Cervical musculoskeletal impairments and temporomandibular disorders

Susan Armijo-Olivo, David Magee, Susan Armijo-Olivo, David Magee

Abstract

Objectives: The study of cervical muscles and their significance in the development and perpetuation of Temporomandibular Disorders has not been elucidated. Thus this project was designed to investigate the association between cervical musculoskeletal impairments and Temporomandibular Disorders.

Material and methods: A sample of 154 subjects participated in this study. All subjects underwent a series of physical tests and electromyographic assessment (i.e. head and neck posture, maximal cervical muscle strength, cervical flexor and extensor muscles endurance, and cervical flexor muscle performance) to determine cervical musculoskeletal impairments.

Results: A strong relationship between neck disability and jaw disability was found (r = 0.82). Craniocervical posture was statistically different between patients with myogenous Temporomandibular Disorders (TMD) and healthy subjects. However, the difference was too small (3.3º) to be considered clinically relevant. Maximal cervical flexor muscle strength was not statistically or clinically different between patients with TMD and healthy subjects. No statistically significant differences were found in electromyographic activity of the sternocleidomastoid or the anterior scalene muscles in patients with TMD when compared to healthy subjects while executing the craniocervical flexion test (P = 0.07). However, clinically important effect sizes (0.42 - 0.82) were found. Subjects with TMD presented with reduced cervical flexor as well as extensor muscle endurance while performing the flexor and extensor muscle endurance tests when compared to healthy individuals.

Conclusions: Subjects with Temporomandibular Disorders presented with impairments of the cervical flexors and extensors muscles. These results could help guide clinicians in the assessment and prescription of more effective interventions for individuals with Temporomandibular Disorders.

Keywords: cervical spine; mucosceletal diseasesimpairments; neck; physical therapy techniques.; temporomandibular disorders.

Figures

Figure 1
Figure 1
Postural variables analyzed in this project.
Figure 2
Figure 2
Set up for measuring maximal voluntary strength and endurance of the cervical flexor muscules.
Figure 3
Figure 3
Neck extensor muscle endurance test (NEMET).
Figure 4
Figure 4
Craniocervical flexion test.

