Forward head posture and neck mobility in chronic tension-type headache: a blinded, controlled study

Abnormal Static Sagittal Cervical Curvatures following Motor Vehicle Collisions: A Retrospective Case Series of 41 Patients before and after a Crash Exposure

Previous investigations have found a correlation between abnormal curvatures and a variety of patient complaints such as cervical pain and disability. However, no study has shown that loss of the cervical curve is a direct result of exposure to a motor vehicle collision (MVC). This investigation presents a retrospective consecutive case series of patients with both a pre-injury cervical lateral radiograph (CLR) and a post-injury CLR after exposure to an MVC. Computer analysis of digitized vertebral body corners on CLRs was performed to investigate the possible alterations in the geometric alignment of the sagittal cervical curve.

METHODS

Three spine clinic records were reviewed over a 2-year period, looking for patients where both an initial lateral cervical X-ray and an examination were performed prior to the patient being exposed to a MVC; afterwards, an additional exam and radiographic analysis were obtained. A total of 41 patients met the inclusion criteria. Examination records of pain intensity on numerical pain rating scores (NPRS) and neck disability index (NDI), if available, were analyzed. The CLRs were digitized and modeled in the sagittal plane using curve fitting and the least squares error approach. Radiographic variables included total cervical curve (ARA C2-C7), Chamberlain's line to horizontal (skull flexion), horizontal translation of C2 relative to C7, segmental translations (retrolisthesis and anterolisthesis), and circular modelling radii.

RESULTS

There were 15 males and 26 females with an age range of 8-65 years. Most participants were drivers (28) involved in rear-end impacts (30). The pre-injury NPRS was 2.7 while the post injury was 5.0; p < 0.001. The NDI was available on 24/41 (58.5%) patients and increased after the MVC from 15.7% to 32.8%, p < 0.001. An altered cervical curvature was identified following exposure to MVC, characterized by an increase in the mean radius of curvature (265.5 vs. 555.5, p < 0.001) and an approximate 8° reduction of lordosis from C2-C7; p < 0.001. The mid-cervical spine (C3-C5) showed the greatest curve reduction with an averaged localized mild kyphosis at these levels. Four participants (10%) developed segmental translations that were just below the threshold of instability, segmental translations < 3.5 mm.

CONCLUSIONS

The post-exposure MVC cervical curvature was characterized by an increase in radius of curvature, an approximate 8° reduction in C2-C7 lordosis, a mild kyphosis of the mid-cervical spine, and a slight increase in anterior translation of C2-C7 sagittal balance. The modelling result indicates that the post-MVC cervical sagittal alignment approximates a second-order buckling alignment, indicating a significant alteration in curve geometry. Future biomechanics experiments and clinical investigations are needed to confirm these findings.

Dry needling in the management of chronic tension-type headache associated with levator scapulae syndrome: A case report

Key Clinical Message

The use of DN to the muscular trigger points and distal periosteal enthesis of the levator scapulae may be a useful adjunct intervention within a multi-modal plan of care for the management of work-related chronic tension-type headaches associated with LSS.

Abstract

Chronic tension-type headaches (CTTH) have a lifetime prevalence of 42% and account for more lost workdays than migraine headaches. Dry needling (DN) is being increasingly used by physical therapists in the management of CTTH; however, to date, the supporting evidence is limited. The purpose of this case report was to describe how three sessions of DN targeting myofascial trigger points in the levator scapulae (LS) muscle and its distal enthesis was used to treat a 63-year-old male patient who presented with work-related CTTH associated with levator scapulae syndrome (LSS). The patient was treated for five visits over the course of 2 months. At discharge and 6-month follow-up, the patient reported full resolution of symptoms. Self-report outcomes included the numeric pain rating scale and the Neck Disability Index. The use of DN to the LS muscle and its distal enthesis may be a valuable addition to a multi-modal plan of care in the treatment of work-related CTTH associated with LSS.

Effect of a slump posture on pain, proprioception, and electrical activity of the muscles in office workers with chronic non-specific neck pain. A retrospective study

BACKGROUND

The impact of computer typing in a slump posture on pain, proprioception and muscle recruitment has not been extensively investigated. Therefore, the purpose of this study was to evaluate the extent of pain, proprioception and muscle activity resulting from computer typing in a slump posture in women who already suffer from chronic neck pain.

METHODS

This cross-sectional study was conducted between May 20 to July 10, 2021. A total of 15 female 42-(±4.96)-year-old office workers with chronic non-specific neck pain participated in this study. Before and after 60 min of computer typing in a slump posture, proprioception and pain were measured using an inclinometer and visual analog scale (VAS), respectively. The activity of the cervical erector spine (CES) and upper trapezius (UT) muscle was also measured before and after the slump-posture computer typing, in upright, forward, and slump postures. RESU: lts: Paired-samples t-tests showed that pain was increased and proprioception in all directions (flexion, extension, right and left lateral flexion, and right, and left rotation) was less accurate (P < 0.05) after 60 min computer typing. The CES and UT muscle activity were elevated more in the forward head and slump posture than in the upright posture (P < 0.05).

CONCLUSION

Sixty minutes computer typing in a slump posture increased neck pain, resulted in a decreased proprioception in the neck and was accompanied by an increased activity of the neck musculature.

Effect of high voltage electrical stimulation in temporomandibular disorders: a randomized controlled trial

OBJECTIVE

To examine the effects of high voltage electrical stimulation (HVES) on pain intensity, maximum mouth opening (MMO), cervical mobility, head position, pressure pain thresholds (PPTs), bite force, joint sounds, and jaw muscle strength in individuals with temporomandibular disorders (TMDs).

METHODS

Thirty-four individuals with TMDs were randomly divided into the exercise group (EG) (n = 17) and the HVES group (HG) (n = 17). For 4 weeks, EG received exercise therapy alone, while HG received HVES (12 sessions in total, 3 days a week to anterior temporalis and masseter) in conjunction with exercise.

RESULTS

After the treatment, in both groups, pain intensity significantly decreased (p < .001); MMO (7.27 mm in HG and 3.61 mm in EG), cervical mobility, head position, PPTs, bite force, and jaw muscle strength significantly increased (p = .043 to < .001). Joint sounds significantly decreased in the HG (p = .008). Left bite force (p = .040) and left medial pterygoid PPT (p = .013) increased more in EG. The change in left bite force in EG over time was significant (p = .040; ηp2 = .126). The effect sizes of treatments were medium to large (from .527 to 1.602) for the evaluated parameters.

CONCLUSION

Although exercise alone was effective in many parameters evaluated, additional application of HVES provided further improvement for pain, MMO, cervical mobility, PPTs, jaw muscle strength and joint sounds. HVES can be routinely used in clinics for individuals with TMDs.

Network analyses reveal the interaction between physical features, fear of movement and neck pain and disability in people with acute and chronic whiplash-associated disorders

BACKGROUND AND OBJECTIVE

A network analysis can be used to quantitatively assess and graphically describe multiple interactions. This study applied network analyses to determine the interaction between physical and pain-related factors and fear of movement in people with whiplash-associated disorders (WAD) during periods of acute and chronic pain.

METHODS

Physical measurements, including pressure pain-thresholds (PPT) over neural structures, cervical range of motion, neck flexor and extensor endurance and the cranio-cervical flexion test (CCFT), in addition to subjective reports including the Tampa Scale of Kinesiophobia (TSK-11), Neck Disability Index (NDI) and neck pain and headache intensity, were assessed at baseline in 47 participants with acute WAD. TSK-11, NDI and pain intensity were assessed for the same participants 6 months later (n = 45). Two network analyses were conducted to estimate the associations between features at baseline and at 6 months and their centrality indices.

RESULTS

Both network analyses revealed that the greatest weight indices were found for NDI and CCFT at baseline and for neck pain and headache intensity and NDI and TSK-11 at both time points. Associations were also found betweeen cervical muscle endurance and neck pain intensity in the acute phase. Cervical muscle endurance assesssed during the acute phase was also associated with NDI after 6 months - whereas PPT measured at baseline was associsated with headache intensity after 6 months.

CONCLUSION

The strongest associations were found for headache and neck pain intensity and neck disability and fear of movement, both during acute pain and when mesured 6 months later. The extent of neck endurance and measures of PPT at baseline may be associated with neck disability and headache, respectively, 6 months after a whiplash injury.

SIGNIFICANCE

Through two network analyses, we evaluated the interaction between pain-related factors, fear of movement, neck disability and physical factors in people who had experienced a whiplash injury. We demonstrated that physical factors may be involved in the maintenance and development of chronic pain after a whiplash injury. Nevertheless, the strongest associations were found for headache and neck pain intensity and neck disability and fear of movement, both during acute and chronic phases.

The relationship between myofascial trigger points sensitivity, cervical postural abnormality, and clinical tension-type headache parameters

BACKGROUND

Myofascial Trigger Points (MTrPs) play a significant role in the pathogenesis of Tension Type Headache (TTH). Abnormal cranio-cervical posture has been linked to various types of headaches. However, the correlation between MTrPs sensitivity, cervical postural alignment, and clinical measures of headache has not been extensively studied in patients with TTH.

OBJECTIVES

To investigate the relationship between MTrPs sensitivity in cervical and pericranial muscles, cervical postural abnormality, and clinical headache parameters in patients with TTH. Furthermore, to investigate the effect of sex on the examined variables and their association with headache type (episodic vs chronic TTH).

