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Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography
Journal of Bodywork & Movement Therapies xxx (2017) 1e6
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Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography Somayeh Amiri Arimi a, b, Mohammad Ali Mohseni Bandpei c, d, Asghar Rezasoltani e, *, Anneli Peolsson f, Masumeh Mohammadi a a
Shahid Beheshti University of Medical Sciences, Physiotherapy Research Center, School of Rehabilitation, Department of Physiotherapy, Tehran, Iran University of Social Welfare and Rehabilitation Sciences, Department of Physiotherapy, Tehran, Iran Pediatric Neurorehabilitation Research Center, Department of Physiotherapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran d University Institute of Physical Therapy, Faculty of Allied Health Sciences, University of Lahore, Lahore, Pakistan e Shahid Beheshti University of Medical Sciences, Physiotherapy Research Centre, School of Rehabilitation, Tehran, Iran f €ping University, Department of Medical and Health Sciences, Physiotherapy, Linko €ping, Sweden Linko b c
a b s t r a c t Keywords: Cervical muscles Multifidus Neck pain Size Ultrasonography
Objective: The aim of the study was to compare the dimensions of cervical multifidus muscle (CMM) in different conditions. Methods: Twenty five women with neck pain and 25 healthy subjects participated in this study. The dimensions of the CMM were measured at rest, 50% and 100% maximum isometric voluntary contraction (MIVC) at six directions of neck movements, using ultrasonography. Results: The size of multifidus was smaller in patients than healthy individuals at rest state (P < 0.05). A significant smaller CMM dimension was found in the affected side compared with unaffected side in patients group (P < 0.05). The result of ANOVA for MLD showed a significant difference for contraction levels (P < 0.001) and neck movements (P < 0.001) in both groups. The MLD of the CMM was significantly different between CMM at rest and 50%, and 100% MIVC (P < 0.001). No significant differences were found between the groups at 50% and 100% MIVC (P > 0.05 in both instances). The most prominent CMM size change was observed during neck extension, flexion, ipsilateral lateral-flexion, and ipsilateral rotation, respectively (P < 0.05). Conclusions: Results of the present study indicate that the size of CMM was decreased in patients with neck pain in rest state. The size of CMM changes in all directions of neck movements, although the most prominent was during neck extension. This points out CMM stabilization role's in different directions of neck movements. © 2017 Elsevier Ltd. All rights reserved.
1. Introduction As an increasing musculoskeletal disorder worldwide, neck pain is experienced in about 67%e71% of people through their lifetime (Fejer et al., 2006; Cote et al., 1998). In cervical region, about 20% of the head weight is tolerated by bones and ligamentous structures, while the rest is tolerated by paraspinal muscles (Panjabi et al., 1998). Weakness and atrophy of segmental paraspinal muscles,
* Corresponding author. E-mail addresses: (A. Rezasoltani).
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abnormal cervical lordosis, fat deposition, delayed muscular activity, compromised proprioception, and changes in muscular fibers type have been reported in patients with chronic neck pain (Uhlig et al., 1995; Kristjansson and Jonsson, 2002; Falla et al., 2004; Elliott ndez-de-las-Pen ~ as et al., 2008; et al., 2006; Wu et al., 2007; Ferna Lee et al., 2009; O'Leary et al., 2009; Chae et al., 2010; Rezasoltani et al., 2010; Javanshir et al., 2011; Amiri Arimi et al., 2016). Biomechanical models demonstrated that activity and function of the short and deep paraspinal muscles, especially the cervical multifidus muscle (CMM), is essential for spinal stability (Cholewicki and McGill, 1996; Panjabi et al., 1998; Kristjansson, 2004; Lee et al., 2007; Ward et al., 2009).
