IJPHY EFFECTS OF WEARING HEADSCARVES ON CERVICAL SPINE MOBILITY ABSTRACT. Int J Physiother. Vol 5(3), , June (2018) ISSN:

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1 Int J Physiother. Vol 5(3), , June (2018) ISSN: ORIGINAL ARTICLE IJPHY ABSTRACT EFFECTS OF WEARING HEADSCARVES ON CERVICAL SPINE MOBILITY *1 Smih F. Alqbbni, DSc ²Gurinder S. Bins, PhD ³Eric G. Johnson, DSc ⁴Everett B. Lohmn, DSc ⁵Noh S. Dher, PhD Bckground: Cervicl spine provides three-dimensionl movements of the hed on the body while keeping the horizontlity of visul gze. Thus, cervicl rnge of motion (ROM) is n importnt ssessment tht is commonly used in clinicl prctice. The hedscrf is commonly used ttire by femles in Islmic cultures. The study imed to investigte the effect of wering hedscrves on cervicl ROM in femles who wer hedscrves compred with femles who don t wer hedscrves. Methods: A cross-sectionl study ws conducted on fifty-two femles with men ge 28.1±3.1 yers were divided into two groups: Hedscrf group (n nd no-scrf group (n. Cervicl Rnge of Motion Device ws used to mesure cervicl spine rnge of motion in seted position for flexion, extension, right lterl flexion, left lterl flexion, right rottion nd left the rottion. Results: The hedscrf group reported significnt limittion in cervicl ROM in ll six directions. Moreover, femles in the hedscrf group who wore the hedscrf for more or equl to 6 hours hd significntly less left rottion compred to those who wer it for less thn 6 hours (71.3±2.1 vs. 64.5±2.1, η2=2.2; p=0.045). No significnt differences in men ROM by ge t onset of wering hedscrf ( 12 yers vs. > 12 yers) or number of yers worn ( 15 yers vs. > 15 yers) were detected (p>0.05). Conclusion: Wering the hedscrf my influence cervicl ROM. Also, six hours or more of dily wer my result in further decline of cervicl ROM. Keywords: Cervicl spine, rnge of motion, mobility, Cervicl Rnge of Motion Device, hedscrf, nd Hijb. Received 26 th Mrch 2018, ccepted 07 th June 2018, published 09 th June /ijphy/2018/v5i3/ ²Associte Professor, Lom Lind University, School of Allied Helth Professions, Deprtment of Allied Helth Studies, Lom Lind, Cliforni. Emil: gbins@llu.edu ³Professor, Lom Lind University, School of Allied Helth Professions, Deprtment of Physicl Therpy, Lom Lind, Cliforni. Emil: ejohnson@llu.edu ⁴Professor, Lom Lind University, School of Allied Helth Professions, Deprtment of Physicl Therpy, Lom Lind, Cliforni. Emil: elohmn@llu.edu ⁵Professor, Lom Lind University, School of Allied Helth Professions, Deprtment of Allied Helth Studies, Lom Lind, Cliforni. Emil: ndher@llu.edu CORRESPONDING AUTHOR *1 Smih F. Alqbbni, DSc Princess Nourh Bint Abdulrhmn University College of Helth nd Rehbilittion Sciences Deprtment of Rehbilittion Sciences King Khlid Interntionl Rod, P.O. Box 84428, Riydh. e-mil: sflqbbni@pnu.edu.s This rticle is licensed under Cretive Commons Attribution-Non Commercil 4.0 Interntionl License. Copyright 2018 Author(s) retin the copyright of this rticle. Int J Physiother 2018; 5(3) Pge 113

2 INTRODUCTION Cervicl spine mobility is mintined by the unique bony nd soft-tissue component of the cervicl spine tht llow for multidirectionl movements of the hed. A mjority of the movements occur in the upper cervicl spine t the crniocervicl junction, which llows for three-dimensionl movements while mintining the horizontlity of visul gze [1]. Hence, cervicl rnge of motion (ROM) is n importnt ssessment tht is commonly used to clssify ptients with neck pin with mobility deficits, ccording to the Interntionl Clssifiction of Function (ICF) [2]. Wering protective hedger hs been shown to decrese ctive cervicl ROM. McCrthy et l. (2015) [3] studied the impct of wering n Americn footbll helmet on ctive cervicl ROM nd found tht wering helmets significntly decresed cervicl extension. Additionlly, soft neck collrs significntly reduce cervicl spine rottion from 75.8 to 67.4 chnge of 11% [4]. Although it is not s rigid s helmet or neck