METHODS

A total of 72 patients with TTH of both sexes were enrolled in this study. Headache frequency and disability as clinical measures of headache, pressure pain threshold (PPT) of bilateral upper trapezius (UT) and suboccipital (SUB) muscles, cervical lordosis angle (CA), and anterior head translation (AHT) were measured.

RESULTS

Pericranial MTrPs sensitivity did not demonstrate any correlation with clinical headache parameters or cervical postural abnormality. However, there was a significant correlation between the frequency of headaches and the level of disability (r = 0.32, P < 0.05). In addition, episodic TTH was more prevalent in females who exhibited greater AHT and MTrPs sensitivity of both bilateral UT and right SUB muscles than males.

CONCLUSIONS

There was no correlation found between the frequency of headaches and the level of disability with measures of cervical posture alignment or MTrPs sensitivity in individuals with TTH.. Based on findings, Clinicians should consider sex differences when assessing patients with TTH.

Positive Outcomes Following Cervical Acceleration-Deceleration (CAD) Injury Using Chiropractic BioPhysics® Methods: A Pre-Auto Injury and Post-Auto Injury Case Series

This series illustrates how rear-end impact motor vehicle collisions (MVCs) alter the cervical spine's alignment and demonstrates therapeutic use of cervical extension traction to improve lordotic alignment and other outcomes. This is a retrospective reporting of 7 adult patients (4 males and 3 females, 28-42 years) treated for cervical hypolordosis. These subjects received Chiropractic BioPhysics® (CBP®) rehabilitation and then were involved in a rear-end MVC. All cases had radiographic assessment that quantified the buckling of the cervical spine, presumably resulting directly from the CAD trauma. After an average of 3 years and 9 months (range: 1-7.6 years) following their initial program of care, the 7 patients sought care for a second time after the MVC. At this time, compared with their previously recorded post-treatment spine radiographs, there was an average 18.7° (range: 7.6-35.4°) reduction in cervical lordosis, a 9.2 mm (range: 3.6-19.8 mm) increase in anterior head translation (AHT), an 11.3° (range: 0.2-19.9°) decrease in the atlas plane line (APL), as well as a 35.7% (range: 22-52%) average neck disability index score (NDI) measured after the MVC. After the crash, a second round of CBP rehabilitation was administered, resulting in an average 15.1° improvement in cervical lordosis, 10.9 mm reduction in AHT, 10.4° increase in APL, and a 23.7% drop in NDI after an average of 35 treatments over 9 weeks. Treatment was universally successful, as an average 80% re-establishment of the lordosis toward its pre-injury state was found. There were no adverse events reported. This case series demonstrates that motor vehicle collisions may alter the alignment of the cervical spine. Rehabilitation of the cervical curve using extension traction improved the patients' initial pre-crash alignments toward their pre-injury alignments and was likely responsible for improvement in the patients' conditions. Clinical trials are needed to confirm these findings.

Clinimetric properties of a smartphone application to measure the craniovertebral angle in different age groups and positions

Background

Craniovertebral angle (CVA) alteration is a causative factor for the neck, shoulder, and temporomandibular joints disorders. Therefore, as an outcome measure for therapeutic intervention, measuring the craniovertebral angle with the Surgimap smartphone app is a cost-effective, easily accessible, and reliable tool. This study's objective was to assess the clinimetric properties of the Surgimap smartphone application with Surgimap system software to measure the Craniovertebral Angle in different age groups and positions.

Method

Ninety subjects with neck pain were randomly allocated to aged between 18 and 30 years (Group A; n = 45) and 45-60 years (Group B; n = 45). Using the Surgimap smartphone application and Surgimap system software, the craniovertebral angle was measured objectively in the sagittal plane. Intraclass correlation coefficients were used to determine validity and reliability. Receiver operating characteristic (ROC) curves and the area under the curves (AUC) were determined to distinguish participants with and without forward head posture.

Result

The result of this study shows that Smartphone Surgimap Application and Surgimap System Software correlate 0.95 and have p-values of 0.01 for diverse positions and ages. CVA measurement in the sitting position was significantly lower than in the standing position, regardless of methodology or age. Both positions demonstrated high intra-rater reliability, as evidenced by Intraclass Correlation Coefficients (ICC) between 0.972 and 0.991. The minimum detectable change (MDC) values ranged from 1.3 to 1.733, indicating high measurement accuracy. The smartphone application demonstrated outstanding diagnostic sensitivity (100.00% for Group A standing) and specificity (93.55% for Group B standing).

Conclusion

The Surgimap smartphone application is a reliable and accurate method for craniovertebral angle measurement and is useful for measuring outcomes. Also standing posture was found to be better than sitting posture while measuring the CVA.

The cervical spine in tension type headache

INTRODUCTION

The concept that headaches may originate in the cervical spine has been discussed over decades and is still a matter of debate. The cervical spine has been traditionally linked to cervicogenic headache; however, current evidence supports the presence of cervical musculoskeletal dysfunctions also in tension-type headache.

PURPOSE

This position paper discusses the most updated clinical and evidence-based data about the cervical spine in tension-type headache.

IMPLICATIONS

Subjects with tension-type headache exhibit concomitant neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, positive flexion-rotation test and also cervical motor control disturbances. In addition, the referred pain elicited by manual examination of the upper cervical joints and muscle trigger points reproduces the pain pattern in tension-type headache. Current data supports that the cervical spine can be also involved in tension-type headache, and not just in cervicogenic headache. Several physical therapies including upper cervical spine mobilization or manipulation, soft tissue interventions (including dry needling) and exercises targeting the cervical spine are proposed for managing tension-type headache; however, the effectiveness of these interventions depends on a proper clinical reasoning since not all will be equally effective for all individuals with tension-type headache. Based on current evidence, we propose to use the terms cervical "component" and cervical "source" when discussing about headache. In such a scenario, in cervicogenic headache the neck can be the cause (source) of the headache whereas in tension-type headache the neck will have a component on the pain pattern, but it will be not the cause since it is a primary headache.

The effect of manual therapies on tension-type headache in patients who do not respond to drug therapy: a randomized clinical trial

BACKGROUNDS

Tension-Type Headache (TTH) is one of the most common types of headache. In patients with TTH, manual therapy can be used to treat myofascial pain.

OBJECTIVES

This study aimed to evaluate the effect of manual therapy on TTH in patients who did not respond to drug therapy.

METHODS

A total of 24 patients with TTH were randomly enrolled into this prospective trial. The participants were divided into an intervention and a control group. The intervention group received the common medication and manual therapy, while the control group only received the common medication. Headache pain intensity, frequency, and duration, tablet count, and Neck Disability Index (NDI) were measured in both groups before, after, and one week after the intervention.

RESULTS

There were significant differences between the two groups (treatment, control) regarding pain intensity (3.04, 6.75, P = 0.0001; effect size (ES) = 1.85), headache frequency (2.33, 5, P = 0.004; ES = 1.48) and duration (91.29, 284.74, P = 0.002; ES = 1.48), tablet count (1.83, 4.91, P = 0.01; ES = 1.04), and NDI (7.33, 20.16, P = 0.003; ES = 1.37). Within group differences were recorded in intervention group only for all dependent variables immediately after intervention and one week after the intervention (p < 0.05).

CONCLUSION

Manual therapy reduced headache pain intensity, frequency and duration, tablet count, and NDI score in patients with TTH.

Is Thoracic Kyphosis Relevant to Pain, Autonomic Nervous System Function, Disability, and Cervical Sensorimotor Control in Patients with Chronic Nonspecific Neck Pain?

There is great interest in thoracic kyphosis, as it is thought to be a contributor to neck pain, neck disability, and sensorimotor control measures; however, this has not been completely investigated in treatment or case control studies. This case control design investigated participants with non-specific chronic neck pain. Eighty participants with a defined hyper-kyphosis (>55°) were compared to eighty matched participants with normal thoracic kyphosis (<55°). Participants were matched for age and neck pain duration. Hyper-kyphosis was further categorized into two distinct types: postural kyphosis (PK) and Scheuermann's kyphosis (SK). Posture measures included formetric thoracic kyphosis and the craniovertebral angle (CVA) to assess forward head posture. Sensorimotor control was assessed by the following measures: smooth pursuit neck torsion test (SPNT), overall stability index (OSI), and left and right rotation repositioning accuracy. A measure of autonomic nervous system function included the amplitude and latency of skin sympathetic response (SSR). Differences in variable measures were examined using the Student's t-test to compare the means of continuous variables between the two groups. One-way ANOVA was used to compare mean values in the three groups: postural kyphosis, Scheuermann's kyphosis, and normal kyphosis group. Pearson correlation was used to evaluate the relationship between participant's thoracic kyphosis magnitude (in each group separately and as an entire population) and their CVA, SPNT, OSI, head repositioning accuracy, and SSR latency and amplitude. Hyper-kyphosis participants had a significantly greater neck disability index compared to the normal kyphosis group (p < 0.001) with the SK group having greatest disability (p < 0.001). Statistically significant differences between the two kyphosis groups and the normal kyphosis group for all the sensorimotor measured variables were identified with the SK group having the most decreased efficiency of the measures in the hyper-kyphosis group, including: SPNT, OSI, and left and right rotation repositioning accuracy. In addition, there was a significant difference in neurophysiological findings for SSR amplitude (entire sample of kyphosis vs. normal kyphosis, p < 0.001), but there was no significant difference for SSR latency (p = 0.07). The CVA was significantly greater in the hyper-kyphosis group (p < 0.001). The magnitude of the thoracic kyphosis correlated with worsening CVA (with the SK group having the smallest CVA; p < 0.001) and the magnitude of the decreased efficiency of the sensorimotor control measures and the amplitude and latency of the SSR. The PK group, overall, showed the greatest correlations between thoracic kyphosis and measured variables. Participants with hyper-thoracic kyphosis exhibited abnormal sensorimotor control and autonomic nervous system dysfunction compared to those with normal thoracic kyphosis.