References

    1. McNeill C. Epidemiology In: CLR (Ed ), editors. Temporomandibular Disorders: Guidelines for Classification, Assessment, and Management. Carol Stream: Quintessence Publishing Company; 1993. p. 19-22.
    1. Drangsholt M, LeResche L. Temporomandibular Disorder Pain In: I Crombie, P Croft, S Linton, L LeResche, M Von Korff, editors Epidemiology of Pain Seatle: IASP Press; 1999. p. 203-33.
    1. McNeely ML, Armijo Olivo S, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther 2006 May;86(5):710-25 Review.
    1. Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther 2006 Jul;86(7):955-73 Review.
    1. Armijo Olivo S, Magee DJ, Parfitt M, Major P, Thie NM. The association between the cervical spine, the stomatognathic system, and craniofacial pain: a critical review. J Orofac Pain 2006 Fall;20(4):271-87 Review.
    1. Olivo SA, Bravo J, Magee DJ, Thie NM, Major PW, Flores-Mir C. The association between head and cervical posture and temporomandibular disorders: a systematic review. J Orofac Pain 2006 Winter;20(1):9-23 Review.
    1. Vernon H. The Neck Disability Index: state-of-the-art, 1991-2008 J Manipulative Physiol Ther 2008 Sep;31(7):491-502 Review.
    1. Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther 1991 Sep;14(7):409-15 Erratum in: J Manipulative Physiol Ther 1992 Jan;15(1):followi.
    1. Sugisaki M, Kino K, Yoshida N, Ishikawa T, Amagasa T, Haketa T. Development of a new questionnaire to assess pain-related limitations of daily functions in Japanese patients with temporomandibular disorders. Community Dent Oral Epidemiol 2005 Oct;33(5):384-95.
    1. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992 Fall;6(4):301-55 Review.
    1. Armijo-Olivo S. Relationship between Cervical Musculoskletal Impairments and Temporomandibular Disorders: Clinical and Electromyographic Variables Faculty of Rehabilitation Medicine Edmonton: University of Alberta; 2010. p. 488.
    1. Armijo-Olivo S, Fuentes JP, da Costa BR, Major PW, Warren S, Thie NM, Magee DJ. Reduced endurance of the cervical flexor muscles in patients with concurrent temporomandibular disorders and neck disability. Man Ther 2010 Dec;15(6):586-92 Epub 2010 Aug 5.
    1. Armijo-Olivo S, Rappoport K, Fuentes J, Gadotti IC, Major PW, Warren S, Thie NM, Magee DJ. Head and cervical posture in patients with temporomandibular disorders. J Orofac Pain 2011 Summer;25(3):199-209.
    1. Armijo-Olivo S, Silvestre R, Fuentes J, da Costa BR, Gadotti IC, Warren S, Major PW, Thie NM, Magee DJ. Electromyographic activity of the cervical flexor muscles in patients with temporomandibular disorders while performing the craniocervical flexion test: a cross-sectional study. Phys Ther 2011 Aug;91(8):1184-97 Epub 2011 Jun 9.
    1. Olivo SA, Fuentes J, Major PW, Warren S, Thie NM, Magee DJ. The association between neck disability and jaw disability. J Oral Rehabil 2010 Sep;37(9):670-9 Epub 2010 May 27.
    1. Armijo-Olivo SL, Fuentes JP, Major PW, Warren S, Thie NM, Magee DJ. Is maximal strength of the cervical flexor muscles reduced in patients with temporomandibular disorders? Arch Phys Med Rehabil 2010 Aug;91(8):1236-42.
    1. Armijo-Olivo S, Silvestre RA, Fuentes JP, da Costa BR, Major PW, Warren S, Thie NM, Magee DJ. Patients with temporomandibular disorders have increased fatigability of the cervical extensor muscles. Clin J Pain 2012 Jan;28(1):55-64.
    1. Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: what is moderate pain in millimetres? Pain 1997 Aug;72(1-2):95-7.
    1. Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001 Nov;94(2):149-58.
    1. Dworkin SF, Sherman J, Mancl L, Ohrbach R, LeResche L, Truelove E. Reliability, validity, and clinical utility of the research diagnostic criteria for Temporomandibular Disorders Axis II Scales: depression, non-specific physical symptoms, and graded chronic pain J Orofac Pain 2002;16(3):207-20.
