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n an upright, neutral posture of sitting.11–14 Moreover, retraining the
the cervical spine, passive resis- deep cervical flexor muscles, which pain.18
tance to motion is minimal.1 Sup- has been shown to decrease neck
port of the cervical segments is pro- symptoms15,16 and increase the activa- Subjects in this category were se-
vided by the muscular sleeve formed tion of the deep cervical flexor mus- lected because previous studies in-
by the longus colli muscle anteriorly cles during performance of the clinical vestigating motor control deficits in
and the semispinalis cervicis and test of craniocervical flexion,16 may people with neck pain examined pa-
cervical multifidus muscles poste- improve the ability to maintain an up- tients with similar perceived pain
riorly.2–5 In particular, the longus right posture of the cervical spine. and disability scores. For example,
colli muscle has a major postural reduced activation of the deep cervi-
function in supporting and straight- This study had 2 purposes: (1) to iden- cal muscles has been observed in
ening the cervical lordosis.4 In addi- tify whether people with neck pain people with neck pain with an NDI
tion, the craniocervical region is demonstrate differences in their ability score of ⱕ15.9,19 Moreover, the av-
supported by muscles that attach to to maintain an upright posture when erage NDI score of the patients in-
the cranium and span the upper distracted by a computer task com- cluded in this study is similar to pre-
cervical motion segments, such as pared with a group of control subjects vious exercise trials.20,21 People with
the longus capitis muscle anteriorly and (2) to compare the effects of a more severe pain were excluded be-
and the subocciptal extensor, semi- low-load craniocervical flexion train- cause the endurance exercise regi-
spinalis, and splenius capitis muscles ing regimen against a conventional men may have increased the symp-
posteriorly.6 neck flexor endurance-strength train- toms of this group.
ing program on functional control of
The importance of the deep mus- head and neck posture in people Subjects also had to have palpable cer-
cles for the maintenance of cervical with chronic neck pain. The low-load vical joint tenderness22 and demon-
posture was verified in a computer craniocervical flexion training regi- strate poor performance (unable to
model, which showed regions of lo- men was compared with a conven- achieve 24 mm Hg) on the clinical test
cal segmental instability if only the tional strengthening regimen because of craniocervical flexion as defined
large superficial muscles of the neck it is not known whether such specific by Jull et al.23 Further details of the
were simulated to produce move- training of the deep cervical muscles is test are presented in the “Exercise
ment, particularly in near-upright or required in rehabilitation or if a more Regimens” section. Subjects were ex-
neutral postures.7 Deep cervical general strengthening exercise of the cluded if they had undergone cervical
muscle activity was required in syn- neck flexor muscles would be suffi- spine surgery, reported any neuro-
ergy with superficial muscle activity cient to improve control of the cervi- logical signs, or had participated in a
to stabilize the cervical segments, cal postural position. neck exercise program in the past 12
especially in functional mid-ranges of months.
the cervical spine. This study forms part of a series of
experiments to investigate the mech- The mean score of subjects on the
Recent studies have identified im- anisms of efficacy of cervical muscle NDI was 9.9 (out of a possible 50)
paired activation of the deep cervical retraining. The effect of both exer- (SD⫽3.1), and the average intensity
flexor muscles, the longus colli and cise regimens on measures of pain of neck pain was 4.1⫾2.1 on a 10-cm
longus capitis, in people with neck and disability have been reported in numerical rating scale (NRS) an-
pain.8,9 Given the role of the deep our previous work.16,17 chored with “no pain” and “the
cervical flexor muscles in postural worst possible pain imaginable.” The
support and the knowledge of im- Method subjects with neck pain who par-
paired activation of these muscles in Subjects ticipated in this study also formed
people with neck pain, it is likely Fifty-eight female subjects (mean part of another study.17 The sample
that this patient population also age⫽37.9 years, SD⫽10.2 years) with size (26 per group plus a 10% drop-
would display deficits in the postural a history of chronic, non-severe neck out allowance) was based on the
endurance of these muscles. Indeed, pain of greater than 3 months (X⫽7.9 difference in fatigue of the cervical
evidence is emerging that suggests years, SD⫽6.4 years) participated in muscles between a group of sub-
that people with neck pain drift into this study. Subjects were recruited by jects with neck pain and subjects
a more forward head position when advertisements in the local press. To who were asymptomatic (mean dif-
distracted.10 This has been observed be included, the subjects had to score ference⫽0.65 Hz, SD⫽0.83, power⫽
despite a lack of postural differences ⱕ15 (out of a possible 50) on the Neck 90%).24 Thus, the study had suffi-
in people with neck pain in erect Disability Index (NDI).18 An NDI score cient power to detect a difference in
the ability of the exercise interven- tragus of the ear and the spinous
tions to change parameters of mus- processes of the seventh cervical
cle function, but was not designed to and seventh thoracic vertebrae and
compare the efficacy of the ap- were fixed with double-sided medical
proach to reduce pain and disability. tape.
