chronic idiopathic neck pain and 45 healthy sex-, age-, height-, and weight-matched controls were voluntarily recruited. The participants' neck muscle strength, endurance of the deep neck flexors, neck range of movement, forward head posture, psychologic states (anxiety, depression, kinesiophobia, and catastrophizing), disability, and pain were assessed. PtcCO2 was assessed using transcutaneous blood gas monitoring., Results: The patients with chronic neck pain presented significantly reduced PtcCO2 (P < 0.01). In the patients, PtcCO2 was significantly correlated with strength of the neck muscles, endurance of the deep neck flexors, kinesiophobia, catastrophizing, and pain intensity (P < 0.05). Pain intensity, endurance of the deep neck flexors, and kinesiophobia remained as significant predictors into the regression model of PtcCO2., Conclusions: Patients with chronic neck pain present with reduced PtcCO2, which can reach the limits of hypocapnia. This disturbance seems to be associated with physical and psychologic manifestations of neck pain. These findings can have a great impact on various clinical aspects, notably, patient assessment, rehabilitation, and drug prescription.

Background: Neck and shoulder complaints can be a direct result of a neck dissection., Methods: Maximal active lateral flexion of the neck, forward flexion and abduction of the shoulder, and self-perceived function were determined in 145 patients treated for oral cancer., Results: No short-term influence of radiotherapy was found on measured range of motion and self-perceived neck and shoulder function (p > .05). One year after a bilateral neck dissection, patients showed deteriorated lateral flexion of the neck, whereas patients treated with a unilateral modified radical neck dissection still reported pain during neck movements. Maximal forward flexion of the shoulder recovered to the level of healthy controls, but maximal abduction was still reduced in all patients., Conclusions: Neck dissection, tumor site, and extensive reconstruction are related to deterioration of shoulder function shortly after intervention. Maximal active shoulder abduction was affected most., (Copyright © 2012 Wiley Periodicals, Inc.)

Objective: The aim of this study was to evaluate the maximal bite force (MBF), electromyographic (EMG) activity and thickness of the masseter, anterior part of the temporalis and sternocleidomastoid (SCM) muscles in a group of young adults with and without temporomandibular disorders (TMDs)., Design: Nineteen individuals comprised the TMD group (6 males/13 females, aged 25.4±3.8 years), classified based on the Research Diagnostic Criteria for TMD (RDC/TMD), and 19 comprised the control group (6 males/13 females, aged 24.1±3.6 years). The MBF was determined with a transducer placed between the dental arches at the first molars level (N). The muscles were evaluated bilaterally at rest and during maximal voluntary clenching (MVC) by assessing EMG activity and performing ultrasonography (USG). The mean values of these measures for both sides of the mouth were used. The normality of the distributions was assessed by the Shapiro-Wilks test. Variables between groups and genders were compared using two-way factorial ANOVA test and correlated using the Spearman coefficient (α=0.05). Unpaired t test was used to compare variables between TMD subgroups. Logistic regression analysis was used to identify the variables associated with the presence of TMD., Results: MBF, EMG and USG data were similar among clinical groups and among TMD subgroups. The thickness of masseter and SCM muscles in the relaxed and clenching states were significantly higher in males than females. On the other hand, the EMG of the temporalis muscle in the rest state was significantly higher in females than males. Additionally, the MBF was positively correlated with the USG characteristics of masseter and SCM muscles, as well as with the EMG activity of masseter and temporalis muscles in the TMD group. In this group, there was also a positive correlation between the thickness of the masseter muscle and its activity. On the other hand, the thickness of the SCM muscle was negatively correlated with its activity. A lower MBF was independently associated with the presence of TMD., Conclusions: Subjects with TMD exhibited similar values of MBF, thickness and electrical activity of masticatory and cervical muscles when compared with controls; positive correlations observed between these variables may suggest a muscular alteration in TMD patients and a co-activation of masticatory and cervical muscles during mandibular movement. This fact may also be confirmed by the negative association between bite forces and presence of TMD., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: The purpose of this preliminary study was to determine feasibility of a clinical trial to measure the effects of manual therapy on sternocleidomastoid active trigger points (TrPs) in patients with cervicogenic headache (CeH)., Methods: Twenty patients, 7 males and 13 females (mean ± SD age, 39 ± 13 years), with a clinical diagnosis of CeH and active TrPs in the sternocleidomastoid muscle were randomly divided into 2 groups. One group received TrP therapy (manual pressure applied to taut bands and passive stretching), and the other group received simulated TrP therapy (after TrP localization no additional pressure was added, and inclusion of longitudinal stroking but no additional stretching). The primary outcome was headache intensity (numeric pain scale) based on the headaches experienced in the preceding week. Secondary outcomes included neck pain intensity, cervical range of motion (CROM), pressure pain thresholds (PPT) over the upper cervical spine joints and deep cervical flexors motor performance. Outcomes were captured at baseline and 1 week after the treatment., Results: Patients receiving TrP therapy showed greater reduction in headache and neck pain intensity than those receiving the simulation (P < .001). Patients receiving the TrP therapy experienced greater improvements in motor performance of the deep cervical flexors, active CROM, and PPT (all, P < .001) than those receiving the simulation. Between-groups effect sizes were large (all, standardized mean difference, >0.84)., Conclusion: This study provides preliminary evidence that a trial of this nature is feasible. The preliminary findings show that manual therapy targeted to active TrPs in the sternocleidomastoid muscle may be effective for reducing headache and neck pain intensity and increasing motor performance of the deep cervical flexors, PPT, and active CROM in individuals with CeH showing active TrPs in this muscle. Studies including greater sample sizes and examining long-term effects are needed., (Copyright © 2013 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)