Association of Vibrotactile Biofeedback With Reduced Ergonomic Risk for Surgeons During Tonsillectomy

Importance

Work-related musculoskeletal disorders are common among otolaryngologists and can be associated with decreased productivity, missed workdays, and reduced quality of life. Ergonomic risk for surgeons is elevated during common otolaryngology procedures; current ergonomic interventions lack the ability to provide real-time feedback. The ability to quantify and mitigate ergonomic risk during surgery may reduce work-related musculoskeletal disorders.

Objective

To quantify the association of vibrotactile biofeedback with intraoperative ergonomic risk to surgeons during tonsillectomy.

Design, Setting, and Participants

This cross-sectional study was conducted between June 2021 and October 2021 at a freestanding tertiary care children's hospital and included 11 attending pediatric otolaryngologists. Data analysis was conducted from August to October 2021.

Interventions

Real-time quantification of ergonomic risk during tonsillectomy and the use of a vibrotactile biofeedback posture monitor.

Main Outcomes and Measures

Association of vibrotactile biofeedback with objective measures of ergonomic risk. Assessment tools included the Rapid Upper Limb Assessment, craniovertebral angle, and time spent in an at-risk posture.

Results

Eleven surgeons (mean [SD] age 42 [7] years; 2 women [18%]) performed 126 procedures with continuous posture monitoring in the presence (80 [63%]) and absence (46 [37%]) of vibrotactile biofeedback. No complications or delays associated with the device were reported. Intraoperative vibrotactile biofeedback was associated with improved Rapid Upper Limit Assessment neck, trunk, and leg scores by 0.15 (95% CI, 0.05-0.25), improved craniovertebral angle by 1.9 (95% CI, 0.32-3.40), and decreased overall time spent in an at-risk posture by 30% (95% CI, 22%-39%).

Conclusions and Relevance

The results of this cross-sectional study suggest that use of a vibrotactile biofeedback device to quantify and mitigate ergonomic risk for surgeons is feasible and safe while performing surgery. Vibrotactile biofeedback was associated with reduced ergonomic risk during tonsillectomy and may have a role in improving surgical ergonomics and preventing work-related musculoskeletal disorders.

Does Forward Head Posture Influence Somatosensory Evoked Potentials and Somatosensory Processing in Asymptomatic Young Adults?

The current investigation used somatosensory evoked potentials (SEPs) to assess differences in sensorimotor integration and somatosensory processing variables between asymptomatic individuals with and without forward head posture (FHP). We assessed different neural regions of the somatosensory pathway, including the amplitudes of the peripheral N9, spinal N13, brainstem P14, peak-to-peak amplitudes of parietal N20 and P27, and frontal N30 potentials. Central conduction time (N13-N20) was measured as the difference in peak latencies of N13 and N20. We measured these variables in 60 participants with FHP defined as a craniovertebral angle (CVA) < 50° and 60 control participants matched for age, gender, and body mass index (BMI) with normal FHP defined as CVA > 55°. Differences in variable measures were examined using the parametric t-test. Pearson's correlation was used to evaluate the relationship between the CVA and sensorimotor integration and SEP measurements. A generalized linear model (GLM) was used to compare the SEP measures between groups, with adjustment for educational level, marital status, BMI, and working hours per week. There were statistically significant differences between the FHP group and control group for all sensorimotor integration and SEP processing variables, including the amplitudes of spinal N13 (p < 0.005), brainstem P14 (p < 0.005), peak-to-peak amplitudes of parietal N20 and P27 (p < 0.005), frontal N30 potentials (p < 0.005), and the conduction time N13-N20 (p = 0.004). The CVA significantly correlated with all measured neurophysiological variables indicating that as FHP increased, sensorimotor integration and SEP processing became less efficient. FHP group correlations were: N9 (r = -0.44, p < 0.001); N13 (r = -0.67, p < 0.001); P14 (r = -0.58, p < 0.001); N20 (r = -0.49, p = 0.001); P27 (r = -0.58, p < 0.001); N30 potentials (r = -0.64, p < 0.001); and N13-N20 (r = -0.61, p < 0.001). GLM identified that increased working hours adversely affected the SEP measures (p < 0.005), while each 1° increase in the CVA was associated with improved SEP amplitudes and more efficient central conduction time (N13-N20; p < 0.005). Less efficient sensorimotor integration and SEP processing may be related to previous scientific reports of altered sensorimotor control and athletic skill measures in populations with FHP. Future investigations should seek to replicate our findings in different spine disorders and symptomatic populations in an effort to understand how improving forward head posture might benefit functional outcomes of patient care.

Physical testing in patients with acute whiplash-associated disorders: A within session test-retest reliability study

BACKGROUND

People with whiplash-associated disorders (WAD) commonly present with a variety of physical impairments. However, the reliability of physical tests has not been established for patients with acute WAD.

OBJECTIVE

To assess test-retest reliability of different physical tests in acute WAD.

DESIGN

Intra-rater test-retest reliability.

METHODS

Patients with acute WAD were recruited. Physical tests were used to evaluate articular, muscular and neural systems in two blocks of measurements separated by 10 min. Bland-Altman plots were performed to assess intrarater agreement, which included calculation of the mean difference (d) between rates, the 95% CI for d, the standard deviation of the differences and the 95% limits of agreement. Reliability was calculated via the standard error of measurement, the minimal detectable change, percent of agreement, the intraclass-correlation coefficient, and kappa coefficient.

RESULTS

47 patients participated. Test-retest reliability was excellent or good for almost all measures, except for extension ROM, ULTT for the radial nerve, and active cervical extension and upper cervical rotation performed in 4-point kneeling, which presented moderate reliability. Systematic bias was found in cervical ROM in flexion, left and right lateral-flexion, left and right rotation; left ULTT for radial nerve; right trapezius, suboccipitalis and temporalis muscles, left temporalis; C3, both sides of C1-C2, left C3-C4.

CONCLUSION

The majority of physical tests achieved good or excellent test-retest intra-rater reliability when tested in patients with acute WAD. Findings must be considered with caution for those tests which demonstrated systematic bias. Additional research is warranted to evaluate inter-rater reliability.

A New Instrument for Assessing Work-Related Body Mechanics and Strain in the General Population

Clinical pain is often linked to poor body mechanics, with individuals sometimes presenting multiple painful disorders. Such disorders may be influenced by behaviors that affect the general resiliency and health of the musculoskeletal system. We aimed to develop a self-reported scale using the Malmö Diet and Cancer Study questions on work-related body mechanical exposures. An expert panel identified 41 variables having content validity for musculoskeletal problems. Exploratory factor analysis was conducted on a random selection of 50% of the cohort (n = 6,789 adults); the remaining was reserved for confirmatory factor analyses (CFA), item response theory (IRT) item calibration, and differential item functioning investigations. Supported by standard measure development methods and fit criteria, the final unidimensional item bank contains 13 items. Overall CFA statistics (root mean square error of approximation = .09; comparative fit index = .96; Tucker-Lewis index = .96; standardized root mean residuals = .05) indicated excellent single-factor model fit and appropriateness of IRT modeling and calibration. Expert review and item information values (score-precision) guided selection of an 8-item short form with acceptable score-level reliabilities (≥.70) for T-scores = 39-80+. This measure provides reliable assessment of body mechanics strain in adults and can be useful when evaluating different contributions to musculoskeletal problems affecting pain-treatment success in future clinical research. PERSPECTIVE: This article presents the development and psychometric properties of a new measure, "Work-related Body Mechanics and Strain Scale (WR-BMSS)." The scale has 13-items or alternatively an 8-item short form. This measure could potentially help clinicians who seek to assess how musculoskeletal problems may contribute to patient pain and disability.

Global trends in research on cervicogenic headache: a bibliometric analysis

Background

There has been a marked increase in cervicogenic headaches in recent years, significantly affecting sufferers' daily lives and work. While several treatments exist for this type of headache, their long-term effects could be improved, and additional data from large clinical samples are needed. This study aims to systematically examine the current state of research in cervicogenic headaches through a bibliometric analysis, identify areas of current interest, and provide insight into potential future research directions.

Methods

This article examines research trends in the field of cervicogenic headache through a bibliometric analysis of scholarly articles in the field of cervicogenic headache over the past four decades. The bibliometric analysis method employed included searching the Web of Science database using topics related to cervicogenic headaches. Inclusion criteria were limited to articles and review papers on cervicogenic headaches published between 1982 and 2022. The retrieved dataset was then analyzed using R software and VOSviewer to identify the major research areas, countries and institutions, the most influential authors, journals and keywords, co-citations in the literature, and co-authorship networks.

Results

This study analyzed 866 articles published between 1982 and 2022, involving 2,688 authors and generating 1,499 unique author keywords. Neuroscience and neurology were the primary focus, with participation from 47 countries, primarily led by the United States, which has the most published articles (n = 207), connections (n = 29), and citations (n = 5,238). In the cervicogenic headache study, which involved 602 institutions, the University of Queensland received the most significant number of citations (n = 876), and Cephalalgia was the journal with the most published articles and received the most local citations (n = 82) and highest growth (n = 36). Two hundred sixty-nine journals have published articles on cervicogenic headaches. Among researchers studying cervicogenic headache, Sjaastad O had the most published articles (n = 51) and citations (n = 22). The most commonly occurring keyword was "cervicogenic headache." Except for the fourth most impactful paper, as determined by the Local Citation Score, which analyzed clinical treatments, all the top documents emphasized investigating the diagnostic mechanisms of cervicogenic headache. The most commonly occurring keyword was "cervicogenic headache."