Endurance-strength training inter- as a change from the starting angle at minute computer task (F⫽19.3;
vention. The endurance-strength each time interval throughout the 10- df⫽1,56; P⬍.001; Fig. 3A). In con-
training regimen consisted of a pro- minute computer task. A repeated- trast, for the control subjects, there
gressive resistance exercise program measures general linear model was was no evidence for a change in cer-
for the neck flexors. The exercise was used to identify whether change in vical angle over the 10-minute com-
performed in supine position, with cervical and thoracic angles across puter task (F⫽1.95; df⫽1,56; P⫽.17;
the head supported in a comfortable the duration of the task were differ- Fig. 3A). Compared with the starting
resting position. Subjects were in- ent between the 2 subject groups. position, the mean change in cervi-
structed to lift up their head so that The independent variable was the cal angle at 10 minutes was 4.4 de-
cervical flexion occurred while main- subject group (between-subjects fac- grees (SD⫽4.1°, 95% CI⫽3.3–5.4)
taining a neutral upper cervical spine tor), and the within-subject factor for the neck pain group and 2.2 de-
position. The subjects slowly moved was the time interval of the task (5 grees (SD⫽1.6°, 95% CI⫽1.0 –3.4)
the head and neck through as full a measurements). for the control group.
range of motion as possible without
causing discomfort or reproducing Change in posture before and af- The subjects with neck pain also dem-
their symptoms. ter intervention for the exercise onstrated a significant, progressive in-
groups. Paired sample t tests were crease in change of thoracic angle
This exercise regimen was a 2-stage conducted to determine if NDI and from baseline across time (F⫽45.3;
program. The first stage was of 2 NRS measurements were significantly df⫽1,56; P⬍.001; Fig. 3B). Although
weeks’ duration and the second was different before and after the interven- less than the subjects with neck pain,
of 4 weeks’ duration as recommend- tion for both exercise groups, and the control subjects also demonstrated
ed30 for initiating a weight program independent sample t tests were con- an increase for the change of thoracic
in previously untrained individuals. ducted to compare for group differ- angle (F⫽11.4; df⫽1,9; P⬍.01;
In stage 1, the subjects performed ences. A repeated-measures general Fig. 3B). Compared with the starting
12 to 15 repetitions with a weight linear model was used to compare position, the mean change in thoracic
that they could lift 12 times (12- baseline cervical and thoracic angles angle at 10 minutes was 8.2 degrees
repetition maximum [RM]) on the between the 2 intervention groups (SD⫽4.8°, 95% CI⫽6.9 –9.5) for the
first training session and progressed with factors of group (craniocervical subjects with neck pain and 4.8 de-
to 15 repetitions and maintained this flexor training and endurance-strength grees (SD⫽3.3°, 95% CI⫽2.4 –7.1) for
level for the remainder of the 2-week training) and time (5 measurements). the control subjects.
period.
For the preintervention to postinter- Changes in Cervical and
In stage 2, the subjects performed 3 vention analysis, a repeated-measures Thoracic Angle After Exercise
sets of 15 repetitions of the initial general linear model was applied. The Intervention
12-RM load once per day. One- independent variables were the 2 in- Of the 58 participants with neck
minute rest intervals were provided tervention groups (between-subjects pain who participated in the exer-
between sets. If repetitions were factor) and the within-subject factor cise interventions, none were lost to
easily achieved, weighted sandbags was the time interval of the task (5 follow up assessment. Subject de-
were applied to the patient’s fore- measurements). A polynomial or lin- scriptive data are presented in the
head in 0.5-kg increments. If the sub- ear trend was fitted to the time factor Table. Baseline characteristics of
ject was unable to perform repeti- to explain the relative change in cer- pain (NRS) and disability (NDI) were
tions of the head lift maneuver then vical and thoracic angle across the du- not different between the 2 interven-
the load on the neck flexors was re- ration of the task. A value of P⬍.05 tion groups (P⬎.05). In addition,
duced by allowing the subject to per- was used as an indicator of statistical preintervention cervical (F1⫽0.28,
form the task with the upper body significance. P⬎.05) and thoracic (F1⫽2.13, P⬎.05)
(trunk and neck) inclined up from angles were not significantly different
the horizontal so that the subject Results between the 2 intervention groups.