http://dx.doi.org/10.1016/j.jbmt.2017.09.011 1360-8592/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Amiri Arimi, S., et al., Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.09.011
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S. Amiri Arimi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
Regarding the changes in muscle size as a measure of mechanical activity, ultrasonography is considered as a common reliable, valid, and available method to evaluate muscular atrophy or hypertrophy in different musculoskeletal conditions (Hides et al., ndez-de-las1995; Rezasoltani, 2003; Rankin et al., 2005; Ferna ~ as et al., 2008; Javanshir et al., 2010; Ghamkhar et al., 2011; Pen Rahmani et al., 2015). Cross-sectional area (CSA) of CMM has been reported to be smaller in patients with bilateral chronic neck ndez-de-las-Pen ~ as et al., pain compared to healthy subjects (Ferna 2008). As the correlation between CMM thickness and an isometric extension force of the head and neck is concerned, the most prominent change in CMM thickness was recorded when the effort was less than 50% of maximum isometric voluntary contraction (MIVC) (Lee et al., 2009). CMM is located in the posterior part of the cervical spine and appears to be active only during extension movement. Earlier studies were conducted on CMM during rest status or extension movement (Kristjansson, 2004; Rankin et al., 2005; Lee et al., 2007; ndez-de-las-Pen ~ as et al., 2008), while the CMM is 2009, Ferna regarded both as a static (Panjabi et al., 1998; Kristjansson and Jonsson, 2002; Ward et al., 2009) and dynamic stabilizer of the cervical spine (Lee et al., 2009). It seems that CMM is also active during other neck movements such as flexion, lateral flexion, and rotation in order to stabilize cervical spine. In the present study, we made an attempt to assess the size of CMM in women suffering from unilateral chronic non-specific neck pain compared to the asymptomatic subjects. Moreover, we evaluated the CMM size changes during isometric contraction in six different directions of head and neck movements, at three contractile levels (0%, 50%, and 100% MIVC) in all participants. 2. Methods
ethical approval from the Medical Sciences’ Ethical Committee at Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2.2. Procedure of ultrasonographic measurements In the present study, a SIUI ultrasound device with the 80 mm convex probe and 5 MHz frequency was used to assess CMM size. The participants were asked to sit on a chair and keep trunk upright, with head and neck in neutral position (Lee et al., 2007; Rezasoltani et al., 2010). Thoracic and pelvic girdle were fastened at the level of scapular spine and iliac crest, respectively (Rezasoltani et al., 2002). In all measurements, both hands were on the thighs, the knees were extended, and the feet were resting on a stool with 15 cm height (Fig. 1) (Rezasoltani et al., 2002; Lee et al., 2007). The size of CMM was assessed bilaterally at the rest, at the level of fourth cervical vertebrae that was defined using manual palpation by an experienced physiotherapist (Kristjansson, 2004; Lee et al., 2007). A probe was placed on one side of the C4 spinous process, perpendicular to the vertical axis of the neck and muscle ndez-de-las-Pen ~ as et al., 2008). CMM is located lateral fibers (Ferna to the junction of the vertebral lamina and spinous process, and anterior to the semispinalis cervices muscle (Lee et al., 2007). Anterior-posterior dimension (APD) and a lateral dimension (LD) were measured. Then, multiplied linear dimensions (MLD) (APD LD) (Rezasoltani et al., 2002, 2010), and shape ratio (LD/ APD) were computed (Kristjansson, 2004; Lee et al., 2007; ~ as et al., 2008; Rezasoltani et al., 2010). The Fern andez-de-las-Pen CMM size was first recorded at rest status. An experienced musculoskeletal operator (at least for 2 years) performed the ultrasound examination.
2.1. Participants
2.3. Dynamometry
This cross-sectional study was performed on 25 women with unilateral chronic non-specific neck pain and 25 healthy women. They participated in this study voluntarily. The samples were recruited by a questionnaire and physical examination provided by a governmental organization. Both groups were computer users who worked for more than 4 h a day. In the patient group, individuals had experienced chronic unilateral non-specific neck pain lasting for at least 12 weeks. Mechanical or non-specific neck pain was defined as a pain in the neck or shoulder regions, elicited by the prolonged constant positioning of the neck, cervical movements, or ndez-de-las-Pen ~ as et al., palpating the local musculature (Ferna 2008). Exclusion criteria were history of any conditions such as bilateral neck pain, cervical radiculopathy, whiplash injury, fibromyalgia, myelopathy, severe osteoarthritis, cervical rib, spinal surgery, history of head and neck trauma or fracture, prior physical treatments during the previous six months, wound in the skin of the neck, systemic or autoimmune disease and pregnancy. The Spurling test (Cleland et al., 2005), as well as X-rays, were used to exclude those with any referred pain or evident degenerative findings. All participants were asked to refrain from any extra physical activity for three days before the test. The control group also performed their overall healthy and daily activities without pain in the last year. The aims and methods of the study were explained to all the participants. All the participants signed a consent form. Demographic data were collected through a general questionnaire. Additionally, in the patient group, the visual analogue scale (VAS) (Jensen et al., 1999; Bijur et al., 2001) and the neck disability index (NDI) (Hains et al., 1998; Mousavi et al., 2007; Cleland et al., 2008) were used to assess the pain intensity and functional disability, respectively. The present study also received
The maximum isometric force of the cervical flexor, extensor, left and right lateral flexors, and left and right rotator muscles were assessed using the isometric measurement device designed for the purpose of the study. It is notable that the high reliability of the
Fig. 1. Experimental set up of the study.