Conclusion

This study used bibliometric analysis to provide a comprehensive overview of the current research on cervicogenic headaches. The findings highlight several areas of research interest, including the need for further investigation into the diagnosis and treatment of cervicogenic headaches, the impact of lifestyle factors on cervicogenic headaches, and the development of new interventions to improve patient outcomes. By identifying these gaps in the literature, this study provides a foundation for guiding future research to improve the diagnosis and treatment of cervicogenic headaches.

Comparison of Sensorimotor Integration and Skill-Related Physical Fitness Components Between College Athletes With and Without Forward Head Posture

OBJECTIVE

To evaluate sensorimotor integration and skill-related physical fitness components for participants with forward head posture (FHP) compared with strictly matched controls with normal head alignment.

MATERIAL AND METHODS

We measured FHP, sensorimotor processing, and skill-related physical fitness variables in 50 participants with FHP and in 50 participants matched for age, gender, and body mass index with normal FHP, defined as having a craniovertebral angle >55°. Sensorimotor processing and integration variables were: (1) amplitudes of the spinal N13, (2) brainstem P14, (3) parietal N20 and P27, and (4) frontal N30 potentials. The skill-related physical fitness variables selected for the study were (1) T-test agility, (2) leg power, (3) stork static balance test, and (4) Y-balance test.

RESULTS

There was a statistically significant difference between the FHP group and control group for the sensorimotor integration variable: frontal N30 potentials (P < .05). Additionally, between-group differences were found for the sensorimotor processing variables: amplitudes of spinal N13, brainstem P14, and parietal N20, and P27 (P < .05). Statistically significant differences between groups for the skill-related physical fitness variables were also identified: T-test agility, leg power, stork static balance test, and Y-balance test (P < .05). The magnitude of the craniovertebral angle showed a correlation with all measured variables (P < .05).

CONCLUSION

College athletes with FHP exhibited altered sensorimotor processing and integration measurements and less efficient skill-related physical fitness compared with athletes with normal sagittal head posture alignment.

Deep Cervical Muscles and Functionality in Patients with Chronic Tension-Type Headache: An Observational Study

Background and objectives: Chronic tension-type headache (TTH) is the type of headache with the highest prevalence. The involvement of musculoskeletal structures in TTH is supported by evidence in the scientific literature. Among these, deep cervical muscle strength appears to be related to the function of the cervical spine and the clinical characteristics of TTH. This study aimed to correlate anatomical, functional, and psychological variables in patients with TTH. Materials and methods: An observational descriptive study was carried out with 22 participants diagnosed with TTH for at least six months. The characteristics of headaches, including ultrasound-based deep neck flexor and extensor muscle thickness, range of motion (ROM), and pressure pain threshold (PPT), were recorded. We also conducted the Pain Vigilance and Awareness Questionnaire (PVAQ) and the Craniocervical Flexion Test (CCFT). Results: Moderate–large negative correlations were found between the PVAQ and the muscle thickness of right deep flexors contracted (r = −0.52; p = 0.01), left multifidus contracted (r = −0.44; p = 0.04), right multifidus at rest (r = −0.48; p = 0.02), and right multifidus contracted (r = −0.45; p = 0.04). Moderate–large positive correlations were found between the CCFT score and the left cervical rotation ROM (r = 0.53; p = 0.01), right cervical rotation ROM (r = 0.48; p = 0.03), muscle thickness of left multifidus contracted (r = 0.50; p = 0.02), and muscle thickness of right multifidus at rest (r = 0.51; p = 0.02). The muscle thickness of the contracted right deep cervical flexors showed a moderate negative correlation with headache intensity (r = −0.464; p = 0.03). No correlations were found between PPT and the rest of the variables analyzed. Conclusions: In patients with TTH, a higher thickness of deep cervical muscles was associated with higher ROM and higher scores in the CCFT. In turn, the thickness of deep cervical muscles showed negative correlations with pain hypervigilance and headache intensity. These results contribute to a better understanding of the physical and psychosocial factors contributing to the development of TTH, which is useful for implementing appropriate prevention and treatment measures.

Deep Learning Enabled Neck Motion Detection Using a Triboelectric Nanogenerator

The state of neck motion reflects cervical health. To detect the motion state of the human neck is of important significance to healthcare intelligence. A practical neck motion detector should be wearable, flexible, power efficient, and low cost. Here, we report such a neck motion detector comprising a self-powered triboelectric sensor group and a deep learning block. Four flexible and stretchable silicon rubber based triboelectric sensors are integrated on a neck collar. With different neck motions, these four sensors lead-out voltage signals with different amplitudes and/or directions. Thus, the combination of these four signals can represent one motion state. Significantly, a carbon-doped silicon rubber layer is attached between the neck collar and the sensors to shield the external electric field (i.e., electrical changes at the skin surface) for a far more robust identification. Furthermore, a deep learning model based on the convolutional neural network is designed to recognize 11 classes of neck motion including eight directions of bending, two directions of twisting, and one resting state with an average recognition accuracy of 92.63%. This developed neck motion detector has promising applications in neck monitoring, rehabilitation, and control.

Short-term effects of instrument-assisted soft tissue mobilization compared to algometry pressure release in tension-type headache: a randomized placebo-controlled trial

PURPOSES

To compare the effectiveness of instrument-assisted soft tissue mobilization (IASTM) and pressure algometry with sham ultrasound (control group) on the clinical measures of headache, pressure pain threshold (PPT) of upper trapezius and suboccipital muscles and cervical alignment in patients with tension type headache (TTH).

METHODS

Seventy-two patients with TTH of both genders were randomly allocated to 3 experimental groups: a) the IASTM group (n=24), b) pressure algometry group (n=24), and c) sham ultrasound control group (n=24). Headache frequency and disability, pressure pain threshold of upper trapezius and suboccipital muscles, cervical lordosis angle (CA) and anterior head translation (AHT) were measured four weeks before and after intervention. Moreover, headache frequency was followed up for two more weeks after intervention.

RESULTS

Statistically significant improvements (P <0.05; effect size ranges 1.1-1.9) were observed in all outcome measures following IASTM compared to the other two intervention methods. In the IASTM group, the headache frequency decreased from 15 to 2 days/month. Also, headache disability decreased from 19 to 10. Further, CA increased from 17.5° to 31.4° and AHT decreased from 24.1 to 15.5 mm. The pressure algometry group showed significantly lower headache frequency at the follow-up (P < 0.01) than the sham ultrasound control group. However, Similar findings in the other evaluated outcomes were found between the pressure algometry and sham ultrasound control groups (P ˃ 0.05).

CONCLUSION

The results of the present study indicate the effectiveness of IASTM in improving headache symptoms and cervical alignment in patients with TTH.

Spine Posture, Mobility, and Stability of Top Mobile Esports Athletes: A Case Series

Professional esports athletes spend a long time in the same sitting posture during training and competition. Mobile esports may exacerbate potential postural problems because of the closer and unsupported arms and because athletes spend more time in a forward-/flexed-head posture. Prolonged sitting in these postures carries significant health risks and may lead to musculoskeletal problems and injuries. The objective of this retrospective study is to assess the posture, mobility, and stability of the spine for professional mobile esports athletes. We collected spine-assessment data from 48 athletes participating in a top-tier league on a real-time-strategy battle-arena online game. The spinal assessment was conducted using the SpinalMouse® under upright standing and trunk flexion in addition to the Matthiass test. Measurements were converted into Idiag Scores by the SpinalMouse® software. The Idiag Posture, Idiag Mobility, and Idiag Stability scores were 62.50 (IQR: 21), 63.50 (IQR: 19.5), and 54.50 (IQR: 14.5), respectively, and were significantly lower (p < 0.001) than the reference normative value (100). Age was found to have a weak positive correlation with the posture score (ρ = 0.29, p = 0.048). Although career duration appeared to lower the scores, the association was insignificant (p > 0.05). The scores also had no significant association with body height, body mass, body mass index, and esports team (p > 0.05). It was anticipated that mobile-based esports would attenuate the biomechanics of the spine and increase the likelihood of musculoskeletal problems, such as neck and back pain.

Reliability of “MB-Ruler Software” to Measure Craniovertebral Angle Using the Photographic Method

Background The craniovertebral angle (CV angle) measurement is a convenient and easy clinical method for the cervical posture assessment. “Markus Bader (MB) ruler software” assists to measure angles and distances on the computer screen. The MB-ruler protractor is almost transparent; hence, it can be easily used on the computer screen. Many studies in physiotherapy have used this software for postural assessment with the photographic method, but the reliability of this software is not available to our knowledge in the Indian population.

Aim The aim of this study was to find inter-rater and intra-rater reliabilities of “MB-Ruler software”, by using the photographic method to measure the CV angle for the cervical postural assessment.

Study Design This is an observational study in healthy young population.

Subjects and Method Total 30 young student volunteers with no clinical symptoms were enrolled for this study. A single standard lateral view image in a sitting position was used for CV angle measurement with “MB ruler software.” Three readings of the CV angle were taken by three different observers (A, B, and C) separately at intervals of time. The CV angle measured by three observers was compared.