could perform the required repeti- Comparison of Postural Position All participants in the endurance-
tions of the movement. Between Subjects With Neck Pain strength training group and cranio-
and Control Subjects cervical flexor training group received
Data Analysis Subjects with neck pain demon- the full 6 treatments. According to the
Comparison between subjects strated a significant, progressive in- patient diaries, adherence to exercise
with neck pain and control sub- crease in change of cervical angle was 91.0% (SD⫽0.12%) for the
jects. Angle data were expressed from baseline throughout the 10- endurance-strength training group
Figure 3.
Group comparisons for change in cervical and thoracic posture. Data (mean and standard deviation) are presented for change in
cervical posture (left) and change in thoracic posture (right) for patients with neck pain and for control subjects. Change in angle
from an erect starting posture (time 0 [T0]) are expressed relative to the angle measured at 2-minute intervals (T2, T4, T6, T8, T10)
throughout the 10-minute task.
and 94.8% (SD⫽0.06%) for the cranio- duction in the change of cervical angle the ability to maintain an upright
cervical flexor training group. No (F⫽7.44; df⫽1,1,1; P⬍.01; Fig. 4) cervical posture during this task.
patients reported any adverse events. across the duration of the task when
compared with the endurance-strength Comparison Between
Both intervention groups demon- training group. In addition, both groups Subjects With Neck Pain and
strated a reduction in average intensity improved their ability to maintain an Control Subjects
of pain (craniocervical flexor training: upright posture of the thoracic spine; In support of previous findings,10
⫺0.9⫾2.3, endurance-strength train- however, there was no significant dif- subjects with neck pain demon-
ing: ⫺1.1⫾2.8), and NDI score (cranio- ference between the 2 intervention groups strated a reduced ability to main-
cervical flexion training: ⫺3.5⫾4.8, (F⫽2.55; df⫽1,1,1; P⬎.05; Fig. 5). tain an upright posture during a
endurance-strength training: ⫺2.8⫾ computer task. There was a subtle
4.0). However, there was no differ- Discussion forward drift of the head of a mag-
ence between groups for change in The results of this study demonstrated nitude of 4.4⫾4.1 degrees in asso-
pain (NRS) or disability (NDI) that subjects with chronic non-severe ciation with a subtle increase in
(P⬎.05). neck pain had a reduced ability to main- the thoracic flexion curve of
tain an upright neutral posture when 8.2⫾4.8 degrees in subjects with
Following 6-weeks of intervention, distracted by a computer task. More- neck pain. This may reflect im-
the craniocervical flexor training over, exercise targeted at training the paired endurance of the muscles
group demonstrated a significant re- craniocervical flexor muscles improved that would be required to control
Table.
Baseline Characteristics for Patients With Chronic Neck Pain Randomized Into a Craniocervical Flexor Exercise Intervention or an
Endurance-Strength Exercise Intervention
Figure 4.
Group data for change in cervical posture following intervention in patients with neck pain. Preintervention and postintervention data
(mean and standard deviation) are presented for change in cervical posture throughout the 10-minute computer task for the
craniocervical flexor (CCF) training group and endurance-strength training group. Change in angle from an erect starting posture
(time 0 [T0]) are expressed relative to the angle measured at 2-minute intervals (T2, T4, T6, T8, T10) throughout the 10-minute task.
the postural position of the spine dur- position awareness also may explain and people with neck pain follow-
ing sitting. In agreement with previous the differences observed for the ing a whiplash injury.32–34
research, decreased endurance of the group with neck pain compared
craniocervical flexor muscles has been with the control group. Evidence A reduced ability to maintain an up-
observed in patients with neck pain at of reduced cervical kinesthetic right posture of the cervical spine
20% of their maximal voluntary contrac- sense has been identified in both when distracted during sitting might
tion.31 Other factors such as reduced people with idiopathic neck pain be considered a measure of impair-
proprioception resulting in poor head ment in the postural supporting mus-
Figure 5.