Please cite this article in press as: Amiri Arimi, S., et al., Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.09.011
S. Amiri Arimi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
device had been already reported (Rezasoltani et al., 2006). The participant was asked to sit in a similar position, and exert maximum effort against the load cell from frontal, occipital, temporal, and maxillary prominence regions, for flexor, extensor, lateral flexor, and rotator muscles, respectively. The load cell was fixed to the bars placed on the wall, but the subjects' position was changed and adjusted to the apparatus. In order to perform the best effort on the load cell, the position of the participant was changed along with the direction during each movement. All participants were allowed to warm up by 2e3 sub-maximal contractions and then were asked to contract at maximum force for three times (Rezasoltani et al., 2006). The highest value was recorded and considered as MIVC of the same direction of the movement (Rezasoltani et al., 2010). During contraction, subjects were asked to relax their trunk and upper limbs. Participants were asked to perform 50% and 100% of their maximum force similar to the previous stage while receiving visual feedback. During two levels of MIVC, the examiner simultaneously imaged the CMM on the dominant side. The right side was dominant side in all participants. The mean value of two ultrasonography measurements was used for data analysis (Rezasoltani et al., 2010). The order for examination of the movements was randomly assigned for each subject. 2.4. Statistical analysis Descriptive statistics were reported for all variables. Normal distribution of the data was assessed with Kolmogorov-Smirnov test. A paired t-test was used to compare the variables within groups, and also an independent t-test was used to compare the variables between the two groups. The Analysis of variance ANOVA test was utilized to assess the variability in the size of CMM at three contraction levels (rest, 50% and 100% MIVC) and six directions of the head and neck movements (flexion, extension, left and right lateral flexion, and left and right rotation) in both groups. The Bonferroni test was used to compare differences between contraction levels and neck movements. A P < 0.05 was considered significant. Data were analyzed using SPSS-16.
Table 2 The mean, standard deviation, and range of CMM size at rest in patients (n ¼ 25) and control (n ¼ 25) groups. Dimensions
APD(cm) LD(cm) MLD(cm2) Shape ratio
Control(n ¼ 25)
Mean ± SD (min-max)
Mean ± SD (min-max)
0.86 ± 0.12 (0.63e1.13) 1.76 ± 0.14 (1.48e2.15) 1.53 ± 0.31 (0.96e2.32) 2.06 ± 0.26 (1.66e2.58)
0.91 ± 0.10 (0.77e1.15) 1.87 ± 0.13 (1.64e2.15) 1.69 ± 0.27 (1.28e2.34) 2.07 ± 0.21 (1.74e2.46)
P-value
0.13 0.01* 0.03* 0.89
significant for LD (P ¼ 0.01) and MLD (P ¼ 0.038) at rest (Table 2). The patients group showed a significant smaller CMM in the affected side (P ¼ 0.001 for APD and MLD; P ¼ 0.004 for LD; P ¼ 0.014 for shape ratio) than unaffected side. In control group, the size of CMM was different between the right and left sides of the neck (the muscle was larger on the right side as the dominant side), but the mean different percentage (Rezasoltani et al., 2012a) between the two sides was smaller in control group than patients group, particularly for APD (P ¼ 0.036) and MLD (P ¼ 0.048). 3.2. Maximum isometric force of cervical muscles Although the maximum isometric force of the cervical muscles in the patient's group was smaller in all directions than the control Table 3 The mean, standard deviation and range of maximum isometric strength of neck muscles in Newton in patients (n ¼ 25) and control (n ¼ 25) groups. Max. Strength (N)
Flexion
The mean, standard deviation and the range of the anthropometric variables for both groups are presented in Table 1. No significant differences were found between the groups for anthropometric variables (P > 0.05 in all instances).