collr, hedscrves my lso provide resistnce to cervicl ROM. The hedscrf is opertionlly defined s scrf tht wrps up over the hed nd round the neck [5]. Femles in Islmic cultures often wer the hedscrf when they re in public nd usully begin wering it t the onset of puberty [6]. According to the Pew Reserch Center (2014), there re pproximtely 1.7 billion Muslims, nd they constitute the second lrgest religious group in the world. Moreover, Muslims re estimted to become the second lrgest religious group in the United Sttes of Americ by the yer 2040 [7]. It is difficult to estimte the totl number of femles worldwide who wer hedscrves, s severl Islmic countries mndte femles to wer them when out in public, while other countries hve bnned the use of hedscrves in public. However, wering hedscrves is optionl in the mjority of the world s countries. For exmple, in the USA, where hedscrves re optionl, 43% of Muslim femles reported tht they wer the hedscrf, which mkes for totl of 433,000 femles [8]. In contrst, in Sudi Arbi, country tht mndtes the wering of hedscrves, ll femles over the ge of 15 re expected to wer them, which mkes for totl of 9,210,133 femles [9]. In such cultures, femles strt wering hedscrves t n erly ge nd for extended periods of time dily. Consequently, the routine wering of hedscrves might influence cervicl ROM. It hs been reported tht people with cervicl spine pin report limited cervicl ROM compred to people without cervicl spine pin [10,11]. Lee et l. (2005) [10] investigted the bility to use ctive cervicl ROM to distinguish between treted nd untreted neck pin. Fifty-five subjects were divided into three groups: treted neck pin, untreted neck pin, nd no neck pin. Subjects in the treted pin group reported more pin thn subjects in the untreted pin group. The results indicted reduction in hed protrction rnge in the treted pin group compred to the untreted pin group. Additionlly, there ws decrese in the rottion nd extension ROM for the pin groups but not for the no-pin group. Lee et l. (2005) [11] further investigted popultion with high incidence of neck pin. They compred ctive cervicl ROM mong computer workers with frequent nd infrequent neck pin. The findings reveled tht cervicl ROM is ffected by the frequency of neck pin with limittions in cervicl ROM with more frequent neck pin. Therefore, Lee et l. (2005) [10,11] suggested tht impirments of cervicl ROM my develop t n erly stge of neck pin nd cn differentite between people with subclinicl neck pin nd no neck pin. Ksch et l. (2008) [12] predicted tht reduced cervicl ROM is one of the prognostic fctors for disbility fter cute whiplsh. Moreover, Dll Alb et l. (2001) [13] indicted tht cervicl ROM successfully discrimintes between subjects with the whiplsh-ssocited disorder (WAD) nd n symptomtic control group. To the best of our knowledge, no previous investigtions into the effects of wering hedscrves on cervicl spine mobility hve been conducted. Therefore, the primry im of the present study ws to investigte the effects of wering hedscrves on cervicl ROM in femles who wer hedscrves compred with femles who do not wer hedscrves. Among femles who wore the hedscrf, secondry im ws to compre cervicl ROM mesures by time spent per dy wering the hedscrf ( 6 hours versus >6 hours) nd ge t onset of wering the hedscrf ( 12 yers versus >12 yers). We lso exmined the reltionship between outcome vribles nd ge t onset of wering the hedscrf, number of yers worn, nd time spent per dy wering the hedscrf. MATERIALS AND METHODS Study Design The study is cross-sectionl study conducted t Lom Lind University. Subjects Fifty-two femles with men ge 28.1±3.1 yers prticipted in the study. Subjects were divided into two groups (hedscrf group: twenty-six femles who routinely wore hedscrves; control group: twenty-six ge-mtched femles who never wore hedscrves). Individuls who met the inclusion criteri rnged from yers of ge, hd been wering the hedscrf for minimum of five yers nd begn wering