Associations between social support and physical activity among postpartum women: a cohort study

Background

Moderate-to-vigorous physical activity (MVPA) enhances postpartum women’s health, and social support is associated with higher self-reported physical activity (PA) postpartum. It is unknown if this association exist across ethnic groups. Our research questions are: are overall family or friends’ support associated with objectively recorded MVPA postpartum, 2) are specific types of family or friends’ support associated with MVPA and 3) does the association differ across ethnic groups?

Methods

We used data from 662 women participating in the STORK Groruddalen cohort study (2008-2010). MVPA in bouts ≥ 10 minutes was recorded by SenseWear ArmbandTM Pro3 14 weeks postpartum. Family and friends’ support was measured by the Social Support for Exercise Scale. We used single items and mean score for family (6 items) and friends’ (6-items) support in separate linear regression models, and adjusted for age, ethnicity, education, parity, weeks since birth and body mass index. We tested for interactions between social support and ethnicity. Analyses were performed on complete cases and imputed data due to missing MVPA data.

Results

Based on imputed data we observed an association between family support and MVPA (β = 4.0, 95% CI, 0.18 to 7.74, p = 0.040). Women reporting high family support on two specific items spent 9 MVPA minutes/day more than women reporting low support (‘discuss PA': β = 8.6, 95% CI: 0.37 to 16.87 and ‘co-participation': β = 8.8, 95% CI: 1.79 to 15.86). Associations were not modified by ethnicity. No statistically significant association between friends’ support and MVPA was observed. Similar results were found in complete case analyses, with few exceptions.

Conclusions

Overall family support and specific form of family support (i.e., PA discussion and co-participation) were associated with MVPA postpartum across ethnic groups. Friends’ support was not associated with MVPA.

Key messages

• Postpartum health may be improved across ethnic groups through increased PA facilitated through overall family support for PA and specifically through PA discussions and co-participation from family.

• Friends’ support for PA was not associated with PA.

Assessing the robustness of time-to-event models for estimating unmarked wildlife abundance using remote cameras

Recently developed methods, including time-to-event and space-to-event models, estimate the abundance of unmarked populations from encounter rates with camera trap arrays, addressing a gap in noninvasive wildlife monitoring. However, estimating abundance from encounter rates relies on assumptions that can be difficult to meet in the field, including random movement, population closure, and an accurate estimate of movement speed. Understanding how these models respond to violation of these assumptions will assist in making them more applicable in real-world settings. We used simulated walk models to test the effects of violating the assumptions of the time-to-event model under four scenarios: (1) incorrectly estimating movement speed, (2) violating closure, (3) individuals moving within simplified territories (i.e., movement restricted to partially overlapping circles), (4) and individuals clustering in preferred habitat. The time-to-event model was robust to closure violations, territoriality, and clustering when cameras were placed randomly. However, the model failed to estimate abundance accurately when movement speed was incorrectly estimated or cameras were placed nonrandomly with respect to habitat. We show that the time-to-event model can provide unbiased estimates of abundance when some assumptions that are commonly violated in wildlife studies are not met. Having a robust method for estimating the abundance of unmarked populations with remote cameras will allow practitioners to monitor a more diverse array of populations noninvasively. With the time-to-event model, placing cameras randomly with respect to animal movement and accurately estimating movement speed allows unbiased estimation of abundance. The model is robust to violating the other assumptions we tested.

Neck pain patterns and subgrouping based on weekly SMS-derived trajectories

BACKGROUND

Neck and low back pain represent dynamic conditions that change over time, often with an initial improvement after the onset of a new episode, followed by flare-ups or variations in intensity. Pain trajectories were previously defined based on longitudinal studies of temporal patterns and pain intensity of individuals with low back pain. In this study, we aimed to 1) investigate if the defined patterns and subgroups for low back pain were applicable to neck pain patients in chiropractic practice, 2) explore the robustness of the defined patterns, and 3) investigate if patients within the various patterns differ concerning characteristics and clinical findings.

METHODS

Prospective cohort study including 1208 neck pain patients from chiropractic practice. Patients responded to weekly SMS-questions about pain intensity and frequency over 43 weeks. We categorized individual responses into four main patterns based on number of days with pain and variations in pain intensity, and subdivided each into four subgroups based on pain intensity, resulting in 16 trajectory subgroups. We compared baseline characteristics and clinical findings between patterns and between Persistent fluctuating and Episodic subgroups.