Extension R Lateral-flexion L Lateral-flexion R Rotation L Rotation
Table 2 presents CMM's dimensions at rest for a basic comparison between the groups. The size of the CMM was smaller in the patient's group than the control group. This difference was
Patients(n ¼ 25)
* The level of significance, P < 0.05. APD: Anterior-Posterior Dimension. LD: Lateral Dimension. MLD: Multiplied Linear Dimension.
3. Results
3.1. Cervical multifidus muscle dimensions at rest
3
Patients(n ¼ 25)
Control(n ¼ 25)
Mean ± SD (min-max)
Mean ± SD (min-max)
42.06 ± 14.35 (22.56e73.58) 54.89 ± 18.72 (21.58e91.23) 40.33 ± 12.95 (21.58e78.48) 42.14 ± 13.00 (23.54e68.67) 38.41 ± 11.96 (19.62e76.52) 38.29 ± 13.22 (20.60e74.56)
48.89 ± 16.27 (23.54e83.38) 63.13 ± 16.82 (25.51e98.10) 46.20 ± 16.47 (22.07e83.38) 49.08 ± 17.14 (24.53e88.29) 42.41 ± 12.86 (22.56e73.58) 45.12 ± 16.08 (19.62e83.38)
P-value
0.12 0.1 0.16 0.11 0.26 0.1
R: Right. L: Left.
Table 1 Demographic characteristics of the participants (n ¼ 50). Mean ± SD (min-max) Groups
N
Age(years)
Weight(kg)
Height(m)
BMI(kg/m2)
VAS(cm)
NDI(%)
Patients
25
Control
25
33.6 ± 7.05 (25e47) 31.8 ± 5.56 (25e47)
65.36 ± 10/63 (45e85) 64.96 ± 9.47 (50e85)
1.60 ± 0.05 (1.48e1.70) 1.61 ± 0.05 (1.50e1.70)
25.35 ± 3.07 (20.16e29.78) 24.95 ± 3.08 (20.08e29.82)
4.4 ± 1.29 (2e7) e
23.19 ± 11.33 (4.44e44.44) -
BMI: Body Mass Index. VAS: Visual Analogue Scale. NDI: Neck Disability Index.
Please cite this article in press as: Amiri Arimi, S., et al., Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.09.011
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S. Amiri Arimi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
group, this was not statistically significant between the two groups (Table 3). 3.3. Change in muscle dimensions during contractions The result of ANOVA for MLD showed a significant difference for contraction levels (P < 0.001) and neck movements (P < 0.001) in both groups. The MLD of the CMM was increased associated with raising the contraction levels (from 0% to 100%) in all participants. The MLD of the CMM was significantly different between CMM at rest and 50%, and 100% MIVC (P < 0.001). There were no significant differences between the groups in MLD changes of the CMM at 50% and 100% MIVC (P ¼ 0.79). The shape ratio was also changed associated with the increase in the level of force, but the difference was not significant for both groups (Table 4). The result of Bonferroni analysis revealed that the mean MLD of the CMM at flexion was smaller than extension (P < 0.001), lateral flexion (right, P ¼ 0.018; left, P ¼ 0.134), and rotation (right, P ¼ 0.017; left, P ¼ 0.021). In other words, during the contraction of the cervical flexor muscles, CMM size was decreased, while during cervical extension, CMM size significantly increased compared to the other neck movements (P < 0.001). The ANOVA for shape ratio showed a significant effect for neck movements (P < 0.001) in patients group. The results of Bonferroni analysis showed significant differences in shape ratio of the CMM, only between extensioncontraction and the other neck movements (P < 0.01) (Table 5). 4. Discussion The results of this study demonstrated that the size of CMM at rest and the strength of cervical muscles in all directions were smaller in women with unilateral chronic non-specific neck pain than the control group. This is consistent with previous studies conducted on the neck semispinalis capitis, longus colli, and multifidus muscles size in patients with chronic neck pain compared to ndez-de-las-Pen ~ as et al., 2008; Rezasoltani control group (Ferna et al., 2010; Javanshir et al., 2011). The results also revealed that the muscle size was significantly smaller on the painful side than the non-painful side in the patients group. A similar result for the size of the lumbar multifidus muscle has already been reported in patients with chronic low back pain (Hides et al., 2008; Nabavi