the hedscrf before or t 15 yers of ge. Subjects were excluded if they hd cervicl pin for less thn six months, or if they hd tenderness or muscle spsm in the cervicl re. Subjects were recruited from Lom Lind University nd the surrounding communities by flyers nd word of mouth. All subjects signed n informed consent form pproved by Lom Lind University Institution Review Bord before prticiption. Cervicl Rnge of Motion device (CROM) The Cervicl Rnge of Motion device (CROM) (Performnce Attinment Assocites, Roseville, MN, USA) ws used. CROM includes three inclinometers for the three plnes of motion. The nondjustble inclinometers mesure the sgittl nd frontl plne movements. While the third inclinometer hs mgnet tht works with the mgnets locted nd secured t the subject s upper trunk to mesure rottion. The inclinometers re ttched to Int J Physiother 2018; 5(3) Pge 114

3 lightweight plstic mount. The mount is positioned on the subjects hed nd secured with fstening strps. It hs good vlidity [14] r= nd intr-rter relibility [15] ICC= PROCEDURES The CROM device ws used to mesure flexion/extension, lterl flexion, nd rottion for ech subject. Subjects were seted in comfortble chir with their feet resting on the floor nd their bcks ginst the chir nd their rms resting on their lps. Any jewelry, hts, nd glsses were removed before securing the CROM device on the subject s hed. Subjects who wore the hedscrves were sked to remove them before CROM device mesurements. First, the investigtor explined the cervicl movements to the subjects nd indicted tht ll movements should be performed to the end rnge. Second, subjects performed prctice tril in ech direction to ensure fmiliriztion when moving their heds with the CROM device. Then, subjects performed the neck movements in the following order: right rottion, left rottion, flexion, extension, right lterl bending, nd left lterl bending. Ech movement ws repeted for three trils. For the sgittl nd frontl plne movements, the investigtor recorded the vlue of the relevnt inclinometer indicting the strting position. At the end of ech movement, the investigtor recorded the vlue of the inclinometer gin, indicting the end position. The mount of movement ws clculted by subtrcting the ending position from the strting position. On the other hnd, the mount of movement for rottion is directly red fter zeroing the inclinometer. Dt Anlysis The Sttisticl Product nd Service Solutions (SPSS) for Windows version 24.0 (IBM Corp., Armonk, New York) were used to nlyze the dt. A smple size of 52 subjects ws needed to obtin medium effect size of 0.7 nd power of 0.8. Dt were summrized using frequencies nd reltive frequencies for ctegoricl vribles nd mens ± stndrd devition (SD) for quntittive vribles. The normlity of the quntittive vribles ws exmined using Kolmogorov-Smirnov nd Shpiro-Wilk tests. Men ge nd body mss index (Kg/m 2 ) of femles in the hedscrf group, nd those in the control group were compred using independent t-test. Men outcome vribles (cervicl ROM right rottion, left rottion, flexion, extension, right lterl flexion, left lterl flexion) by time spent per dy wering the hedscrf ( 6 hours versus > 6 hours) nd ge t onset of wering the hedscrf ( 12 yers versus >12 yers) were compred using independent t-test. The reltionship between cervicl ROM mesures nd ge t onset of wering the hedscrf, number of yers worn, nd hours per dy spent wering the hedscrf were exmined using Person s correltion. Men outcome vribles by time spent per dy wering the hedscrf ( 6 hours versus > 6 hours) nd ge t onset of wering the hedscrf ( 12 yers versus >12 yers) were ssessed using independent t-test. The level of significnce ws set t p-vlue of Fisher s Chi-squre test of independence ws used to compre hnd dominnce between the two groups. The significnce level ws set t p-vlue of less or equl thn RESULTS A totl of 52 femles with men ge 28.1± 3.1 yers prticipted in the study. The distribution of ge, body mss index (BMI) in Kg/m 