Dissertation submitted in partial compliance with the requirements for the Master’s degree in technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2013. / Background: Forward head posture (FHP) is a common postural abnormality that is commonly associated with weak deep cervical flexor muscles (DCF). The craniovertebral (CV) angle lies between a horizontal line running through C7 spinous process and a line connecting the C7 spinous process to the tragus of the ear. The smaller the angle, the greater the forward head posture. Weak DCF musculature and FHP has been linked to cervical dysfunction in the short and long term such as cervicogenic headache and premature development of cervical regional degenerative joint disease. Improving isometric endurance and neuromotor control of the DCF muscles using craniocervical flexion exercise (CCFE) has been shown to be efficient in patients experiencing cervical dysfunction such as headache, although the relevance of CCFE has not been established in the asymptomatic group. Deficiency in the activity of these muscles can be accurately measured using craniocervical flexion testing (CCFT). There is a paucity of information regarding the definitive relationship between weakness of the DCF and FHP in asymptomatic participants. This research will help establish an efficient and safe prophylactic treatment protocol preventing long term sequela associated with FHP. Objectives: To determine the effect of CCFE on cervical posture by assessment of the CV angle in asymptomatic participants as well as to determine the effect of CCFE on cervical range of motion by assessment of flexion, extension, bilateral rotation and lateral flexion movements in asymptomatic participants whilst measuring the effect of CCFE on isometric endurance and neuromotor control of the DCF muscles assessed by the CCFT in asymptomatic participants. Method: This is a quantitative pre/post intervention study comparing the results of one group of 45 asymptomatic participants before and after the CCFE protocol has been allocated to them over a period of 3-5 weeks. Participants FHP was assessed by measuring the CV angle. This was done by marking the C7 spinous process and extending a horizontal line toward the shoulder. Then marking the tragus of the ipsilateral ear and measuring the angle using the smart tool angle finder (MD products). iv CCFT measurements were taken and the CCFE protocol allocated to those who qualified to take part in the study. Lastly, cervical range of motion was measured. This group received a home exercise protocol of 3 sets of 10 supine chin tucks daily with each repetition being held for 10 seconds. The technique was first ensured by the researcher prior to leaving the consultation rooms and an exercise diary was given to the participant until the 5th and final consultation to record the progress and efficiency of the home programme as well as any complaints regarding this. Result: The asymptomatic group included in the study improved in both the seated and standing CV angle measurements in that the CV was greater at the conclusion of the pre/post intervention (p=0.00000002) and (p=0.000003) respectively . Cervical range of motion showed improvement in some but not all ranges. Flexion showed a reduction in range of motion (p=0.0086) which was significant. Extension showed an improvement in range of motion (p=0.0000002) which was significant. Rotation toward the left (p=0.00003) and right (p=0.00063) showed an improvement in range of motion which was significant. Lateral flexion showed improvement which was not significant in both, left (p=0.0145) and right (p= 0.24985) ranges of motion. Neuromotor control showed 100 percent improvement in that all 45 of the participants were able to perform CCFT correctly through all five stages at conclusion of the study. Conclusion: Therefore it can be concluded that asymptomatic participants will benefit from CCFEs In terms of CV angle improvement, cervical range of motion as well as neuromotor control of the DCF muscles.

Dissertation submitted in partial compliance with the requirements for the Masters Degree in Technology: Chiropractic at the Durban University of Technology, 2009. / It has been noted that in many recent research studies mechanical neck pain is a serious problem in the world today. There are epidemiological and statistical studies documenting the high incidence and prevalence of mechanical neck pain, which effects people’s daily living (Drew, 1995; Ferrari and Russell, 2003; Cote et al., 2000, Venketsamy, 2007 and Haldeman et al., 2008). Background: Treatments for chronic neck pain, which are non-surgical, appear to be the most beneficial for patients (Haldeman, 2008). In brief, the presentation of chronic mechanical neck pain is defined as localised, asymmetrical neck pain with restricted range of motion and dysfunctional musculature (Grieve, 1988). The muscular dysfunction known as the upper cross syndrome is defined as tightness of the upper trapezius, pectoralis major and levator scapulae and weakness of rhomboids, serratus anterior, middle and lower trapezius and deep neck flexors. These muscles are responsible for stabilizing the scapula and the patient may present with rounded, elevated shoulders and anterior head carriage when diagnosed with this syndrome (Liebenson, 1996). Clinical trials conducted by Cassidy et al., (1992 a, b) concluded that spinal manipulative therapy (SMT) was highly effective in treating mechanical dysfunctions within the cervical spine. However, due to multi systemic involvement of the muscular, neural and passive systems in mechanical neck pain, the treatment may need to target all three of the subsystems of spinal stability to be most effective (Panjabi, 1992 a, b; Lee et al., 1998; Lee 2004 and Richardson et al., 2002). No research has been conducted on the effects and benefits of treatment directed on the cervical spine and upper cross syndromes. This research will compare scapula stabilization training and SMT to SMT in isolation, as a treatment for chronic mechanical neck pain. Objectives: The purpose of this study was to determine the effect that scapula stabilization had on chronic mechanical neck pain. Pilates exercises were used to strengthen and stabilize the scapula muscles (this included stretching out the hypertonic musculature of the upper cross syndrome). The aim