Group data for change in thoracic posture following intervention in patients with neck pain. Preintervention and postintervention
data (mean and standard deviation) are presented for change in thoracic posture throughout the 10-minute computer task for the
craniocervical flexor (CCF) training group and the endurance-strength training group. Change in angle from an erect starting posture
(time 0 [T0]) are expressed relative to the angle measured at 2-minute intervals (T2, T4, T6, T8, T10) throughout the 10-minute task.
cles during a functional task, an out- Craniocervical flexor training involves theless, it can be questioned whether
come that can be easily replicated performing and holding inner range the subtle maintenance of postural
clinically. positions of craniocervical flexion, the angles is clinically meaningful. This
anatomical action of the deep cervical question cannot be answered directly
A sustained forward flexion posture flexor muscles. This training has been in this study. However, the magnitude
of the spine has been associated shown to increase the activation of of change in cervical posture follow-
with increased cervical compressive these muscles.16 The improved ability ing craniocervical flexion training is
loading and a creep response in the to maintain an upright position of the similar to the magnitude of difference
connective tissue.35,36 It would not cervical spine, which was observed observed between the subjects with
be unreasonable to consider that a for the craniocervical flexor training neck pain and the control subjects in
sustained forward head posture asso- group, may reflect an improved en- the first phase of this study. Further-
ciated with prolonged sitting could durance of the deep cervical flexor more, such subtlety in head drift
aggravate, if not initiate, neck pain. muscles, which was identified dur- was also observed by Szeto et al43 in
There is some evidence that has ing the functional task of sitting. This their comparison of computer work-
linked prolonged static posture with improvement occurred even though ers with and without neck pain. The
increased muscle loading and subse- there was no exercise instruction outcomes of both studies suggest that,
quent risk for the development of on postural correction in sitting. This in sitting working postures, subtle
symptoms in the upper body.37,38 finding supports our previous sug- changes in posture over time, possibly
gestion that inadequate control of reflective of poor muscle control as
Although both the subjects with the head in prolonged sitting may be proposed in this study, might be very
neck pain and the control subjects a functional correlate of deep cervi- relevant to the function of office
demonstrated progressive change in cal muscle impairment. workers with neck pain. The possible
thoracic posture throughout the 10- associations between functional work-
minute computer task, this change Moreover, craniocervical flexion di- ing postures and neck pain justifies
was greater for the subjects with rectly activates the deep cervical further research towards meeting the
neck pain. The observation that tho- flexor musculature,19,39 which have challenge of prevention of neck pain
racic angle increased progressively a relatively high density of muscle in office workers, which is recognized
in the control subjects throughout spindles.2 Improved cervical kines- as a significant contemporary problem
the task in the absence of a change in thetic sense following craniocervical in the workforce.44
cervical posture was somewhat sur- flexor training40 also may explain the
prising, but could indicate earlier fa- improved ability to maintain an up- Change in Pain and
tigue in the trunk extensors than in right position of the cervical spine. Perceived Disability
the neck muscles. Further investiga- Following 6 weeks of exercise, a
tion of this finding is necessary. It is notable that the endurance- significant reduction in average in-
strength regimen did not influence tensity of pain (NRS) and perceived
Effect of Exercise on Control of postural parameters of the cervical disability (NDI score) was identified
Posture During Sitting in spine. Although there is some evi- for both training groups. Although
Subjects With Neck Pain dence to suggest that an endurance- only the craniocervical flexor training
Following a 6-week intervention with strength regimen for the neck flexor group showed a significant improve-
either craniocervical flexor training or muscles reduces neck pain,17,41,42 ment in their ability to maintain an
neck flexor endurance-strength train- improves strength,17,42 and reduces upright position of the cervical spine,
ing, the participants with neck pain fatigue of the sternocleidomastoid this was not associated with a greater
improved their ability to maintain an and anterior scalene muscles,17 it reduction in pain or perceived disabil-
upright posture of the thoracic spine does not appear to improve the ity compared with the endurance-
during the 10-minute computer task. ability to maintain an upright strength regimen group. However,
This improvement could be attributed posture of the cervical spine in a because a sustained forward flexion
to factors such as task familiarity or sitting task. posture of the spine has been associ-
increased postural awareness; how- ated with compressive loading of the
ever, only the group that received the The maintenance of cervical postural cervical tissues,35,36 improved cervical
specific craniocervical flexor training angle with the craniocervical flexor posture during sitting may have an ad-
improved their ability to maintain an training during the 10-minute dis- ditional long-term benefit of reducing
upright position of the cervical spine. traction task reached statistical sig- recurrent episodes of neck pain. This
nificance when compared with the is of particular relevance given the high
endurance-strength regimen. Never- recurrence rate of neck pain.45 Further
research is now warranted to examine maintain an upright neutral posture 4 Mayoux-Benhamou MA, Revel M, Vallee C,
et al. Longus colli has a postural function
whether an improved ability to main- when distracted by a computer task. on cervical curvature. Surg Radiol Anat.