Results Cronbach's ɑ coefficient value for intra-rater (ICC 0.999) (intra-class correlation coefficient) as well as inter-rater (ICC 0.892) reliability for measuring CV angle was very high.

Conclusion MB ruler demonstrates high intra-rater and inter-rater reliabilities and can be used for the photographic evaluation of posture by assessing the CV angle.

Using the Craniovertebral Angle to Quantify Intraoperative Ergonomic Risk

OBJECTIVE

To measure the craniovertebral angle during tonsillectomy, assess the interrater reliability of our methodology, and investigate the correlations of the Rapid Upper Limb Assessment and the craniovertebral angle to quantify ergonomic risk.

STUDY DESIGN

Prospective, observational study.

SETTING

Tertiary care pediatric institution.

METHODS

Neck posture was evaluated for 92 images with 7 surgeons. Lateral images of the surgeon were captured every minute in a standardized method. Images were assessed by 3 raters, measuring the craniovertebral angle, defined as the angle between a horizontal line through the C7 vertebrae and another line through C7 and the tragus of the ear. Interrater reliability of the craniovertebral angle was evaluated using the κ statistic. Per prior publications, reports of neck pain were frequent when the craniovertebral angle value was <50°; thus, we defined an abnormal posture if the craniovertebral angle was <50°.

RESULTS

Mean (SD) craniovertebral angle during tonsillectomy was 26.0° (11.3°). One hundred percent of procedures had at least 1 assessment of abnormal posture. The lowest interrater reliability was 0.77 (CI: 0.67-0.87). Rapid Upper Limb Assessment and craniovertebral angle (CA) correlation was -0.12 (P = .27) and, therefore, null.

CONCLUSION

Poor posture during tonsillectomy places otolaryngologists at intraoperative ergonomic risk. The craniovertebral angle is a predictor of future neck pain, and a pathologic neck position during tonsillectomy was identified. Given the high interrater reliability, our approach to assessing intraoperative surgical ergonomics was validated. Overall, RULA and the CA are not a substitute for one another but complementary.

Changes in deep neck muscle length from the neutral to forward head posture. A cadaveric study using Thiel cadavers

Forward head posture (FHP) is one of the most common postural deviations. Deep neck muscle imbalance of individuals with FHP is of primary concern in clinical rehabilitation. However, there is scarce quantitative research on changes in deep neck muscle length with the head moving forward. This study aimed to investigate changes in deep neck muscle length with different severity levels of FHP. Six Thiel‐embalmed cadavers (four males and two females) were dissected, and 16 deep neck muscles in each cadaver were modeled by a MicroScribe 3D Digitizer in the neutral head posture, slight FHP, and severe FHP. The craniovertebral angle was used to evaluate the degrees of FHP. Quantitative length change of the deep neck muscles was analyzed using Rhinoceros 3D. In slight FHP significant changes in length occurred in four muscles: two shortened (upper semispinalis capitis, rectus capitis posterior minor) and two lengthened (longus capitis, splenius cervicis). In severe FHP all occipital extensors were significantly shortened (10.6 ± 6.4%), except for obliquus capitis superior, and all cervical extensors were significantly lengthened (4.8 ± 3.4%), while longus capitis (occipital flexor) and the superior oblique part of the longus colli (cervical flexor) were lengthened by 8.8 ± 3.8% and 4.2 ± 3.1%, respectively. No significant length change was observed for the axial rotator. This study presents an alternate anatomical insight into the clinical rehabilitation of FHP. Six muscles appear to be important in restoring optimal head posture, with improvements in FHP being related to interventions associated with the occipital and cervical extensors.

Restoring cervical lordosis by cervical extension traction methods in the treatment of cervical spine disorders: a systematic review of controlled trials

[Purpose] To systematically review the literature on the use of cervical extension traction methods for increasing cervical lordosis in those with hypolordosis and cervical spine disorders. [Methods] Literature searches for controlled clinical trials were performed in Pubmed, PEDro, Cochrane, and ICL databases. Search terms included iterations related to the cervical spine, neck pain and disorders, and extension traction rehabilitation. [Results] Of 1,001 initially located articles, 9 met the inclusion/exclusion criteria. The trials demonstrated increases in radiographically measured lordosis of 12-18°, over 5-15 weeks, after 15-60 treatment sessions. Untreated controls/comparison groups not receiving extension traction showed no increase in cervical lordosis. Several trials demonstrated that both traction and comparison treatment groups experienced immediate pain relief. Traction treatment groups maintained their pain and disability improvements up to 1.5 years later. Comparative groups not receiving lordosis improvement experienced regression of symptoms towards pre-treatment values by 1 years' follow-up. [Conclusion] There are several high-quality controlled clinical trials substantiating that increasing cervical lordosis by extension traction as part of a spinal rehabilitation program reduces pain and disability and improves functional measures, and that these improvements are maintained long-term. Comparative groups who receive multimodal rehabilitation but not extension traction experience temporary relief that regresses after treatment cessation.

Ultrasound Measurement of the Transverse Abdominis, Internal Oblique, and External Oblique Muscles Associated with Forward Head Posture and Reduced Cranio-Vertebral Angle

Background

Abnormal posture can affect the alignment of the cervical spine, which can lead to various physical problems. There are many ways to solve the problem by limiting the area around the neck to restore abnormal neck condition. However, there is a need to look at these problems from an enlarged perspective through the relationship between the cervical spine and trunk. This study aimed to investigate the significance of the thickness of the transverse abdominis, internal oblique, and external oblique muscles in patients with forward head posture and reduced cranio-vertebral angle.

Material/Methods

We included 24 healthy adult males in their 20s without lower back pain. The cranio-vertebral angle (CVA) in all the subjects was measured with the help of pictures taken in the sagittal plane using a digital camera. The thickness of muscles, including transverse abdominis (TrA), internal oblique (IO), and external oblique (EO), was measured using a diagnostic ultrasound device. Pearson’s correlation analysis was used to identify the correlation between the variables measured.

Results

CVA showed a statistically significant correlation with TrA thickness (r=0.506/p=0.012), and among the abdominal muscles, there was a significant correlation between IO and EO thickness (r=0.663/p=0.000).

Conclusions

A reduced CVA due to FHP was significantly associated with reduced TrA thickness. Therefore, increasing the bulk of the abdominal muscles with restoration of the abnormal CVA is a potential treatment approach and requires further study.

Effect of Deep Cervical Flexor Muscle Training Using Pressure Biofeedback on Pain and Forward Head Posture in School Teachers with Neck Pain: An Observational Study

BACKGROUND

Teaching is one of the professions where incidence and prevalence of neck pain is high. Prolonged use of computers, which has further increased due to online teaching amid pandemic, is known to cause neck pain and alter posture, while people with forward head posture (FHP) are prone to develop neck pain and related disability. Research has shown that impairment of deep cervical flexor (DCF) muscles leads to insufficiency in coordination, activation, overload, and poor support on cervical structures that further lead to development of neck pain and altered neck posture. The objective of this study was to see the effect of DCF muscle training using pressure biofeedback on pain and FHP in school teachers with neck pain.

METHODS

This observational study was conducted at medical center in school premises. Fifty-five school teachers aged between 25 and 40 years with experience of more than 5 years were invited to participate in this study. Subjects were divided in two groups. Both the groups received conventional exercises while in experimental group DCF muscle training using pressure biofeedback was given additionally. Pain and FHP were assessed using NPRS and cranio-vertebral angle using digital photograph technique, respectively, at baseline and end of four weeks of treatment.

RESULTS

Although pain and FHP improved in both the groups, mean improvement in both the measures was more in the group that also received DCF training using pressure biofeedback.

CONCLUSIONS

This study shows that although pain and FHP improved following conventional exercises in school teachers with neck pain, mean improvement was more significant among those who received additional DCF muscle training using pressure biofeedback.

Chronic Primary Headache Subjects Have Greater Forward Head Posture than Asymptomatic and Episodic Primary Headache Sufferers: Systematic Review and Meta-analysis

OBJECTIVE

To summarize the cervical physical examination characteristics in subjects with chronic primary headache and compare those with a healthy population and a population with episodic primary headache.

DESIGN

Systematic review and meta-analysis.

SUBJECTS

Humans ≥18 years old. At least one of the study groups should be constituted by subjects diagnosed with one of the chronic primary headache subtypes according to the International Classification of Headache Disorders, 3rd Edition.

COMPARISON

Neck physical examination outcomes of subjects with chronic primary headache compared with a healthy population or subjects with episodic primary headache.

OUTCOMES

Forward head posture (FHP), cervical range of movement, motor control, neck muscle activity, and reproduction and resolution of symptoms.

METHODS

Two reviewers assessed independently the MEDLINE, EMBASE, WOS, MEDES, PEDro, and CINAHL databases to select observational studies. First, both implemented an agreement for a search strategy. Then, they screened independently for duplicates, titles, abstracts, and full-text information. A meta-analysis was conducted to compare measures between groups.

RESULTS

Twelve studies (N = 1,083) with moderate quality (mean ± SD = 7.75 ± 1.48 on the Newcastle Ottawa Scale) were selected for the qualitative analysis. The meta-analysis showed that patients with chronic primary headache presented greater forward head posture than asymptomatic participants (N = 275, Hg = 0.68, 95% CI = 0.25-1.1, Z = 3.14, P < 0.01) and patients with episodic primary headache (N = 268, Hg = 0.39, 95% CI = 0.13-0.65, Z = 2.98, P < 0.01).