RESULTS

All but two patients could be classified into one of the 16 subgroups, with 94% in the Persistent fluctuating or Episodic patterns. In the largest subgroup, "Mild Persistent fluctuating" (25%), mean (SD) pain intensity was 3.4 (0.6) and mean days with pain 130. Patients grouped as "Moderate Episodic" (24%) reported a mean pain intensity of 2.7 (0.6) and 39 days with pain. Eight of the 16 subgroups each contained less than 1% of the cohort. Patients in the Persistent fluctuating pattern scored higher than the other patterns in terms of reduced function and psychosocial factors.

CONCLUSIONS

The same subgroups seem to fit neck and low back pain patients, with pain that typically persists and varies in intensity or is episodic. Patients in a Persistent fluctuating pattern are more bothered by their pain than those in other patterns. The low back pain definitions can be used on patients with neck pain, but with the majority of patients classified into 8 subgroups, there seems to be a redundancy in the original model.

Estimating large carnivore populations at global scale based on spatial predictions of density and distribution - Application to the jaguar (Panthera onca)

Broad scale population estimates of declining species are desired for conservation efforts. However, for many secretive species including large carnivores, such estimates are often difficult. Based on published density estimates obtained through camera trapping, presence/absence data, and globally available predictive variables derived from satellite imagery, we modelled density and occurrence of a large carnivore, the jaguar, across the species' entire range. We then combined these models in a hierarchical framework to estimate the total population. Our models indicate that potential jaguar density is best predicted by measures of primary productivity, with the highest densities in the most productive tropical habitats and a clear declining gradient with distance from the equator. Jaguar distribution, in contrast, is determined by the combined effects of human impacts and environmental factors: probability of jaguar occurrence increased with forest cover, mean temperature, and annual precipitation and declined with increases in human foot print index and human density. Probability of occurrence was also significantly higher for protected areas than outside of them. We estimated the world's jaguar population at 173,000 (95% CI: 138,000-208,000) individuals, mostly concentrated in the Amazon Basin; elsewhere, populations tend to be small and fragmented. The high number of jaguars results from the large total area still occupied (almost 9 million km2) and low human densities (< 1 person/km2) coinciding with high primary productivity in the core area of jaguar range. Our results show the importance of protected areas for jaguar persistence. We conclude that combining modelling of density and distribution can reveal ecological patterns and processes at global scales, can provide robust estimates for use in species assessments, and can guide broad-scale conservation actions.

Flexibility in the duration of parental care: Female leopards prioritise cub survival over reproductive output

Deciding when to terminate care of offspring is a key consideration for parents. Prolonging care may increase fitness of current offspring, but it can also reduce opportunities for future reproduction. Despite its evolutionary importance, few studies have explored the optimal duration of parental care, particularly among large carnivores. We used a 40-year dataset to assess the trade-offs associated with the length of maternal care in leopards in the Sabi Sand Game Reserve, South Africa. We compared the costs imposed by care on the survival and residual reproductive value of leopard mothers against the benefits derived from maternal care in terms of increased offspring survival, recruitment and reproduction. We also examined the demographic and ecological factors affecting the duration of care in the light of five explanatory hypotheses: litter size, sex allocation, resource limitation, timing of independence and terminal investment. Duration of care exhibited by female leopards varied markedly, from 9 to 35 months. Mothers did not appear to suffer any short- or long-term survival costs from caring for cubs, but extending care reduced the number of litters that mothers could produce during their lifetimes. Interestingly, the duration of care did not appear to affect the post-independence survival or reproductive success of offspring (although it may have indirectly affected offspring survival by influencing dispersal distance). However, results from generalised linear mixed models showed that mothers prolonged care during periods of prey scarcity, supporting the resource limitation hypothesis. Female leopards also cared for sons longer than daughters, in line with the sex-allocation hypothesis. Cub survival is an important determinant of the lifetime reproductive success in leopards. By buffering offspring against environmental perturbation without jeopardising their own survivorship, female leopards apparently "hedge their bets" with current offspring rather than gamble on future offspring which have a small probability of surviving. In many species, parents put their own needs before that of their offspring. Leopard mothers appear sensitive to their offspring's demands, and adjust levels of care accordingly.