2, nd rnge of motion (degrees) ws pproximtely norml. Age, BMI, nd hnd dominnce were similr between the two groups (Tble 1). There ws no significnt difference in men BMI between the hedscrf nd control groups (26.9±5.3 vs. 27.4± 5.0, p= 0.73) nd hnd dominnce (right-hnded (92.3%, n=24) in the hedscrf group vs. (84.6%, n=22) in the control group; p=0.33). In the hedscrf group, the men ge t onset of wering the hedscrf ws 12.6±1.6 yers, the men time spent per dy wering the hedscrf ws 7.0±2.3 hours, nd the men number of yers worn ws 15.5±3.6 yers. Tble 1: Men (SD) of subjects demogrphics by study group (N= 52) Hedscrf Control Age (yers) 28.1(3.1) 28.1(3.1) 1.0 BMI (Kg/m 2 ) 26.9(5.3) 27.4(5.0) 0.73 Right hnded b,c 24(92.3) 22(84.6) 0.33 Abbrevition: SD, stndrd devition; BMI, body mss index; ROM, rnge of motion b Chi-squre test c results re reported s n (%) There ws significnt difference in men± stndrd error (SE) in rnge of motion in ll directions between the two groups (Tble 2). Femles in the hedscrf group hd significnt reduction in cervicl ROM for right rottion (60.9±1.6 vs. 71.1±1.7, η2=1.2; p<0.001), left rottion (67.2±1.7 vs. 73.6±2.2, η2=0.7; p=0.024), flexion (55.0±1.3 vs. 61.4±1.6, η2=0.9; p=0.004), extension (63.5±2.0 vs. 72.0±1.8, η2=0.9; p=0.003), right flexion (40.6±1.3 vs. 46.5±1.8, η2=0.7; p=0.01), nd left flexion (43.8±1.3 vs. 49.4±1.6, η2=0.7; p=0.011). Tble 2: Men (SE) of cervicl ROM between hedscrf group nd control group (N= 52) Hedscrf Group Control Group Effect size Right Rottion 60.9 (1.6) 71.1(1.7) 1.2 <0.001 Left Rottion 67.2(1.7) 73.6(2.2) (1.3) 61.4(1.6) Extension 63.5(2.0) 72.0(1.8) Right Lterl Left Lterl 40.6(1.3) 46.5(1.8) (1.3) 49.4(1.6) Abbrevition: SE, Stndrd error of the men; ROM, rnge of motion. In ddition, there ws significnt difference in men cervicl ROM in left rottion by the hours per dy spent wering the hedscrf (71.3±2.1 vs. 64.5±2.1, η 2 =2.2; p=0.045), nd trend towrds sttisticl significnce in men ROM Int J Physiother 2018; 5(3) Pge 115

4 in flexion (57.8±2.4 vs. 53.2±1.4, η 2 =1.6; p=0.093; Tble 3). Tble 3: Men (SE) of outcome vribles by hours per dy spent wering the hedscrf (N= 26) 6 Hours =10) > 6 Hours =16) Effect size Right Rottion 63.8(2.4) 59.0(2.1) Left Rottion 71.3(2.1) 64.5(2.1) (2.4) 53.2(1.4) Extension 65.9(3.3) 62.0(2.5) Right Lterl Left Lterl 42.5(2.6) 39.5( (2.4) 43.7(1.6) Abbrevition: SE, Stndrd error of the men. There ws lso correltion between the ge subjects strted wering the hedscrf nd left flexion ROM (r=0.36, p=0.04). However, no significnt differences in men ROM by ge t onset of wering hedscrf ( 12 yers vs. > 12 yers) were detected (p>0.05, Tble 4). Tble 4. Men (SE) of outcome vribles by the onset of wering the hedscrf (N= 26) 12 yers =12) > 12 yers =14) Effect size Right Rottion 61.9(2.2) 59.9(2.4) Left Rottion 68.2(2.1) 66.3(2.6) (2.1) 55.5(1.7) Extension 63.1(3.6) 63.9(2.3) Right Lterl Left Lterl 39.4(2.2) 41.6(1.5) (2.6) 44.6(1.2) Abbrevition: SE, Stndrd error of the men. DISCUSSION In this study, the differences in ctive cervicl ROM between femles who routinely wore the hedscrf nd femles who never wore the hedscrf were investigted. The findings indicted tht the hedscrf group reported significnt limittion in cervicl ROM in ll six directions. Additionlly, femles in the hedscrf group who wore the hedscrf for six hours or more dy hd significntly less left rottion compred to those who wore it for less thn six hours dy. There ws no significnt difference in cervicl ROM by ge t onset of wering the hedscrf or number of yers worn. Podolsky et l. (1983) [4] reveled significnt cervicl rottion limittion when using soft-collr. Also, McCrthy et l. (2015) [3] reported limittion in cervicl extension ssocited with helmet-wering seen in Americn footbll plyers. However, no limittions were detected when mesuring cervicl ROM without the helmet. In contrst to our study, ll mesurements of cervicl ROM were performed without the hedscrf. This reveled significnt decrese