CONCLUSIONS

There is moderate to strong evidence that patients with chronic primary headache present greater FHP than asymptomatic individuals and moderate evidence that patients with chronic primary headache present greater forward head posture than those with episodic primary headache.

Lumbar Roll Usage While Sitting Reduces the Forward Head Posture in Healthy Individuals: A Systematic Review with Meta-Analysis

This systematic review and meta-analysis investigated whether the use of a lumbar roll reduced forward head posture (FHP) while sitting among individuals with or without musculoskeletal disorders. EMBASE, MEDLINE, and the Cochrane Library were systematically searched from their inception to August 2020. The quality of evidence for variables used in the meta-analysis was determined using the GRADE system. Five studies satisfied the criteria for data analysis. All studies included individuals without any spinal symptoms. Data from five studies on neck angle showed a statistically significant (p = 0.02) overall effect (standardized mean difference (SMD) = 0.77), indicating a lesser neck flexion angle while sitting with a lumbar roll than without it. Data from two studies on head angle showed a statistically significant (p = 0.04) overall effect (SMD = 0.47), indicating a lesser head extension angle while sitting with a lumbar roll than without it. In each meta-analysis, the quality of evidence was very low in the GRADE system. The use of a lumbar roll while sitting reduced FHP among individuals without spinal symptoms.

A Two Joint Neck Model to Identify Malposition of the Head Relative to the Thorax

Neck pain is a frequent health complaint. Prolonged protracted malpositions of the head are associated with neck pain and headaches and could be prevented using biofeedback systems. A practical biofeedback system to detect malpositions should be realized with a simple measurement setup. To achieve this, a simple biomechanical model representing head orientation and translation relative to the thorax is introduced. To identify the parameters of this model, anthropometric data were acquired from eight healthy volunteers. In this work we determine (i) the accuracy of the proposed model when the neck length is known, (ii) the dependency of the neck length on the body height, and (iii) the impact of a wrong neck length on the models accuracy. The resulting model is able to describe the motion of the head with a maximum uncertainty of 5 mm only. To achieve this high accuracy the effective neck length must be known a priory. If however, this parameter is assumed to be a linear function of the palpable neck length, the measurement error increases. Still, the resulting accuracy can be sufficient to identify and monitor a protracted malposition of the head relative to the thorax.

Effect of standing desk use on cognitive performance and physical workload while engaged with high cognitive demand tasks

It is clear that the cognitive resources invested in standing are greater than in sitting, but six of eight previous studies suggested that there is no difference in cognitive performance. This study investigated the effects of sitting and standing workstations on the physical workload and cognitive performance under variable cognitive demand conditions. Fifteen participants visited two times for testing sitting and standing workstations, and were asked to play two difficulty levels of Tetris game for 40 min while kinematic variables, CoP regularity, CoP SD, and cognitive performances were captured every 5 min. Results revealed a more neural posture in standing than in sitting, but using the standing workstation degraded attention and executive function. The CoP SD was 7 times greater in standing, but the CoP regularity was 1/4 in sitting, denoting greater attentional investment while engaged at the standing workstation.

Posture and Health: Are the Biomechanical Postural Evaluation and the Postural Evaluation Questionnaire Comparable to and Predictive of the Digitized Biometrics Examination?

Background: Postural tone alterations are expressions of myofascial and, therefore, of structural, visceral, and emotional disorders. To prevent these disorders, this study proposes a quantitative investigation method which administers a postural evaluation questionnaire and a postural biomechanical evaluation to 100 healthy subjects. Methods: The reliability of the method is studied by comparing both assessments with digitized biometrics. In addition, 50 subjects undergo the biomechanical evaluation form twice, by four different operators, to study the intraoperative repeatability. Results: The results show a satisfactory overlap between the results obtained with the postural evaluation questionnaire and the postural biomechanical evaluation compared to computerized biometrics. Furthermore, intraoperative repeatability in the use of the biomechanical evaluation form is demonstrated thanks to a minimal margin of error. Conclusions: This experience suggests the importance of undertaking this path in both the curative and the preventive sphere on a large scale and on different types of people who easily, and even unknowingly, may face dysfunctional syndromes, not only structural and myofascial but also consequently of the entire body’s homeostasis.

Effectiveness of clinical Pilates and home exercises in sagittal cervical disorientation: randomized controlled study

Aim: To compare effects of clinical Pilates and home exercises on postural disorders, strength and endurance of deep cervical flexors (DCF), cervical range of motion (CROM), pain intensity and functional disability in sagittal cervical disorientation. Patients & methods: Fourty six patients were included and divided into two groups. Clinical Pilates group performed stabilization based exercise and home exercise group performed conventional exercises. Results: Craniovertebral, head tilt, cervicothoracic angles and strength and endurance of DCF muscles had improvement in favor of clinical Pilates group (p < 0.05). There was no difference between groups in terms of right-left acromial distance, pain intensity, functional disability and CROM parameters (p > 0.05). Conclusion: Clinical Pilates exercises have been found to provide clinically significant improvements in craniovertebral, head tilt, cervicothoracic angles and strength and endurance of DCF muscles. However, in the increase of CROM, decreasing pain severity and functional impairment parameters there was no superiority of both exercise training. Clinical trial registration number: NCT03352921 (Clinicaltrials.gov).

Does restoration of sagittal cervical alignment improve cervicogenic headache pain and disability: A 2-year pilot randomized controlled trial

BACKGROUND

To investigate the feasibility and effect of a multimodal program for improving chronic cervicogenic headache (CGH) via the addition of sagittal cervical spine alignment correction.

DESIGN

Pilot, parallel-group, randomized controlled trial.

PARTICIPANTS

60 patients with CGH, straightening of the cervical lordosis, and forward head posture (FHP) were randomly assigned using permuted-block randomization either to a control (n = 30) or an experimental group (n = 30).

INTERVENTIONS

Subjects in both groups received a multimodal program where the denneroll cervical spine extension traction orthotic was added to the experimental group only. Feasibility was assessed through recruitment rate, compliance rate, adherence rate, safety, and global satisfaction in addition to clinical outcome measures: FHP distance, cervical lordosis, headache frequency, headache disability inventory (HDI), headache impact test-6 (HIT-6), and daily defined dose (DDD). Evaluations were performed at: baseline, 10 weeks, 1 year follow up, and 2-year follow up. The assessor was blind to group allocation for all measured outcomes.

RESULTS

The recruitment rate was 60%, 78 % out of them completed the entire study. The recruited participants complied with 98% of the required visits. No adverse events were recorded and greater overall satisfaction with the interventions was reported. Greater improvements were found for the experimental group's cervical lordosis (f = 259.9, P< < .001) and FHP (f = 142.5, P< < .001). At 10 weeks, both groups showed equal improvements in CGH outcomes: headache frequency (P = 0.07), HDI (P = 0.07), HIT-6 (P = .2), and DDD (P = .3). In contrast, at the 1-year and 2-year follow up, between group differences were found for all CGH outcomes, P < .00, indicating greater improvement in the experimental group.

CONCLUSION

The results indicated feasibility for recruitment rate, compliance rate, exercise session adherence, safety, and global satisfaction. At 1-year and 2-year follow-up, the addition of the denneroll orthotic device revealed positive influence on CGH management outcomes.

TRIAL REGISTRATION

The trial was retrospectively registered with the Pan African Clinical Trial Registry (PACTR201605001650300).

Improved neck posture and reduced neck muscle activity when using a novel camera based workstation for manual precision inspection tasks

PURPOSE

This study investigates the effects of the usage of a novel camera system compared to a conventional lens system for manual precision tasks. Utilizing the novel camera system aims to improve neck posture, reduce neck muscle tension and thereby minimize the risk of neck pain.

METHODS

Camera and lens systems were compared by assessing the craniovertebral angle (CVA), electromyographic activity of the M.trapezius and perceived exertion. 16 healthy participants (n = 8 female, 24 ± 2 years; n = 8 male, 30 ± 5 years) performed manual precision tasks in a cross-over design using both systems in sitting and standing positions.

RESULTS

Analyses showed that using the camera system improved the CVA in sitting [28.4° (22.8°-33.9°) to 42.5° (38.9°-46.1°); p < 0.01] and decreased the M.trapezius activity in standing [13.1% (7.7%-18.6%) to 8.65% (5.49%-11.81%)]. Additionally, overall and neck specific perceived exertion decreased when using the camera system in standing.

CONCLUSIONS

The camera system may prevent neck pain in workers performing manual precision tasks in sitting and standing postures.

The effect of backpack load position on photographic measures of craniovertebral posture in 150 asymptomatic young adults

BACKGROUND

Altering the horizontal position of the weight in a backpack will influence the magnitude of the external torque it creates but the effect on posture is unclear.

OBJECTIVE

To use photogrammetry to determine if changes in the horizontal position of a fixed backpack weight affect external measures of craniovertebral posture in 150 asymptomatic young adults.

METHODS

A backpack was attached to a steel frame with a bar protruding posteriorly. A fixed load (5% body mass) was placed at three distances along the bar -0 m, 0.20 m, and 0.40 m. Sagittal and frontal plane photogrammetry was used to measure the craniovertebral angle (CVA), upper cervical gaze angle (UCGA) and lateral head tilt angle (LHTA). A comparison was made across unloaded (no backpack) and loaded conditions.

RESULTS

There was a significant decrease in the CVA between unloaded and loaded conditions. Changes in the UCGA were small and, while significant, may not have practical importance. There were no differences in the LHTA between the conditions.