tain an upright position of the cervical Following intervention with an exer- 1994;16:367–371.
spine following specific exercise inter- cise program targeted at retraining 5 Vasavada AN, Li S, Delp SL. Influence of
muscle morphometry and moment arms
vention is maintained in the long term the craniocervical flexor muscles, on the moment-generating capacity of
and the effect that this may have on subjects with chronic neck pain human neck muscles. Spine. 1998;23:
412– 422.
the recurrence rate of neck pain. demonstrated improved ability to
6 Kettler A, Hartwig E, Schultheiss M, et al.
maintain a neutral cervical posture Mechanically simulated muscle forces
Methodological Considerations during prolonged sitting. This most strongly stabilize intact and injured upper
cervical spine specimens. J Biomech.
This study used photographic analy- likely reflects an improvement in the 2002;35:339 –346.
sis to describe change in cervical and endurance of the muscles that con- 7 Winters JM, Peles JD. Neck muscle activity
thoracic posture using anatomical trol the postural position of the neck and 3D head kinematics during quasistatic
and dynamic tracking movements. In:
markers. Although photographic during function. Winters JM, Woo SLY, eds. Multiple Mus-
analysis has shown to be a reliable cle Systems: Biomechanics and Move-
ment Organization. New York, NY:
tool for quantifying change in cervi- Springer-Verlag; 1990:461– 480.
Dr Falla, Dr Jull, Dr Vincenzino, and Dr
cal angle,46 precise conclusions Hodges provided concept/idea/research de- 8 Falla DL, Jull GA, Hodges PW. Patients
about the anatomical alignment of sign and fund procurement. Dr Falla, Dr Jull, with neck pain demonstrate reduced elec-
tromyographic activity of the deep cervi-
the spine as identified on radio- Mr Russell, and Dr Hodges provided writing. cal flexor muscles during performance of
graphs cannot be inferred from vari- Dr Falla provided data collection, and Dr the craniocervical flexion test. Spine.
Falla, Mr Russell, and Dr Hodges provided 2004;29:2108 –2114.
ation in surface measurement.47 De- data analysis. Dr Falla and Dr Jull provided 9 Falla D, Jull G, Hodges PW. Feedforward
spite this limitation, this study project management. Dr Jull and Dr Hodges activity of the cervical flexor muscles dur-
demonstrates that postural analysis provided facilities/equipment. Mr Russell ing voluntary arm movements is delayed in
chronic neck pain. Exp Brain Res. 2004;
during a common functional activity provided consultation (including review of 157:43– 48.
in sitting may provide a useful mea- manuscript prior to submission). The authors
10 Szeto GP, Straker LM, O’Sullivan PB. A
thank Amy Fagan from The University of
sure to quantify postural changes Queensland, Australia for assistance with
comparison of symptomatic and asymp-
tomatic office workers performing monot-
during tasks and to monitor the ef- data collection. onous keyboard work, 2: neck and
fects of rehabilitation. shoulder kinematics. Man Ther. 2005;10:
Dr Falla is supported by the National Health 281–291.
and Medical Research Council of Australia 11 Grimmer K. The relationship between cer-
Only posture of the cervical and tho- (ID 351678). This study was funded by a vical resting posture and neck pain. Phys-
racic spine were analyzed in this grant (ID 252771) received from the Na- iotherapy. 1996;82:45–51.