et al., 2014). It is believed that the strength generated by a group of muscles is directly related to the size of these muscles (Rezasoltani et al., 2002, 2010; O'Leary et al., 2009; Rezasoltani et al., 2010). In the present study, the MIVC of cervical muscles was also lower in all directions of the movements in the patient group compared to the control group. Previous studies have also reported that isometric strength of cervical muscles is significantly lower in patients with chronic neck pain compared with the control groups (Ylinen et al., 2004a; Rezasoltani et al., 2010; Lindstrøm et al., 2011), which seems to be attributed to the pain and discomfort. Ylinen et al. reported that pain is associated with the decreased force generation of cervical muscles in patients with chronic neck pain (Ylinen et al., 2004b). They suggested that pain may prevent full effort during strength tests and also the generation of maximal force. Accordingly, muscle impairment, atrophy, the neural inhibition induced by pain, may affect the size and muscle contractibility and prevent the MIVC of the muscle (Falla, 2004; Ylinen et al., 2004a; O'Leary et al., 2009; Lindstrøm et al., 2011). Therefore, chronic neck pain may lead to paraspinal muscles weakness and also increase musculoskeletal dysfunctions during routine and repetitive activities at work and ndez-de-las-Pen ~ as et al., 2008; Rezasoltani et al., daily life (Ferna 2010). Most of the previous studies conducted on the CMM size have been performed at the rest of the muscle (Kristjansson, 2004; ndez-de-las-Pen ~ as Rankin et al., 2005; Lee et al., 2007; Ferna et al., 2008). To the knowledge of the authors of this study, it seems that this is the first study in which the CMM changes during isometric contraction of flexion, lateral flexion and rotation movements were investigated. Also, the size of CMM was measured during three levels of isometric contraction of neck muscles at six different directions of head and neck movements, in order to detect the level of contribution of this muscle as a function of providing the spinal stability. The maximum change in muscle dimensions was observed during neck extension indicating the main function of this muscle to be head and neck extension. The minimum size of CMM was seen during neck flexion (reduction in APD and increase in LD). It is assumed that CMM stabilizes cervical spine by exerting compression force between vertebrae as a synergistic effect with neck flexors (Rezasoltani et al., 2012a,b). Although the size of the muscle was increased during neck ipsilateral lateral flexion and
Table 4 Mean of MLD and shape ratio of the CMM at different contractile levels (rest, 50 and 100% MIVC) in patients (n ¼ 25) and control (n ¼ 25) groups. Contraction Levels
Rest 50% 100%
Mean MLD
Mean Shape ratio
Patients(n ¼ 25)
Control(n ¼ 25)
Patients(n ¼ 25)
Control(n ¼ 25)
1.53 1.70 1.72
1.69 1.74 1.75
2.06 2.06 2.07
2.07 2.09 2.08
MLD: Multiplied Linear Dimension.
Table 5 Mean of MLD and shape ratio of the CMM at different directions of neck movements in patients (n ¼ 25) and control (n ¼ 25) groups. Directions
Mean MLD
Mean Shape ratio
Patients(n ¼ 25)
Control(n ¼ 25)
Patients(n ¼ 25)
Control(n ¼ 25)
Flexion Extension R Lateral-flexion L Lateral-flexion R Rotation L Rotation
1.51 1.91 1.65 1.59 1.65 1.63
1.52 1.95 1.71 1.62 1.66 1.65
2.14 1.95 2.08 2.08 2.09 2.06
2.18 1.94 2.09 2.08 2.10 2.08
R: Right. L: Left.