CONCLUSIONS

Changes in the horizontal position of a fixed load affect external measures of craniovertebral posture so consideration needs to be given to not only the weight of a backpack but how the weight is positioned within the backpack.

Neurodynamic evaluation and nerve conduction studies in patients with forward head posture

Forward head posture (FHP) is one of the most frequently seen problems. The aim of this study was to evaluate the neurodynamic tests and peripheral nerve conductions of upper extremity in patients with FHP. The study population included 100 patients with upper extremity and neck problems and 34 healthy individuals as a control group. Craniovertebral angle measurement was used to determine forward head posture. Stretch tests for radial, ulnar and median nerves were performed. Nerve conductions of bilateral median, radial, ulnar and medial antebrachial cutaneous (MAC) nerves were examined in all patients included in the study. The most significant nerve conduction differences in moderate-to-severe FHP patients were a decrease in the sensory nerve action potential (SNAP) and compound muscle action potential (CMAP) amplitudes of median nerves, a decrease in the SNAP amplitude of ulnar nerves, a delay in the F response latency of ulnar nerves and prolongation in the SNAP latency of the MAC nerve. FHP makes patients more prone to peripheral entrapments.

Relationship between Forward Head Posture and Tissue Mechanosensitivity: A Cross-Sectional Study

The relationship between forward head posture (FHP) and neck pain is not clear. FHP could possibly increase the mechanosensitivity of cervical tissues, which could lead to the development of pain depending on the adaptation capability of the central nervous system. The purpose of this study was to analyse the influence of FHP in the mechanosensitivity of articular, muscular, and neural tissues related to the cervical spine. The pressure pain threshold was bilaterally measured in different muscles and nerves and the second cervical vertebrae. The cervical spine’s range of movement was also examined. The measurements were obtained from people with (n = 32) and without (n = 64) FHP. The analyses included a 2-by-2 mixed analysis of variance (ANOVA), pairwise comparisons with Bonferroni correction, and point-biserial correlation coefficients. Subjects with FHP showed a less pressure pain threshold (PPT) in all locations except for the upper trapezius and scalenus medius muscles. They also showed less extension and right-rotation range of motion. There was no association between FHP, neck pain, disability, and headache. Nevertheless, more research is needed to evaluate the relationship between FHP, tissue mechanosensitivity, and neck pain.

Prevalence and risk factors associated with headache amongst medical staff in South China

BACKGROUND

A previous study by our team reported the prevalence of primary headache disorders and factors associated with headache among nurses in three hospitals in North China. The aim of this cross-sectional survey was to learn more about how medical nurses in South China were affected by headache. Additionally, we determined the prevalence of headache and measured the impact of headache among doctors in mainland China for the first time.

METHODS

Stratified random cluster sampling was used to select 280 physicians and 365 nurses from various departments in four hospitals in Sanya, which is one of southernmost cities in China. Information was collected on demographic data, occupational factors and headache characteristics by using a structured questionnaire.

RESULTS

Among 645 medical staff, 548 (85%) responded (doctors = 240, nurses = 308). Among the medical staff, the 1-year prevalence of primary headache disorders was 50%, with 25.9% experiencing migraine and 24.1% experiencing tension-type headache (TTH). The prevalence of migraine in female doctors was higher than that in female nurses, although this difference was not significant (32.4% vs. 29.8%, P = 0.628). Multivariate analysis showed that being female and working in other specialties (Emergency Department & Radiology Department) remained independent risk factors for migraine in doctors (OR 2.314 and 3.223). In nurses, being married was a risk factor for migraine (OR 3.728), and job titles remained an independent risk factor for migraine and TTH (OR 2.294 and 4.695). Working more than 6 night-shifts per month was associated with an increased prevalence of migraine and TTH in doctors; the same was true in nurses for migraine, but not for TTH.

CONCLUSION

The prevalence of primary headache disorders in both nurses and doctors is higher than that in the general population in South China. Our study shows that occupation, geography and sex may play an important role. Further, female doctors are more susceptible than female nurses to migraine. The risk factors relevant to headache that were found in this study should provide an important reference for promoting occupational health in medical staff, especially female doctors in China.

Impact of Cervical Sensory Feedback for Forward Head Posture on Headache Severity and Physiological Factors in Patients with Tension-type Headache: A Randomized, Single-Blind, Controlled Trial

BACKGROUND Tension-type headache (TTH) decreases the ability to concentrate and function during daily activities in affected patients. As most patients with TTH exhibit forward head posture (FHP). Various interventions have been proposed to resolve TTH. However, research regarding the efficacy of these interventions remains lacking. The present study aimed to investigate the association between FHP and TTH, and to evaluate the efficacy of various intervention methods on headache symptoms and other clinical variables in patients with TTH induced by FHP. MATERIAL AND METHODS Participants were randomly allocated to 3 groups: biofeedback (BF, n₁=21), manual therapy (MT, n₂=20) and, stretching (ST, n₃=21). Interventions were conducted 3 times per week for 4 weeks. Craniovertebral angle (CVA), electroencephalographic findings for attention, stress, and pressure-pain threshold (PPT), headache on activities of daily living (Henry Ford Headache Disability Inventory, HDI), and quality of life (QoL) assessments were obtained pre-intervention, post-intervention, and at the 2-week follow-up. RESULTS The correlation between CVA and HDI after intervention (R²=0.324, P<0.001), and at 2-week follow-up (R²=0.115, P<0.01) are significant. BF was associated with significant improvements in CVA (F₂,₅₉=3.393, P<0.001, η^2/P=0.130), attention (F₂,₅₉=5.186, P<0.01, η^2/P=0.150), stress [skin temperature (F₂,₅₉=6.005, P<0.001, η^2/P=0.169) and skin conductance (F₂,₅₉=4.900, P<0.01, η^2/P=0.142)], PPT (F₂,₅₉=5.050, P<0.01, η^2/P=0.146), HDI (F₂,₅₉=3.303, P<0.01, η^2/P=0.101), and QoL (F₂,₅₉=3.409, P<0.05, η^2/P=0.104). CONCLUSIONS Our findings indicate that BF was more effective than MT and ST in the treatment of TTH due to FHP. Such findings highlight the need to develop and promote a controlled exercise program to facilitate a return to normal daily activities in patients with TTH due to FHP.

Cervical musculoskeletal impairments in migraine and tension type headache: A systematic review and meta-analysis

AIMS

Neck pain is common in migraine and tension type headache (TTH). This review aimed to examine the evidence for cervical musculoskeletal impairments in these headaches.

METHODS

Databases PubMed (Medline), EMBASE, CINAHL, SCOPUS, and Web of Science were searched from inception to December 2018. Observational studies using a comparator group were included. Risk of bias was assessed using the Appraisal tool for Cross-Sectional Studies. Results were pooled using random effects meta-analysis. Level of evidence for each outcome was assigned based on risk of bias, consistency of results and magnitude of difference between participants with headache and controls. (PROSPERO registration: CRD42018083683).

RESULTS

Of 48 studies included, the majority were rated moderate risk of bias due to possible confounding influences. In total, 17 cervical outcomes were assessed, with confidence in findings ranging from very low to moderate levels. Compared to controls, participants with TTH had greater forward head posture (FHP) (MD = -6.18°, 95% CI [-8.18°, -4.18°]) and less cervical range of motion (ROM) (greatest difference transverse plane MD = -15.0°, 95% CI [-27.7°, -2.3°]. Participants with migraine demonstrated minimally reduced cervical ROM (greatest difference sagittal plane MD = -5.4°, 95% CI [-9.9°, -0.9°]. No differences presented in head posture, strength, craniocervical flexion test performance or joint position error between migraineurs and controls.

CONCLUSIONS

TTH presented with more findings of cervical musculoskeletal impairments than migraine however levels of confidence in findings were low. Future studies should differentiate episodic from chronic headache, identify coexisting musculoskeletal cervical disorders, and describe neck pain behaviour in headache.

[Somatic dysfunctions of the cervical spine and fixed orthodontic treatment: a 145 subjects-cross sectional study]

Objectives : The aim of this blind cross-sectional study is to evaluate the influence of a fixed orthodontic appliance on the cervical spine.

MATERIALS AND METHODS

 Number and severity of somatic dysfunctions (i.e. alteration of the function of an element constituting the somatic system or SD) of the cervical spine have been searched on patients sorted out in three groups: subjects without orthodontic treatment (group 1), subjects wearing fixed orthodontic appliance (group 2) and subjects in a retention period after removal of the fixed orthodontic appliance (group 3) and were compared thanks to khi² test.

RESULTS

 A total of 145 patients from 6 to 17 years old was included. There are more SD in the second group (p = 0.006) than in the first group. There is no difference between the 1^st and the 3^rd group (p = 0.2), between the 2^nd and the 3^rd group (p = 0.4) and between the three groups (p = 0.6) concerning the severity of SD.

CONCLUSION

 Cervical disorders should not be attributed to long-term multi-attachment treatment since once the active orthodontic treatment is finished, the SD are not significantly increased compared to the control group. These results may encourage to make a study to evaluate benefits of cervical osteopathic follow-up for patients at risk after the setting of the fixed appliance.

Influence of Forward Head Posture on Myotonometric Measurements of Superficial Neck Muscle Tone, Elasticity, and Stiffness in Asymptomatic Individuals With Sedentary Jobs

OBJECTIVE

The objective of the study was to assess the influence of forward head posture on the mechanical parameters and pressure pain threshold of superficial neck muscles in clinically nonsymptomatic individuals with sedentary jobs.