Estimating abundance and density of Amur tigers along the Sino-Russian border

As an apex predator the Amur tiger (Panthera tigris altaica) could play a pivotal role in maintaining the integrity of forest ecosystems in Northeast Asia. Due to habitat loss and harvest over the past century, tigers rapidly declined in China and are now restricted to the Russian Far East and bordering habitat in nearby China. To facilitate restoration of the tiger in its historical range, reliable estimates of population size are essential to assess effectiveness of conservation interventions. Here we used camera trap data collected in Hunchun National Nature Reserve from April to June 2013 and 2014 to estimate tiger density and abundance using both maximum likelihood and Bayesian spatially explicit capture-recapture (SECR) methods. A minimum of 8 individuals were detected in both sample periods and the documentation of marking behavior and reproduction suggests the presence of a resident population. Using Bayesian SECR modeling within the 11 400 km(2) state space, density estimates were 0.33 and 0.40 individuals/100 km(2) in 2013 and 2014, respectively, corresponding to an estimated abundance of 38 and 45 animals for this transboundary Sino-Russian population. In a maximum likelihood framework, we estimated densities of 0.30 and 0.24 individuals/100 km(2) corresponding to abundances of 34 and 27, in 2013 and 2014, respectively. These density estimates are comparable to other published estimates for resident Amur tiger populations in the Russian Far East. This study reveals promising signs of tiger recovery in Northeast China, and demonstrates the importance of connectivity between the Russian and Chinese populations for recovering tigers in Northeast China.

Structural habitat predicts functional dispersal habitat of a large carnivore: how leopards change spots

Natal dispersal promotes inter-population linkage, and is key to spatial distribution of populations. Degradation of suitable landscape structures beyond the specific threshold of an individual's ability to disperse can therefore lead to disruption of functional landscape connectivity and impact metapopulation function. Because it ignores behavioral responses of individuals, structural connectivity is easier to assess than functional connectivity and is often used as a surrogate for landscape connectivity modeling. However using structural resource selection models as surrogate for modeling functional connectivity through dispersal could be erroneous. We tested how well a second-order resource selection function (RSF) models (structural connectivity), based on GPS telemetry data from resident adult leopard (Panthera pardus L.), could predict subadult habitat use during dispersal (functional connectivity). We created eight non-exclusive subsets of the subadult data based on differing definitions of dispersal to assess the predictive ability of our adult-based RSF model extrapolated over a broader landscape. Dispersing leopards used habitats in accordance with adult selection patterns, regardless of the definition of dispersal considered. We demonstrate that, for a wide-ranging apex carnivore, functional connectivity through natal dispersal corresponds to structural connectivity as modeled by a second-order RSF. Mapping of the adult-based habitat classes provides direct visualization of the potential linkages between populations, without the need to model paths between a priori starting and destination points. The use of such landscape scale RSFs may provide insight into predicting suitable dispersal habitat peninsulas in human-dominated landscapes where mitigation of human-wildlife conflict should be focused. We recommend the use of second-order RSFs for landscape conservation planning and propose a similar approach to the conservation of other wide-ranging large carnivore species where landscape-scale resource selection data already exist.

Mental health among people with psoriasis undergoing patient education in climate therapy

This study investigated the mental health of people with psoriasis undergoing patient education in climate therapy. A prospective design included a baseline assessment and two follow-ups after a 3-week patient education program. Participants were 254 adults. Positive mental health was measured by the mental health continuum short form (0-70), and negative mental health by the emotional distress subscale (1-4) of the health education impact questionnaire. Paired-samples t-tests were used to evaluate changes in mental health from baseline to follow-up. Multiple linear regression was used to analyse the ability of socio-demographic and clinical variables and emotional distress to predict changes in positive mental health. To predict change in negative mental health we repeated the same analysis but with a change in negative mental health as a dependent variable and positive mental health as an independent variable. The results show that positive mental health and health-related emotional distress improved significantly from before to after the intervention by 7.1 points, p < 0.001 and 0.21 points, p < 0.001) respectively. At the second follow-up, health-related emotional distress remained significantly improved compared with baseline levels by 0.11 points, p = 0.004. The longer participants had lived with psoriasis ( β = 146, p = 0.027), and the presence of co-morbid health problems (β  =  111, p = 0.051) the greater the improvement in the positive mental health immediately after the intervention. No predictors were identified for negative mental health. This study indicates that the promotion of positive mental health needs to be integrated into the climate therapy program, and sustained in their home context.