in cervicl ROM in ll directions. Our subjects wore the hedscrf for n extended period. The men time spent per dy wering the hedscrf ws 7.0±2.3 hours nd the men number of yers worn ws 15.5±3.6 yers. Consequently, the hedscrf cn ct s physicl restriction to mximum cervicl mobility during everydy ctivities. This physicl restriction over time my result in muscle dptive shortening nd posturl chnges, leding to restrictions in cervicl ROM. Dunlevy nd Goldberg (2013) [16] reported tht erect posture is more likely to improve the mount of neck mobility s compred to hbitul posture. Since, in the current study, neither EMG nor posturl nlysis ws ssessed, this explntion needs to be explored in future studies. The stndrd error of mesurement (SEM) for CROM device in ll directions rnged from for right-lterl bending nd flexion respectively [14]. Audette et l. (2010) [14] indicted tht the miniml detectble chnge (MDC) rnged from 3.6 to 6.5 for right lterl bending nd flexion respectively. In our study, the decrese in cervicl ROM ws cliniclly importnt since the difference in CROM device mesurements between the groups vried from 5.6 to 10.2 for Left lterl bending nd right rottion respectively. Wering the hedscrf for six hours or more resulted in significnt decrese in the left cervicl rottion. Sjolnder et l. (2008) [17] investigted chronic neck pin with insidious onset nd reported similr findings in left rottion limittion. In their study, they ssessed cervicl ROM in the trnsverse plne motion only. Also, Lee et l. (2005) [11] reported significnt limittion in left rottion cervicl ROM only in group of young subjects with subclinicl neck pin. Those studies were conducted to detect ny limittion in cervicl ROM regrdless of the direction. Additionlly, the studies clculted cervicl ROM in one plne of motion. Therefore, no explntions or specultions on why the limittion ws only recorded in the left rottion were provided. Deficiencies in cervicl mobility my strt t n erly phse of neck pin nd cn distinguish between people with subclinicl neck pin nd no neck pin [10,11]. Additionlly, reduction in cervicl ROM is one of the prognostic fctors tht my predict disbility fter cute whiplsh [12]. There is n ssocition between decresed cervicl mobility nd ctivity limittion in subjects with neck pin [13]. This ssocition supports the clinicl importnce of detecting impirments in ROM when evluting tretment effects on neck pin. Hnd dominnce my be considered fctor, s 92.3% of the hedscrf group prticipnts were right-hnded. Usully, right-hnded femles wrp the hedscrf first over the left side then insert it ner the right er side. In this hedscrf style, the femle my void moving the hed to the left side to keep the hedscrf on. This hedscrf style my explin the significnt reduction in the left rottion. However, no detiled informtion ws obtined from the subjects regrding hedscrf style. In the current study, when the time spent per dy wering the hedscrf ws considered, it reveled trend towrd further implictions in cervicl ROM. This suggests tht the mount of time femles spend wering the hedscrf is fctor in cervicl ROM limittion. Int J Physiother 2018; 5(3) Pge 116

5 There is generl greement in the literture tht ge genertes significnt decrese in rnge of motion in symptomtic subjects [18,19,20], s well s with subjects with neck pin [13]. In our smple, the men ge for the subjects ws 28.1± 3.1 yers, which represents reltively young popultion. Nevertheless, within this ge rnge, significnt reduction in cervicl ROM ws detected. It is resonble to predict tht, within the popultion of femles who wer hedscrves, the limittion in cervicl ROM my tend to be greter s they grow older. Therefore, future studies should investigte older dult femles who wer hedscrves. There is lso link between hedscrf use nd cervicl proprioception. Alqbbni et l. (2016) [21] found trend towrds less cervicl repositioning ccurcy in women who regulrly wore hedscrves. This suggests tht wering the hedscrf my implicte