was to improve posture as well as to decrease the mechanical stress on the neck. SMT was also concomitantly used to correct any cervical restrictions that were present. These results were then compared to the results of a group that only received spinal manipulative therapy. The null hypothesis was that the intervention group would not respond differently to the treatment protocol in terms of the subjective and objectives measurements. iv Method: This clinical trial was conducted on a sample population of 30 patients with chronic mechanical neck pain. Each patient was assigned to one of two groups (n=15) according to convenience sampling. Both groups received SMT to the cervical spine, while group B (intervention group) also received pilates classes twice weekly for four weeks, which retrained the scapula stabilization muscles to function optimally. The patients each underwent six spinal manipulative treatments over four weeks and a seventh consultation in the fifth week for data collection. Both groups were evaluated in terms of subjective and objective clinical findings. Subjectively the assessment included 2 questionnaires (Numerical Pain Rating Scale and Canadian Memorial Chiropractic College [CMCC] neck disability index). Objective assessment included cervical motion palpation, Cervical Range Of Motion goniometer (CROM) measurements, scapula stabilization tests and a postural analysis with the use of digital photography. The statistics were completed under the guidance of a biostatistician, from the College of Health Science, University of KwaZulu – Natal, (Esterhuizen, 2008) who analyzed the captured data with the use of SPSS version 15. All outcome measures were quantitative. Repeated measures ANOVA testing was used to assess the presence of a different effect for each outcome measure over time between the two treatment groups. A statistically significant time by group effect would indicate a significant treatment effect. The minimum significance level was 0.05. The trends and direction of the effect were assessed via profile plots. Result: According to the statistical analysis, both groups showed improvements - subjectively and objectively - with regards to chronic mechanical neck pain, which is in keeping with the literature. In terms of the inter-group comparison the SMT group (Group A) showed a more constant improvement in range of motion, pain and disability indexes with the SMT only group while the SMT and pilates group (Group B) showed a greater effect in stabilizing the scapula and increasing the functionality of the surrounding musculature. Conclusions and Recommendations: The intervention treatment (Group B) did not have a greater effect on the short-term treatment of chronic mechanical neck pain than the reference group (Group A). It was also evident that the intervention group (Group B) often continued to improve when the SMT (Group A) only group often regressed at the follow up sessions. This improvement was either not significant enough or v the follow up session did not allow for enough time for a true reflection to be noted. It is recommended that more research be carried out to gain conclusive results indicating whether there is a more beneficial long term result to this treatment protocol.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic Durban University of Technology, 2013. / Background : Chronic non-specific neck pain is a common condition that negatively affects cervical muscle functioning and activities of daily living. Combined exercise and mobilisation are currently recommended as the most effective treatment for this condition. Mobilisation, such as mobilisation of the cervical spine, provides short-term pain relief and affects neural activity, while the craniocervical flexion exercise provides immediate pain relief and activates the deep cervical flexors. The short-term effect of mobilisation and the craniocervical flexion exercise have not been compared. Objectives : This study aimed to compare mobilisation and craniocervical flexion exercise in terms of subjective and objective outcome measures at a short-term follow-up consultation for the treatment of chronic non-specific neck pain. The null-hypothesis was that the mobilisation group would not respond differently to the craniocervical flexion exercise group. Method : A group of thirty females between the ages of 20 and 35 complaining of non-specific neck pain for more than three months were randomly allocated into either the mobilisation or craniocervical flexion exercise groups. During the first two consultations, a mobilisation was administered to the mobilisation group. Whereas the craniocervical flexion exercise and a posture correcting exercise were taught to the participants of the craniocervical flexion exercise group. The Numerical Pain Rating Scale, Neck Disability Index, Neck Bournemouth Questionnaire, cervical range of motion and algometer readings were taken at each of the three consultations. The Patient Global Impression of Change Scale was administered at the last consultation one week after the first consultation. Results : Both the mobilisation and craniocervical flexion exercise groups showed significant improvements in all of the subjective outcomes. The Neck Disability Index score of the craniocervical flexion exercise group was the only subjective outcome that did not decrease enough to be considered clinically significant. The PGIC score of the mobilisation group was slightly higher than that of the craniocervical flexion exercise group. There was no statistically significant improvement in the objective outcomes of either group. All ranges of motion decreased in both groups, while pain pressure threshold improved in both groups. There was no significant difference between the results of the subjective and objective outcomes of the mobilisation and craniocervical flexion exercise groups. Conclusions and recommendations : The two interventions were found to have a similar effect in the treatment of chronic non-specific neck pain in terms of subjective and objective outcome measures. Participants of both groups indicated on the subjective scales that their conditions improved, even though objective outcomes showed no significant change. In future studies, a larger sample size should be used and the sample should be stratified for ethnicity to increase validity of the results.