The effect of fire on spatial separation between wolves and caribou

Fire management is an important conservation tool in Canada’s national parks. Fires can benefit some species, while others may be negatively impacted. We used GPS and VHF collar data for 47 wolves from 12 separate packs and 153 caribou from 5 separate herds, and resource selection analysis to model the effects of fire on these species’ habitat and potential interactions. Resource selection modeling showed that wolves select for burned areas and areas close to burns, presumably due to the presence of primary prey (i.e., elk and moose), while caribou avoid burns. Fire reduced the amount of high quality caribou habitat (a direct effect), but also increased the probability of wolf-caribou overlap (an indirect effect). We delineated a spatial index of caribou “safe zones” (areas of low overlap with wolves), and found a positive relationship between the proportion of a herd’s home range represented by “safe zone” in winter and population size (P = 0.10, n=4). While currently-planned prescribed fires in Banff and Jasper reduced the amount of quality caribou habitat by up to 4%, they reduced the area of “safe zones” by up to 7%, varying by herd, location, and season. We suggest that conservation managers should account for the indirect, predator-mediated impacts of fire on caribou in addition to direct effects of habitat loss.

Neonatal mortality of elk driven by climate, predator phenology and predator community composition

1. Understanding the interaction among predators and between predation and climate is critical to understanding the mechanisms for compensatory mortality. We used data from 1999 radio-marked neonatal elk (Cervus elaphus) calves from 12 populations in the north-western United States to test for effects of predation on neonatal survival, and whether predation interacted with climate to render mortality compensatory. 2. Weibull survival models with a random effect for each population were fit as a function of the number of predator species in a community (3-5), seven indices of climatic variability, sex, birth date, birth weight, and all interactions between climate and predators. Cumulative incidence functions (CIF) were used to test whether the effects of individual species of predators were additive or compensatory. 3. Neonatal elk survival to 3 months declined following hotter previous summers and increased with higher May precipitation, especially in areas with wolves and/or grizzly bears. Mortality hazards were significantly lower in systems with only coyotes (Canis latrans), cougars (Puma concolor) and black bears (Ursus americanus) compared to higher mortality hazards experienced with gray wolves (Canis lupus) and grizzly bears (Ursus horribilis). 4. In systems with wolves and grizzly bears, mortality by cougars decreased, and predation by bears was the dominant cause of neonatal mortality. Only bear predation appeared additive and occurred earlier than other predators, which may render later mortality by other predators compensatory as calves age. Wolf predation was low and most likely a compensatory source of mortality for neonatal elk calves. 5. Functional redundancy and interspecific competition among predators may combine with the effects of climate on vulnerability to predation to drive compensatory mortality of neonatal elk calves. The exception was the evidence for additive bear predation. These results suggest that effects of predation by recovering wolves on neonatal elk survival, a contentious issue for management of elk populations, may be less important than the composition of the predator community. Future studies would benefit by synthesizing overwinter calf and adult-survival data sets, ideally from experimental studies, to test the roles of predation in annual compensatory and additive mortality of elk.

Does hunting regulate cougar populations? A test of the compensatory mortality hypothesis

Many wildlife species are managed based on the compensatory mortality hypothesis, which predicts that harvest mortality (especially adult male mortality) will trigger density-dependent responses in reproduction, survival, and population growth caused via reduced competition for resources. We tested the compensatory mortality hypothesis on two cougar (Puma concolor) populations in Washington, USA (one heavily hunted and one lightly hunted). We estimated population growth, density, survival, and reproduction to determine the effects of hunting on cougar population demography based on data collected from 2002 to 2007. In the heavily hunted population, the total hunting mortality rate (mean +/- SD) was 0.24 +/- 0.05 (0.35 +/- 0.08 for males, 0.16 +/- 0.05 for females). In the lightly hunted population, the total hunting mortality rate was 0.11 +/- 0.04 (0.16 +/- 0.06 for males, 0.07 +/- 0.05 for females). The compensatory mortality hypothesis predicts that higher mortality will result in higher maternity, kitten survival, reproductive success, and lower natural mortality. We found no differences in rates of maternity or natural mortality between study areas, and kitten survival was lower in the heavily hunted population. We rejected the compensatory mortality hypothesis because vital rates did not compensate for hunting mortality. Heavy harvest corresponded with increased immigration, reduced kitten survival, reduced female population growth, and a younger overall age structure. Light harvest corresponded with increased emigration, higher kitten survival, increased female population growth, and an older overall age structure. Managers should not assume the existence of compensatory mortality when developing harvest prescriptions for cougars.