other sensory-motor dysfunctions of the cervicl spine. Further investigtions re needed to determine the impct of using the hedscrves on other cervicl spine outcomes. Furthermore, there is reltionship between cervicl ROM nd forwrd hed posture (FHP) [22]. However, in this study, no FHP mesurements were obtined. Thus, future studies re wrrnted to include posturl or movement nlysis to further explin the limittions of cervicl ROM. In this study, we considered three fctors relted to hedscrves: onset of the prctice, hours worn per dy, nd the number of yers worn. Future reserch should include fctors such s styles nd textures of hedscrves. Additionlly, to further nlyze the fctors, more smple size is needed to chieve the required power. CONCLUSION In conclusion, wering the hedscrf is n essentil religious prctice by femles in Islmic cultures. Regulr wer of the hedscrf my influence cervicl mobility. Additionlly, wering it for six hours or more my result in further decline of cervicl ROM. Therefore, it is suggested tht femles minimize the mount of time spent wering the hedscrf, if pproprite. Moreover, to mintin cervicl mobility, the performnce of regulr rnge of motion exercises is recommended, especilly for femles whose dily routines require them to wer the hedscrf for more thn six hours. ABBREVIATIONS ROM Rnge of Motion CROM Cervicl Rgne of Motion Device WAD Whiplsh-Associted Disorder ICF Interntionl Clssifiction of Function SPSS Sttisticl Product nd Service Solutions BMI Body Mss Index FHP Forwrd Hed Posture ACKNOWLEDGMENT We would like to cknowledge Belind Mirnd nd Kirn Kulkrni for their hrd work, vluble support, nd commitment in the dt collection process. IRB Approvl: Lom Lind University Institution Review Bord pproved this study (IRB # ). All subjects signed n informed consent before prticiption. Conflicts of Interest nd Source of Funding This study ws funded by Deprtment of Physicl Therpy, School of Allied Helth Professions, Lom Lind University, Lom Lind, Cliforni. Authors declred no conflict of interest. The views nd opinions stted in this mnuscript re those of the uthors nd do not necessrily represents the opinion of the institution. Level of Evidence: Level 3 ccording to Oxford Centre for Evidence-Bsed Medicine REFERENCES [1] An HS, Wise JJ, Xu R. Antomy of the cervicothorcic junction: study of cdveric dissection, cryomicrotomy, nd mgnetic resonnce imging. Journl of spinl disorders 1999;12(6): doi: / [2] Childs JD, Clelnd JA, Elliott JM, Teyhen DS, Winnr RS, Whitmn JM, et l. Neck pin: Clinicl Prctice Guidelines Linked to the Interntionl Clssifiction of Functioning, Disbility, nd Helth From the Orthopedic Section of the Americn Physicl Therpy Assocition. J Orthop Sports Phys Ther 2008;38(10): doi: /jospt [3] McCrthy PW, Hume PJ, Heusch AI, Lrk SD. Wering Americn Footbll helmets increses cervicocephlic kinesthetic wreness in elite Americn Footbll plyers but not controls. Chiroprctic & Mnul Therpies 2015;23:32. doi: /s [4] Podolsky S, Brff LJ, Simon RR, Hoffmn JR, Lrmon B, Ablon W. Efficcy of cervicl spine immobiliztion methods. The Journl of trum 1983;23(6): doi: / (84) [5] Hddd YY, Smith JI, Moore KM. Muslim Women in Americ: the Chllenge of Islmic Identity Tody. New York: Oxford University Press; [6] Glssé C. The New Encyclopedi of Islm: Revised Edition of the Concise Encyclopedi of Islm. Wlnut Creek: Altmir; [7] Mohmed B. A new estimte of the U.S. Muslim popultion. Pew Reserch Center RSS. Published Jnury 6, Accessed October 10, [8] Muslim Americns: Middle Clss nd Mostly Minstrem. pdf/muslim-mericns.pdf. Published My 22, Accessed October 14, [9] Contct CIA. Centrl Intelligence Agency. Accessed November 14, [10] Lee H, Nicholson LL, Adms RD. Neck muscle endurnce, self-report, nd rnge of motion dt from subjects with treted nd untreted neck pin. Journl of mnipultive nd physiologicl therpeutics 2005;28(1): doi: /j.jmpt Int J Physiother 2018; 5(3) Pge 117

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