METHODS

Twenty-five office workers with forward head posture and 25 office workers with normal head posture were matched for sex, age, body mass index, and the nature and duration of their work and were compared at a single point. The study participants were divided into study groups on the basis of photometric craniovertebral angle measurements. The upper trapezius, sternocleidomastoid, and splenius capitis mechanical properties were assessed in the sitting position. Primary outcome measures were muscle stiffness (N/m), muscle tone (Hz), and muscle elasticity. The secondary variable was perceived pain threshold.

RESULTS

No significant differences between the groups were found for biomechanical properties and perceived pain threshold in the studied muscles.

CONCLUSION

Forward head posture has no impact on muscle stiffness, tone, and elasticity, nor does it increase the pressure sensitivity of superficial neck muscles in healthy, mildly symptomatic office workers. It is most likely that not incorrect posture of the cervical spine, but probably other factors combined with forward head posture, like comorbid acute and chronic cervical pain and musculoskeletal disorders or prolonged sitting, contribute to changes in active myofascial tone and tensegrity as well as increased pressure sensitivity of neck muscles.

Comparing neck extensor muscle function in asymptomatic Canadian adults and adults with tension-type headache: a cross-sectional study

AIM

To further the understanding of the pathophysiological mechanisms underlying tension-type headache (TTH) by comparing the endurance and strength of neck extensor muscles under acute muscle fatigue in participants with TTH and asymptomatic participants.

METHODS

We conducted a cross-sectional analysis of neck extensor muscle performance. Asymptomatic participants and participants with TTH were recruited via social media platforms and from the Université du Québec à Trois-Rivières community and employees. A total of 44 participants with TTH and 40 asymptomatic participants took part in an isometric neck extensor endurance task performed at 60% of their maximum voluntary contraction. Inclusion criteria for the headache group were to be older than 18 years old and to fulfil the International Headache Society classification's criteria for either frequent episodic or chronic TTH. Clinical (self-efficacy, anxiety, neck disability and kinesiophobia) and physical parameters (neck extensors maximum voluntary contraction, endurance time, muscle fatigue) as well as characteristics of headache episodes (intensity, frequency and associated disability) were collected for all participants. Surface electromyography was used to document upper trapezius, splenius capitis and sternocleidomastoids muscle activity and muscle fatigue.

RESULTS

Both groups displayed similar neck extensor muscle endurance capacity with a mean difference of 6.2 s (p>0.05) in favour of the control group (control=68.1±32.3; TTH=61.9±20.1). Similarly, participants in the headache group showed comparable neck extensor muscle strength (95.9±30.4 N) to the control group (111.3±38.7 N). Among participants with TTH, those scoring as severely incapacitated by headaches were the ones with higher neck-related disability (F[1,44]=10.77; p=0.002), the more frequent headache episodes (F[1,44]=6.70; p=0.01) and higher maximum headache intensity (F[1,44]=10.81; p=0.002).

CONCLUSION

A fatigue task consisting of isometric neck extension cannot efficiently differentiate participants with TTH from asymptomatic participants.

Is There Support for the Paradigm 'Spinal Posture as a Trigger for Episodic Headache'? A Comprehensive Review

PURPOSE OF REVIEW

The International Classification of Headache Disorders provides an extensive framework to classify headaches. Physiotherapy is indicated if neuromusculoskeletal dysfunctions are involved in the pathophysiology. Maladaptive postures seem a dominant trigger in tension-type and cervicogenic headache. Yet, outcomes following physiotherapy vary. The absence of protocol studies to identify determinants concerning the role of spinal posture in headache might explain such variability. Hence, multi-dimensional profiling of patients with headache based on interactions between spinal posture, psychosocial and lifestyle factors might be essential. Therefore, the aim of this paper was to perform a comprehensive review to find support for the paradigm of spinal posture triggering episodic headache based on a multi-dimensional view on tension-type and cervicogenic headache including modern pain neuroscience.

RECENT FINDINGS

A review was conducted to support spinal posture-induced episodic headache. Pubmed, Web of Science, Pedro and the Cochrane database were explored based on the following 'Mesh' or 'Topics': 'Headache', 'Posture', 'Spine', 'Psychosocial', 'Lifestyle'. The contemporary review of neuroanatomical, biomechanical and non-nociceptive pathways, with integration of modern pain neuroscience in tension-type and cervicogenic headache, supports spinal posture as a trigger for episodic headache. Maladaptive postures can activate C1-C3 nociceptors. Convergence with trigeminal afferents at the trigeminocervical nucleus could explain spinal headache. Interactions with psychosocial and lifestyle factors might contribute to peripheral and central sensitisation. Neuroanatomical, biomechanical and non-nociceptive pathways seem to justify profiling patients based on a postural trigger. Further research is needed to determine the contribution of postural dysfunctions in headache and the effect of specific interventions.

Short-term effects of the suboccipital muscle inhibition technique and cranio-cervical flexion exercise on hamstring flexibility, cranio-vertebral angle, and range of motion of the cervical spine in subjects with neck pain: A randomized controlled trial

BACKGROUND

Cervical spinal instability often leads to neck pain and forward head posture (FHP). To improve neck pain and FHP, both the suboccipital muscle inhibition (SMI) technique and cranio-cervical flexion exercise (CCFE) have been used. However, little is known regarding the validity of hamstring flexibility in neck pain subjects after CCFE as a treatment index, and comparison between the SMI technique and CCFE for neck pain treatment.

OBJECTIVE

This study aimed to determine the short-term effects of SMI technique and CCFE, which represent passive and active exercise programs, respectively, and whether these improve the straight leg raise (SLR) test results, popliteal angle (PA), cranio-vertebral angle (CVA), and cervical range of motion (CROM) and are equally effective in immediate enhancement of such measures in neck pain subjects.

METHODS

Twenty subjects with neck pain were randomly allocated to the SMI and CCFE groups (n= 10 each). The outcomes were evaluated via clinical evaluation and SLR, PA, CVA, and CROM measurement before and after intervention.

RESULTS

SLR test results, PA, CVA (sitting and standing), and CROM (flexion, extension, lateral flexion, and right and left rotations) after both interventions were significantly higher than those before the interventions (P< 0.05). The SLR test results (left), PA, and CVA (standing) after the SMI technique improved to levels similar to those observed after CCFE.

CONCLUSIONS

Both the SMI technique and CCFE improve SLR test results, PA, CVA, and CROM and are equally effective in immediate enhancement of the hamstring flexibility, CVA, and CROM in subjects with neck pain.

Effect of forward head posture on thoracic shape and respiratory function

[Purpose] This study investigated the effect of forward head posture on upper and lower thoracic shape in adults to better understand the relationship between a forward head posture and respiratory function. [Participants and Methods] Fifteen healthy males were recruited after obtaining informed consent from all participants. All participants were instructed to respire in both the forward and neutral head postures while seated. Respiratory function was assessed using spirometry. Thoracic shape during respiration was assessed using 23 markers on both the upper and the lower thorax and compared between the 2 postures. [Results] Forced vital capacity, expiratory and inspiratory reserve volumes, forced expiratory volume at 1 second, and the peak flow rate observed with the forward head posture were significantly lower than that with the neutral head posture. The upper thorax showed a greater forward shift and the lower thorax showed a greater forward and inward shift with the forward head posture than with the neutral head posture. No significant difference in upper thoracic mobility was observed during respiration between the forward head posture and the neutral head posture. However, mobility of the lower thorax during respiration was significantly reduced with the forward head posture. [Conclusion] The forward head posture causes expansion of the upper thorax and contraction of the lower thorax, and these morphological changes cause decreased respiratory function.

Surgeon's Neck Posture during Spine Surgeries: "The Unrecognised Potential Occupational Hazard"

STUDY DESIGN

Observational study.

PURPOSE

The purpose of this study is to analyze the surgeon's neck postures while performing lumbar spinal surgeries.

OVERVIEW OF LITERATURE

Lumbar spinal surgeries are on rising trend, and with increase in number of procedures, the average time spent by a spine surgeon performing surgical procedures is also increasing. The effect of operating posture on the surgeon's neck is largely unknown. From the studies conducted on usage of smartphones, abnormal neck postures, especially the forward head posture (FHP), were found to adversely affect the cervical spine of individuals. The present study analyzes the neck position of spine surgeons during lumbar spine surgeries.

METHODOLOGY

Sixty video recordings (25 open transforaminal lumbar interbody fusions [TLIFs] and 35 lumbar decompression [LD] procedures - 15 with headlight and 20 with operating microscope) of surgeries performed by three spine surgeons of different heights were analyzed. Running videos of the surgeries were recorded concentrating on the surgeons with reflective markers taped to their surface landmarks corresponding to C7 spinous process, tragus of the ear, and outer canthus of the eye. Video recordings were standardized by a fixed video recorder in the same operating theater. Snapshots from the video were obtained whenever the surgeon changes the position. Head flexion angle (HFA), neck flexion angle (NFA), and cervical angle (CA) were measured and analyzed.

RESULTS

During TLIF, HFA and NFA were significantly higher during the phases of decompression and fusion (P < 0.05). The average CA of all surgeons was lower, thereby adversely affecting the cervical spine (20.15° ± 5.05°). During LD, CA showed significant difference between usage of microscope and headlight (P < 0.001).

CONCLUSION

Surgeon's FHP is frequently caused by a compromise between the need to perform surgery with hands, without elevating the arms, and simultaneous control of gaze at surgical field. The usage of microscope was found to reduce the stress on neck while performing surgery.