Sink populations in carnivore management: cougar demography and immigration in a hunted population

Carnivores are widely hunted for both sport and population control, especially where they conflict with human interests. It is widely believed that sport hunting is effective in reducing carnivore populations and related human-carnivore conflicts, while maintaining viable populations. However, the way in which carnivore populations respond to harvest can vary greatly depending on their social structure, reproductive strategies, and dispersal patterns. For example, hunted cougar (Puma concolor) populations have shown a great degree of resiliency. Although hunting cougars on a broad geographic scale (> 2000 km2) has reduced densities, hunting of smaller areas (i.e., game management units, < 1000 km2), could conceivably fail because of increased immigration from adjacent source areas. We monitored a heavily hunted population from 2001 to 2006 to test for the effects of hunting at a small scale (< 1000 km2) and to gauge whether population control was achieved (lambda < or = 1.0) or if hunting losses were negated by increased immigration allowing the population to remain stable or increase (lambda > or = 1.0). The observed growth rate of 1.00 was significantly higher than our predicted survival/fecundity growth rates (using a Leslie matrix) of 0.89 (deterministic) and 0.84 (stochastic), with the difference representing an 11-16% annual immigration rate. We observed no decline in density of the total population or the adult population, but a significant decrease in the average age of independent males. We found that the male component of the population was increasing (observed male population growth rate, lambda(OM) = 1.09), masking a decrease in the female component (lambda(OF) = 0.91). Our data support the compensatory immigration sink hypothesis; cougar removal in small game management areas (< 1000 km2) increased immigration and recruitment of younger animals from adjacent areas, resulting in little or no reduction in local cougar densities and a shift in population structure toward younger animals. Hunting in high-quality habitats may create an attractive sink, leading to misinterpretation of population trends and masking population declines in the sink and surrounding source areas.

Cougar predation and population growth of sympatric mule deer and white-tailed deer

Mule deer (Odocoileus hemionus) populations throughout the west appear to be declining, whereas white-tailed deer (Odocoileus virginianus) populations are increasing. We compared abundance, number of fetuses per female (maternity rate), recruitment, and cause-specific adult ([Formula: see text]1 year old) mortality rate for sympatric mule deer and white-tailed deer in south-central British Columbia to assess population growth for each species. White-tailed deer were three times more abundant (908 ± 152) than mule deer (336 ± 122) (mean ± 1 SE). Fetal rates of white-tailed deer (1.83) were similar to those of mule deer (1.78). There was no statistically significant difference in recruitment of white-tailed deer (56 fawns : 100 does) and mule deer (38 fawns : 100 does). The annual survival rate for adult white-tailed deer (SWT = 0.81) was significantly higher than that for mule deer (SMD = 0.72). The main cause of mortality in both populations was cougar predation. The lower mule deer survival rate could be directly linked to a higher predation rate (0.17) than for white-tailed deer (0.09). The finite growth rate (λ) was 0.88 for mule deer and 1.02 for white-tailed deer. The disparate survival and predation rates are consistent with the apparent-competition hypothesis.

Osteoarthritis: the peripheral joints

UNDERSTANDING OF OSTEOARTHRITIS HAS INCREASED: the simplistic "wear and tear" concept no longer holds and this has positive clinical implications. A parallel development has taken place in treatment techniques: there is increasing expertise in the use of physical measures and in new orthopedic reconstructive surgical approaches to multiple joints. This gives the physician alternative approaches to the patient with painful and disabling osteoarthritis. The timing of these treatment options and some considerations which lead to orthopedic referral are considered in this general discussion.

Anderson Ruffin Abbott, MD, 1837--1913

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Evaluation of a province-wide physiotherapy monitoring service in an arthritis control program

We evaluated our rheumatoid arthritis patient follow-up service in British Columbia in a 1 yr prospective study. The follow-up by 45 specially trained Arthritis Society physiotherapists involved contact of 1,701 patients; 1,081 were assessed and 440 were judged to need therapy or physician services; 279 required further physiotherapy, 191 had functional problems needing occupational therapy and 108 had medical problems requiring return to the family doctor. Within 2 months 72% of patients requiring physiotherapy and 84% of patients requiring occupational therapy had received their therapy. The study underlines the value of physiotherapy follow-up monitoring of rheumatoid patients.