    1. Sandoval P, Henríquez J, Fuentes R, Cabezas G, Roldán R. [Cervical curvature A cephalometric study in position of clinical rest] Rev Med Chil 1999 May;127(5):547-55 Spanish.
    1. Cooke MS, Wei SH. The reproducibility of natural head posture: a methodological study Am J Orthod Dentofacial Orthop 1988 Apr;93(4):280-8.
    1. Gadotti IC, Bérzin F, Biasotto-Gonzalez D. Preliminary rapport on head posture and muscle activity in subjects with class I and II J Oral Rehabil 2005 Nov;32(11):794-9.
    1. Cesar GM, Tosato Jde P, Biasotto-Gonzalez DA. Correlation between occlusion and cervical posture in patients with bruxism Compend Contin Educ Dent 2006 Aug;27(8):463-6; quiz 467-8.
    1. Armijo-Olivo S. Relationship between Cervical Musculoskletal Impairments and Temporomandibular Disorders: Clinical and Electromyographic Variables Faculty of Rehabilitation Medicine Edmonton: University of Alberta; 2010. p. 488.
    1. Lee H, Nicholson LL, Adams RD. Neck muscle endurance, self-report, and range of motion data from subjects with treated and untreated neck pain J Manipulative Physiol Ther 2005 Jan;28(1):25-32.
    1. Falla D, Jull G, Dall'Alba P, Rainoldi A, Merletti R. An electromyographic analysis of the deep cervical flexor muscles in performance of craniocervical flexion Phys Ther 2003 Oct;83(10):899-906.
    1. Armijo-Olivo S, Warren S, Fuentes J, Magee DJ. Clinical relevance vs statistical significance: Using neck outcomes in patients with temporomandibular disorders as an example Man Ther 2011 Dec;16(6):563-72.
    1. Rocabado M. The importance of soft tissue mechanics in stability and instability of the cervical spine: a functional diagnosis for treatment planning Cranio 1987 Apr;5(2):130-8.
    1. Gross AR, Goldsmith C, Hoving JL, Haines T, Peloso P, Aker P, Santaguida P, Myers C; Cervical Overview Group. Conservative management of mechanical neck disorders: a systematic review J Rheumatol 2007 May;34(5):1083-102 Epub 2007 Jan 15 Review.
    1. Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review Phys Ther 2009 Jan;89(1):9-25 Epub 2008 Dec 4 Review.
    1. Fransen M, McConnell S. Exercise for osteoarthritis of the knee Cochrane Database Syst Rev 2008 Oct 8;(4):CD004376 Review.
    1. Sokunbi O, Moore A, Watt P. Plasma levels of Beta-endorphin and Serotonin in response to specific spinal base exercises South African Journal of Physiotherapy 2008;64(1): 31-7. URL: .
    1. Sokunbi O, Watt P, Moore A. Changes in plasma concentration of serotonin in response to spinal stabilisation exercises in chronic low back pain patient Nig Q J Hosp Med 2007 Jul-Sep;17(3):108-11.
    1. de Wijer A, Steenks MH, Bosman F, Helders PJ, Faber J. Symptoms of the stomatognathic system in temporomandibular and cervical spine disorders J Oral Rehabil 1996 Nov;23(11):733-41.
    1. de Wijer A, Steenks MH, de Leeuw JR, Bosman F, Helders PJ. Symptoms of the cervical spine in temporomandibular and cervical spine disorders J Oral Rehabil 1996 Nov;23(11):742-50.
    1. Wiesinger B, Malker H, Englund E, Wänman A. Does a dose-response relation exist between spinal pain and temporomandibular disorders? BMC Musculoskelet Disord 2009 Mar 2;10:28.
    1. En MC, Clair DA, Edmondston SJ. Validity of the Neck Disability Index and Neck Pain and Disability Scale for measuring disability associated with chronic, non-traumatic neck pain Man Ther 2009 Aug;14(4):433-8 Epub 2008 Sep 27.
    1. Pietrobon R, Coeytaux RR, Carey TS, Richardson WJ, DeVellis RF. Standard scales for measurement of functional outcome for cervical pain or dysfunction: a systematic review Spine (Phila Pa 1976) 2002 Mar 1;27(5):515-22 Review.
    1. Ohrbach R. Disability assessment in temporomandibular disorders and masticatory system rehabilitation J Oral Rehabil 2010 May;37(6):452-80 Epub 2010 Feb 11 Review.
    1. Allet L, Burge E, Monnin D. ICF: Clinical relevance for physiotherapy? A critical review Advances in Physiotherapy 2008;10(3):127-37.