study. In future studies, electromyo- tional Health and Medical Research Council 12 Hanten WP, Olson SL, Russell JL, et al. To-
of Australia. tal head excursion and resting head pos-
graphy could be used concurrently ture: normal and patient comparisons.
to provide additional information on Ethical approval for the study was granted by Arch Phys Med Rehabil. 2000;81:62– 66.
muscle activation associated with the Institutional Medical Research Ethics 13 Haughie LJ, Fiebert IM, Roach KE. Rela-
Committee of The University of Queensland, tionship of forward head posture and cer-
the observed postural changes. vical backward bending to neck pain.
and all procedures were conducted accord- Journal of Manual and Manipulative
ing to the Declaration of Helsinki. Therapy. 1995;3:91–97.
Additional methodological aspects
This article was submitted January 9, 2006, 14 Treleaven J, Jull G, Atkinson L. Cervical
may include the duration of the com- musculoskeletal dysfunction in post-
and was accepted December 19, 2006.
puter task used in this study (10 min- concussional headache. Cephalalgia.
1994;14:273–279.
utes). However, the duration of the DOI: 10.2522/ptj.20060009
15 Jull G, Trott P, Potter H, et al. A random-
task was sufficient to demonstrate ized controlled trial of exercise and
differences between subjects with manipulative therapy for cervicogenic
headache. Spine. 2002;27:1835–1843.
neck pain and control subjects.
References 16 Jull G, Falla D, Hodges P, et al. Cervical
Finally, it must be noted that it is not flexor muscle retraining: physiological
1 Oatis CA. Kinesiology: The Mechanics
known whether the improvements and Pathomechanics of Human Move- mechanisms of efficacy. Paper presented
ment. Philadelphia, Pa: Lippincott Wil- at: 2nd International Conference on Move-
in postural endurance that were ob- ment Dysfunction; September 23–25,
liams & Wilkins; 2004.
served following 6-weeks of exercise 2005; Edinburgh, Scotland.
2 Boyd-Clark LC, Briggs CA, Galea MP. Mus-
intervention would be maintained in cle spindle distribution, morphology, and 17 Falla D, Jull G, Hodges P, Vicenzino B. An
density in longus colli and multifidus mus- endurance-strength training regime is ef-
the long term. Additional research is fective in reducing myoelectric manifesta-
cles of the cervical spine. Spine. 2002;27:
warranted to address these issues. 694 –701. tions of cervical flexor muscle fatigue in
females with chronic neck pain. Clin Neu-
3 Conley MS, Meyer RA, Bloomberg JJ, et al. rophysiol. 2006;117:828 – 837.
Conclusion Noninvasive analysis of human neck mus-
cle function. Spine. 1995;20:2505–2512.
Subjects with chronic neck pain
demonstrated a reduced ability to
18 Vernon H, Mior S. The Neck Disability In- 28 Watson DH, Trott PH. Cervical head- 38 Schuldt K, Ekholm J, Harms-Ringdahl K,
dex: A study of reliability and validity. ache: an investigation of natural head et al. Effects of changes in sitting work
J Manipulative Physiol Ther. 1991;14: posture and upper cervical flexor mus- posture on static neck and shoulder
409 – 415. cle performance. Cephalalgia. 1993;13: muscle activity. Ergonomics. 1986;29:
272–284. 1525–1537.
19 Falla D, Bilenkij G, Jull G. Patients with
chronic neck pain demonstrate altered 29 Falla D, Jull G, O’Leary S, Dall’Alba P. Fur- 39 Falla D, Jull G, Dall’Alba P, et al. An elec-
patterns of muscle activation during per- ther evaluation of an EMG technique for tromyographic analysis of the deep cervi-
formance of a functional upper limb task. assessment of the deep cervical flexor cal flexor muscles during craniocervical
Spine. 2004;29:1436 –1440. muscles. J Electromyogr Kinesiol. 2006; flexion. Phys Ther. 2003;83:899 –906.
16:621– 628.
20 Ylinen J, Takala EP, Nykanen M, et al. Ac- 40 Jull G, Falla D, Treleaven J, et al. Retraining
tive neck muscle training in the treatment 30 McArdle WD, Katch FI, Katch VL. Exercise cervical joint position sense: The effect of
of chronic neck pain in women: a random- Physiology: Energy, Nutrition, and Hu- two exercise regimes. J Orthop Res. 2006
ized controlled trial. JAMA. 2003;289: man Performance. 4th ed. Baltimore, Md: Dec 1: Epub ahead of print.