Furman Jeremiah Shadd, MD 1852-1908

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Adverse effects of D-penicillamine in rheumatoid arthritis

Adverse effects to D-penicillamine were studied prospectively over 3 years in 259 patients with rheumatoid arthritis. Ninety-five percent had had gold therapy previously, yet 70% benefited from D-penicillamine therapy. Of the 275 courses given, 160 (58%) were complicated by at least one reaction, including rashes (44%), dysgeusia (20%), gastrointestinal upset (18%), stomatitis (10%), proteinuria (7%), thrombocytopenia (3%), and leukopenia (2%). Their occurrences peaked in the first 6 months of treatment, except for proteinuria and thrombocytopenia, which peaked in the second 6 months. Reactions were commoner at daily doses above 250 mg; mean daily doses for proteinuria, thrombocytopenia, and leukopenia were higher (approximately 600 mg/d) than for the others (approximately 500 mg/d). Of 114 discontinued courses, 73 (27%) were due to adverse reactions. The remaining reactions were controlled by altering dosages and symptomatic treatment. Only obliterative bronchiolitis (two cases) was irreversible; it resulted in the only death in our series, possibly attributable to penicillamine.

Patterns of work--rheumatoid arthritis

Fifty rheumatoid adults successfully competing in full time competitive work were interviewed to determine the factors which distinguish this group and enable their continuing work, which included physical and social barriers and aids to working full time. The data indicate that as a whole they had significant disease, most falling in functional class 2 and 3 (ARA). As a group they were well educated with occupations mirroring their educational attainments. Almost all had inside jobs and most had worked for long times in their occupations. The majority did not change occupations after disease onset and many had been in their jobs for years, often in the same firm. Promotions were few. They had stable marriage patterns. Patients were motivated for work and did what was necessary to get to work despite their disease. These workers had a low level of absenteeism, enjoyed their jobs and felt that personal desire was the most important factor in keeping at work. From consideration of the disease itself, in addition to upper and lower extremity problems, morning stiffness, fatigue and public transport difficulties were highlighted and focus attention on the need to better control these features of the disease and environment.

D-penicillamine in the treatment of rheumatoid arthritis

Forty-four patients with definite or classic rheumatoid arthritis and failure to tolerate or respond to gold therapy were treated with D-penicillamine on a so-called go-slow, go-low regime. Seventeen patients tolerated the drug and had a 3-13 month follow-up assessment; 8 were markedly improved, 6 moderately or slightly improved, and 3 unimproved. Penicillamine had to be discontinued in 9 patients because of toxic side effects.

Return to work after treatment of rheumatoid arthritis

This study reports on the prognosis for return to competitive work of men disabled by rheumatoid arthritis following an intensive in-patient rehabilitation program. Ninety-four men were followed up at a mean time of 3.5 years after discharge from the unit. Sixty-five per cent of the city dwellers and 50% of those living in small communities or rural areas were working either full-time or half-time. Other factors such as education, work background and geographical location influenced the success of return to work.In the city, 12 families (22%) were receiving welfare assistance prior to admission to the comprehensive rehabilitation program. At follow-up six of these families were off welfare and paying taxes. This group alone represented a minimum saving of $35,000 yearly to public funds.

William Henry Harris, M.D., 1867-1934, with notes on the Georgia State Medical Association

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Rheumatoid arthritis--atlanto-axial subluxation and its clinical presentation

The clinical picture, radiological findings and treatment of 22 patients with atlantoaxial subluxation and rheumatoid arthritis are described. This lesion, untreated, may result in damage to the spinal cord, paresis or sudden death. Occipital headache, present in 13 of 22 patients, was often aggravated by working with the head in forward flexion. Paresthesias were present in six patients. The spine of the axis was often prominent. In three patients there was objective evidence of cord compression with sensory and/or pyramidal signs. In eight the lesion was asymptomatic and discovered by routine lateral radiography in flexion, the position of maximum subluxation.Conservative treatment involved the continuous use of a cervical collar to limit neck flexion. This usually relieved subjective symptoms including headaches. Successful surgical fixation was performed in two individuals. Surgical indications included acute or chronic cord compression or severe symptoms unrelieved by a collar.