    1. Weigl M, Cieza A, Cantista P, Reinhardt JD, Stucki G. Determinants of disability in chronic musculoskeletal health conditions: a literature review Eur J Phys Rehabil Med 2008 Mar;44(1):67-79 Review.
    1. O'Leary S, Falla D, Elliott JM, Jull G. Muscle dysfunction in cervical spine pain: implications for assessment and management J Orthop Sports Phys Ther 2009 May;39(5):324-33.
    1. Gonzalez HE, Manns A. Forward head posture: its structural and functional influence on the stomatognathic system, a conceptual study Cranio 1996 Jan;14(1):71-80 Review.
    1. Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain Phys Ther 2007 Apr;87(4):408-17 Epub 2007 Mar 6.
    1. Falla D. Unravelling the complexity of muscle impairment in chronic neck pain Man Ther 2004 Aug;9(3):125-33 Review.
    1. Falla D, Bilenkij G, Jull G. Patients with chronic neck pain demonstrate altered patterns of muscle activation during performance of a functional upper limb task Spine (Phila Pa 1976) 2004 Jul 1;29(13):1436-40.
    1. Falla D, Farina D. Neuromuscular adaptation in experimental and clinical neck pain J Electromyogr Kinesiol 2008 Apr;18(2):255-61 Epub 2006 Dec 29 Review.
    1. Falla D, Farina D. Neural and muscular factors associated with motor impairment in neck pain Curr Rheumatol Rep 2007 Dec;9(6):497-502 Review.
    1. Falla D, Farina D, Graven-Nielsen T. Upper Trapezius Muscle Pain Results in Reorganization of Coordination among Trapezius Muscle Divisions During Dynamic Movement of the Upper Limb In: A Rainoldi, M Minetto, eds XVI Congress of the International Society of Electrophysiology and Kinesiology Turin, Italy: ISEK 2006. p. 66.
    1. Falla D, Jull G, Edwards S, Koh K, Rainoldi A. Neuromuscular efficiency of the sternocleidomastoid and anterior scalene muscles in patients with chronic neck pain Disabil Rehabil 2004 Jun 17;26(12):712-7.
    1. Falla D, Jull G, Hodges PW. Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain Exp Brain Res 2004 Jul;157(1):43-8 Epub 2004 Feb 5.
    1. Falla D, Jull G, Rainoldi A, Merletti R. Neck flexor muscle fatigue is side specific in patients with unilateral neck pain Eur J Pain 2004 Feb;8(1):71-7.
    1. Falla D, Rainoldi A, Merletti R, Jull G. Myoelectric manifestations of sternocleidomastoid and anterior scalene muscle fatigue in chronic neck pain patients Clin Neurophysiol 2003 Mar;114(3):488-95.
    1. Falla DL, Jull GA, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test Spine (Phila Pa 1976) 2004 Oct 1;29(19):2108-14.
    1. Lund JP, Donga R, Widmer CG, Stohler CS. The pain-adaptation model: a discussion of the relationship between chronic musculoskeletal pain and motor activity Can J Physiol Pharmacol 1991 May;69(5):683-94 Review.
    1. Sterling M, Jull G, Wright A. The effect of musculoskeletal pain on motor activity and control J Pain 2001 Jun;2(3):135-45.
    1. Murray GM, Peck CC. Orofacial pain and jaw muscle activity: a new model J Orofac Pain 2007 Fall;21(4):263-78; discussion 279-88 Review.
    1. Hodges PW, Cholewicki J, Coppieters MW, MacDonald D. Trunk muscle activity is increased during experimental back pain, but the pattern varies between individuals Proceedings of the XVI congress of the international society of electrophysiology and kinesiology 2006: 140.
    1. Jull GA, Sterling M, Falla D, Treleaven J, O'Leary S. Alterations in Cervical Muscle Function in Neck Pain In: GA Jull, M Sterling, D Falla, J Treleaven, S O'Leary, eds Whiplash, headache, and neck pain : research-based directions for physical therapies Edinburgh; New York: Churchill Livingstone/Elsevier; 2008. p. 41-58.
    1. Elliott J, Jull G, Noteboom JT, Darnell R, Galloway G, Gibbon WW. Fatty infiltration in the cervical extensor muscles in persistent whiplash-associated disorders: a magnetic resonance imaging analysis Spine (Phila Pa 1976) 2006 Oct 15;31(22):E847-55.
    1. Elliott J, Jull G, Noteboom JT, Galloway G. MRI study of the cross-sectional area for the cervical extensor musculature in patients with persistent whiplash associated disorders (WAD) Man Ther 2008 Jun;13(3):258-65 Epub 2007 Mar 26.