Dissertation submitted in partial compliance with the requirements for the Masters Degree in Technology: Chiropractic at the Durban University of Technology, 2009. / It has been noted that in many recent research studies mechanical neck pain is a serious problem in the world today. There are epidemiological and statistical studies documenting the high incidence and prevalence of mechanical neck pain, which effects people’s daily living (Drew, 1995; Ferrari and Russell, 2003; Cote et al., 2000, Venketsamy, 2007 and Haldeman et al., 2008). Background: Treatments for chronic neck pain, which are non-surgical, appear to be the most beneficial for patients (Haldeman, 2008). In brief, the presentation of chronic mechanical neck pain is defined as localised, asymmetrical neck pain with restricted range of motion and dysfunctional musculature (Grieve, 1988). The muscular dysfunction known as the upper cross syndrome is defined as tightness of the upper trapezius, pectoralis major and levator scapulae and weakness of rhomboids, serratus anterior, middle and lower trapezius and deep neck flexors. These muscles are responsible for stabilizing the scapula and the patient may present with rounded, elevated shoulders and anterior head carriage when diagnosed with this syndrome (Liebenson, 1996). Clinical trials conducted by Cassidy et al., (1992 a, b) concluded that spinal manipulative therapy (SMT) was highly effective in treating mechanical dysfunctions within the cervical spine. However, due to multi systemic involvement of the muscular, neural and passive systems in mechanical neck pain, the treatment may need to target all three of the subsystems of spinal stability to be most effective (Panjabi, 1992 a, b; Lee et al., 1998; Lee 2004 and Richardson et al., 2002). No research has been conducted on the effects and benefits of treatment directed on the cervical spine and upper cross syndromes. This research will compare scapula stabilization training and SMT to SMT in isolation, as a treatment for chronic mechanical neck pain. Objectives: The purpose of this study was to determine the effect that scapula stabilization had on chronic mechanical neck pain. Pilates exercises were used to strengthen and stabilize the scapula muscles (this included stretching out the hypertonic musculature of the upper cross syndrome). The aim was to improve posture as well as to decrease the mechanical stress on the neck. SMT was also concomitantly used to correct any cervical restrictions that were present. These results were then compared to the results of a group that only received spinal manipulative therapy. The null hypothesis was that the intervention group would not respond differently to the treatment protocol in terms of the subjective and objectives measurements. iv Method: This clinical trial was conducted on a sample population of 30 patients with chronic mechanical neck pain. Each patient was assigned to one of two groups (n=15) according to convenience sampling. Both groups received SMT to the cervical spine, while group B (intervention group) also received pilates classes twice weekly for four weeks, which retrained the scapula stabilization muscles to function optimally. The patients each underwent six spinal manipulative treatments over four weeks and a seventh consultation in the fifth week for data collection. Both groups were evaluated in terms of subjective and objective clinical findings. Subjectively the assessment included 2 questionnaires (Numerical Pain Rating Scale and Canadian Memorial Chiropractic College [CMCC] neck disability index). Objective assessment included cervical motion palpation, Cervical Range Of Motion goniometer (CROM) measurements, scapula stabilization tests and a postural analysis with the use of digital photography. The statistics were completed under the guidance of a biostatistician, from the College of Health Science, University of KwaZulu – Natal, (Esterhuizen, 2008) who analyzed the captured data with the use of SPSS version 15. All outcome measures were quantitative. Repeated measures ANOVA testing was used to assess the presence of a different effect for each outcome measure over time between the two treatment groups. A statistically significant time by group effect would indicate a significant treatment effect. The minimum significance level was 0.05. The trends and direction of the effect were assessed via profile plots. Result: According to the statistical analysis, both groups showed improvements - subjectively and objectively - with regards to chronic mechanical neck pain, which is in keeping with the literature. In terms of the inter-group comparison the SMT group (Group A) showed a more constant improvement in range of motion, pain and disability indexes with the SMT only group while the SMT and pilates group (Group B) showed a greater effect in stabilizing the scapula and increasing the functionality of the surrounding musculature. Conclusions and Recommendations: The intervention treatment (Group B) did not have a greater effect on the short-term treatment of chronic mechanical neck pain than the reference group (Group A). It was also evident that the intervention group (Group B) often continued to improve when the SMT (Group A) only group often regressed at the follow up sessions. This improvement was either not significant enough or v the follow up session did not allow for enough time for a true reflection to be noted. It is recommended that more research be carried out to gain conclusive results indicating whether there is a more beneficial long term result to this treatment protocol.