2509 –2516. Williams & Wilkins; 1996. 41 Berg HE, Berggren G, Tesch PA. Dynamic
21 Jull G, Barrett C, Magee R, Ho P. Further 31 O’Leary S, Jull G, Kim M, Vicenzino B. neck strength training effect on pain and
clinical clarification of the muscle dysfunc- Cranio-cervical flexor muscle impairment function. Arch Phys Med Rehabil. 1994;
tion in cervical headache. Cephalalgia. at maximal, moderate, and low loads is a 75:661– 665.
1999;19:179 –185. feature of neck pain. Man Ther. 2006 Jun 42 Bronfort G, Evans R, Nelson B, et al. A ran-
12: Epub ahead of print.
22 Jull G, Bogduk N, Marsland A. The accu- domized clinical trial of exercise and spinal
racy of manual diagnosis for cervical zyg- 32 Heikkila H, Astrom PG. Cervicocephlic manipulation for patients with chronic neck
apophysial joint pain syndromes. Med J kinesthetic sensibility in patients with pain. Spine. 2001;26:788 –797.
Aust. 1988;148:233–236. whiplash injury. Scand J Rehabil Med. 43 Szeto GP, Straker L, Raine S. A field com-
1996;28:133–138.
23 Jull G, Falla D, Treleaven J, et al. A thera- parison of neck and shoulder postures in
peutic exercise approach for cervical dis- 33 Kristjansson E, Dall’Alba P, Jull G. A study symptomatic and asymptomatic office
orders. In: Boyling JD, Jull G, eds. Grieve’s of five cervicocephalic relocation tests in workers. Appl Ergon. 2002;33:75– 84.
Modern Manual Therapy: The Vertebral three different subject groups. Clin Reha- 44 Blatter BM, Bongers PM. Duration of com-
Column. 3rd ed. Edinburgh, United King- bil. 2003;17:768 –774. puter use and mouse use in relation to
dom: Elsevier; 2004. 34 Revel M, Andre-Deshays C, Minguet M. musculoskeletal disorders of neck or up-
24 Falla D, Rainoldi A, Merletti R, Jull G. Myo- Cervicocephalic kinesthetic sensibility in per limb. International Journal of Indus-
electric manifestations of sternocleido- patients with cervical pain. Arch Phys Med trial Ergonomics. 2002;30:295–306.
mastoid and anterior scalene muscle Rehabil. 1991;72:288 –291. 45 Gore DR, Sepic SB, Gardner GM, Murray
fatigue in chronic neck pain patients. 35 Harms-Ringdahl K, Ekholm J, Schuldt K, MP. Neck pain: a long term follow-up of
Clin Neurophysiol. 2003;114:488 – 495. et al. Load moments and myoelectric ac- 205 patients. Spine. 1987;12:1–5.
25 Russell TG, Jull GA, Wootton R. Can the tivity when the cervical spine is held in full 46 Falla DL, Campbell CD, Fagan AE, et al.
Internet be used as a medium to evalu- flexion and extension. Ergonomics. 1986; Relationship between cranio-cervical flex-
ate knee angle? Man Ther. 2003;8:242– 29:1539 –1552. ion range of motion and pressure change
246. 36 Twomey L, Taylor J. Flexion creep defor- during the cranio-cervical flexion test.
26 Russell TG, Wootton R, Jull GA. Physical mation and hysteresis in the lumbar verte- Man Ther. 2003;8:92–96.
outcome measurements via the Internet: re- bral column. Spine. 1982;7:116 –122. 47 Johnson GM. The correlation between sur-
liability at two Internet speeds. J Telemed 37 Aaras A, Fostervold KI, Ro O, et al. Pos- face measurement of head and neck pos-
Telecare. 2002;8:50 –52. tural load during VDU work: a comparison ture and the anatomic position of the up-
27 Haley SM, Fragala-Pinkham MA. Interpret- between various work postures. Ergo- per cervical vertebrae. Spine. 1998;23:
ing change scores of tests and measures nomics. 1997;40:1255–1268. 921–927.
used in physical therapy. Phys Ther. 2006;
86:735–743.