    1. Elliott J, Sterling M, Noteboom JT, Darnell R, Galloway G, Jull G. Fatty infiltrate in the cervical extensor muscles is not a feature of chronic, insidious-onset neck pain Clin Radiol 2008 Jun;63(6):681-7 Epub 2008 Jan 31.
    1. Uhlig Y, Weber BR, Grob D, Müntener M. Fiber composition and fiber transformations in neck muscles of patients with dysfunction of the cervical spine J Orthop Res 1995 Mar;13(2):240-9.
    1. Pallegama RW, Ranasinghe AW, Weerasinghe VS, Sitheeque MA. Influence of masticatory muscle pain on electromyographic activities of cervical muscles in patients with myogenous temporomandibular disorders J Oral Rehabil 2004 May;31(5):423-9.
    1. Herzog W, Longino D, Clark A. The role of muscles in joint adaptation and degeneration Langenbecks Arch Surg 2003 Oct;388(5):305-15 Epub 2003 Sep 20 Review.
    1. Cholewicki J, Panjabi MM, Khachatryan A. Stabilizing function of trunk flexor-extensor muscles around a neutral spine posture Spine (Phila Pa 1976) 1997 Oct 1;22(19):2207-12.
    1. Panjabi M. Dysfunction of the spinal Stability System and Its Restabilization In: L Giles, K Singer, editors Clinical Anatomy and Management of Cervical Spine Pain Oxford, Boston; 1998.
    1. Panjabi M, Abumi K, Duranceau J, Oxland T. Spinal stability and intersegmental muscle forces A biomechanical model Spine (Phila Pa 1976) 1989 Feb;14(2):194-200.
    1. Panjabi MM. The stabilizing system of the spine Part I Function, dysfunction, adaptation, and enhancement J Spinal Disord 1992 Dec;5(4):383-9; discussion 397.
    1. Panjabi MM. The stabilizing system of the spine Part II Neutral zone and instability hypothesis J Spinal Disord 1992 Dec;5(4):390-6; discussion 397.
    1. Winters J. Biomechanical Modeling of the Human Head and Neck In: B Peterson, FJ Richmond, editors Control of Head Movement New York: Oxford University Press; 1988. p. 22-36.
    1. Winters J, Peles J. Neck Muscle activity and 3-D Head Kinematics During Quasi-Static and Dynamic Tracking Movements In: J Winters, S Woo, eds Multiple Muscle Systems: Biomechanics and Movement Organization New York: Springer-Verlag; 1990. p. 461-80.
    1. An KN. Muscle force and its role in joint dynamic stability Clin Orthop Relat Res 2002 Oct;(403 Suppl):S37-42 Review.
    1. Hurley MV. The effects of joint damage on muscle function, proprioception and rehabilitation Man Ther 1997 Feb;2(1):11-17.
    1. Hurley MV, Jones DW, Newham DJ. Arthrogenic quadriceps inhibition and rehabilitation of patients with extensive traumatic knee injuries Clin Sci (Lond) 1994 Mar;86(3):305-10 Erratum in: Clin Sci 1994 Jun;86(6):xxii.
    1. Hasler EM, Herzog W, Leonard TR, Stano A, Nguyen H. In vivo knee joint loading and kinematics before and after ACL transection in an animal model J Biomech 1998 Mar;31(3):253-62.
    1. Kerr FW. Central relationships of trigeminal and cervical primary afferents in the spinal cord and medulla Brain Res 1972 Aug 25;43(2):561-72.
    1. Sessle BJ. Neural mechanisms and pathways in craniofacial pain Can J Neurol Sci 1999 Nov;26 Suppl 3:S7-11 Review.
    1. Sessle BJ, Hu JW, Amano N, Zhong G. Convergence of cutaneous, tooth pulp, visceral, neck and muscle afferents onto nociceptive and non-nociceptive neurons in trigeminal subnucleus caudalis (medullary dorsal horn) and its implications for referred pain Pain 1986 Nov;27(2):219-35.
    1. Bogduk N. The clinical anatomy of the cervical dorsal rami Spine (Phila Pa 1976) 1982 Jul-Aug;7(4):319-30.
    1. Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophysial joint blocks Pain 1993 Aug;54(2):213-7.
    1. Bogduk N, Marsland A. The cervical zygapophysial joints as a source of neck pain Spine (Phila Pa 1976) 1988 Jun;13(6):610-7.
    1. Bogduk N. Cervicogenic headache: anatomic basis and pathophysiologic mechanisms Curr Pain Headache Rep 2001 Aug;5(4):382-6 Review.
    1. Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns II: Aclinical evaluation Spine (Phila Pa 1976) 1990 Jun;15(6):458-61.
    1. Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns I: A study in normal volunteers Spine (Phila Pa 1976) 1990 Jun;15(6):453-7.
    1. Edmeads J. [Headache of cervical origin] Rev Prat 1990 Feb 11;40(5):399-402 French.
    1. Ehni G, Benner B. Occipital neuralgia and the C1-2 arthrosis syndrome J Neurosurg 1984 Nov;61(5):961-5.
    1. Hellström F, Thunberg J, Bergenheim M, Sjölander P, Djupsjöbacka M, Johansson H. Increased intra-articular concentration of bradykinin in the temporomandibular joint changes the sensitivity of muscle spindles in dorsal neck muscles in the cat Neurosci Res 2002 Feb;42(2):91-9.
    1. Falla D, Jull G, Hodges P, Vicenzino B. An endurance-strength training regime is effective in reducing myoelectric manifestations of cervical flexor muscle fatigue in females with chronic neck pain Clin Neurophysiol 2006 Apr;117(4):828-37 Epub 2006 Feb 21.
    1. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache Spine (Phila Pa 1976) 2002 Sep 1;27(17):1835-43; discussion 1843.
    1. Ylinen J, Takala EP, Nykänen M, Häkkinen A, Mälkiä E, Pohjolainen T, Karppi SL, Kautiainen H, Airaksinen O. Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial JAMA 2003 May 21;289(19):2509-16.
    1. Yelland M. Both endurance training and strength training reduced disability and pain in chronic nonspecific neck pain in women ACP J Club 2003 Nov-Dec;139(3):75.
    1. van Ettekoven H, Lucas C. Efficacy of physiotherapy including a craniocervical training programme for tension-type headache; a randomized clinical trial Cephalalgia 2006 Aug;26(8):983-91.
    1. O'Leary S, Jull G, Kim M, Vicenzino B. Specificity in retraining craniocervical flexor muscle performance. Journal of Orthopaedic and Sports Physical Therapy 2007;37: 3-9.
    1. Peolsson A, Kjellman G. Neck muscle endurance in nonspecific patients with neck pain and in patients after anterior cervical decompression and fusion J Manipulative Physiol Ther 2007 Jun;30(5):343-50.
    1. Armstrong BS, McNair PJ, Williams M. Head and neck position sense in whiplash patients and healthy individuals and the effect of the cranio-cervical flexion action Clin Biomech (Bristol, Avon) 2005 Aug;20(7):675-84.
    1. La Touche R, Fernández-de-las-Peñas C, Fernández-Carnero J, Escalante K, Angulo-Díaz-Parreño S, Paris-Alemany A, Cleland JA. The effects of manual therapy and exercise directed at the cervical spine on pain and pressure pain sensitivity in patients with myofascial temporomandibular disorders. J Oral Rehabil 2009 Sep;36(9):644-52 Epub 2009 Jul 14.
    1. Conley MS, Stone MH, Nimmons M, Dudley GA. Specificity of resistance training responses in neck muscle size and strength. Eur J Appl Physiol Occup Physiol 1997;75(5):443-8.
    1. Portero P, Bigard AX, Gamet D, Flageat JR, Guézennec CY. Effects of resistance training in humans on neck muscle performance, and electromyogram power spectrum changes. Eur J Appl Physiol 2001 Jun;84(6):540-6.
    1. Kraus S. Temporomandibular disorders, head and orofacial pain: cervical spine considerations. Dent Clin North Am 2007 Jan;51(1):161-93.
    1. Gadotti IC, Magee DJ. Validity of surface measurements to assess craniocervical posture in the sagittal plane: a critical review. Physical Therapy Reviews 2008 Aug;13(4): 258-68.
    1. Kumbhare DA, Balsor B, Parkinson WL, Harding Bsckin P, Bedard M, Papaioannou A, Adachi JD. Measurement of cervical flexor endurance following whiplash. Disabil Rehabil 2005 Jul 22;27(14):801-7.
    1. Elliott J, Sterling M, Noteboom JT, Treleaven J, Galloway G, Jull G. The clinical presentation of chronic whiplash and the relationship to findings of MRI fatty infiltrates in the cervical extensor musculature: a preliminary investigation. Eur Spine J 2009 Sep;18(9):1371-8.

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