Please cite this article in press as: Amiri Arimi, S., et al., Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.09.011
S. Amiri Arimi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
rotation contractions, this was less than that of extension. The size change was almost similar in both movements. A mild increase or decrease in CMM size was also shown in contra-lateral isometric contraction, of both lateral flexion and rotation. It is possible that the CMM is less involved in these movements and the slight observed changes are may be attributed to the co-activation or stabilization effects of the muscle. In this regard, no significant difference was seen between the patients and the control groups. The greatest variability in the size of the CMM in both groups was detected between the 0% and 50% MIVC, and the 0% and 100% MIVC. Although the size of the muscle was improved from 50% to 100% of MIVC, this difference was not statistically significant, which is consistent with the result of previous studies (Hodges et al., 2003; Lee et al., 2009). Lee et al. assessed the contraction pattern of the CMM during progressive isometric extension of the neck using ultrasonography, and reported that the greatest change in the thickness may occur in the contraction of less than 50% MIVC, while at higher levels of the contraction, muscle thickness remained unchanged or reduced (Lee et al., 2009). Hodges et al. also demonstrated that at the lower contractile levels (less than 20e30% MIVC), small changes in muscular function is associated with significant changes in its structure. In contrast, at the higher contractile levels, the structure of the muscle does not change greatly (Hodges et al., 2003). They concluded that the structural changes of muscles at low contractile levels can be detected using ultrasonography but it cannot be used at moderate to high contractile levels (Hodges et al., 2003). In fact, it is consistent with the postural and tonic role of the CMM (Ward et al., 2009). CMM mainly consists of type one fibers and has many muscle spindles indicating the low load and tonic activity of this muscle, that is essential for segmental spinal stability (Boyd-Clark et al., 2002). In the present study, the echogenicity of the CMM did not measure, but it would be useful to include this kind of measurements in future studies. 5. Conclusion Results of the present study indicate that the CMM size was smaller in women with chronic non-specific neck pain compared to the control group at rest. Also, it was observed that in the patient group, the CMM size on the painful side was smaller than on the non-painful side. Although the size of CMM was changed in all directions of neck movements, the most prominent change was observed during neck extension, in descending order, associated with flexion, ipsilateral lateral flexion, and ipsilateral rotation, respectively. The greatest change in the CMM size occurred from 0 to 50% MIVC contraction levels in both groups. The results of this study can be beneficial to clinicians when prescribing therapeutic exercises for patients with chronic non-specific neck pain. It seems that specific exercise therapy, particularly those involving neck extension may strengthen the CMM. Exercises focusing on the stabilization of the neck in different directions of movement, at low contractile levels are recommended. Ethical approval The Shahid Beheshti University of Medical Sciences, approved the study. Funding This study did not receive funding from any organization. Conflict of interest No conflict of interests have been reported by the authors or by
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study of neck muscle size and strength measurements in females with chronic non-specific neck pain and healthy control subjects. Man. Ther. 15 (4), 400e403. Rezasoltani, A., Nasiri, R., Feyzi, M., Javanshir, K., 2012b. Assessment of dimensions of semispinalis capitis muscle and isometric strength of cervical extensor muscles in three different neck positions including neutral, flexion and extension in female healthy subjects. Mazandaran Univ. Med. Sci. J. (Persian) 22 (88), 70e79. Rezasoltani, A., Ylinen, J., Vihko, V., 2002. Isometric cervical extension force and dimensions of semispinalis capitis muscle. J. Rehabilitation Res. Dev. 39 (3), 423e428. Uhlig, Y., Weber, B., Grob, D., Müntener, M., 1995. Fiber composition and fiber transformations in neck muscles of patients with dysfunction of the cervical spine. J. Orthop. Res. 13 (2), 240e249. Ward, S., Kim, C., Eng, C., Gottschalk, L., Tomiya, A., Garfin, S., Lieber, R., 2009. Architectural analysis and intraoperative measurements demonstrate the unique design of the multifidus muscle for lumbar spine stability. J. Bone & Jt. Surg. 91 (1), 176e185. Wu, J.P., Tsia, S.Y., Shau, Y.W., Wang, C., Chai, H., Wang, S., 2007. Change of cervicocephalic kinesthetic sensibility in relation to thickness of cervical multifidus in patients with cervical symptoms. J. Biomechanics 40 (2), S415. Ylinen, J., Salo, P., Nyk€ anen, M., Kautiainen, H., H€ akkinen, A., 2004a. Decreased isometric neck strength in women with chronic neck pain and the repeatability of neck strength measurements. Archives Phys. Med. Rehabilitation 85 (8), 1303e1308. Ylinen, J., Takala, E.P., Kautiainen, H., Nykanen, M., Hakkinen, A., Pohjolainen, T., Karppi, S.L., Airaksinen, O., 2004b. Association of neck pain, disability and neck pain during maximal effort with neck muscle strength and range of movement in women with chronic non-specific neck pain. Eur. J. Pain 8 (5), 473e478.
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Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography Somayeh Amiri Arimi a, b, Mohammad Ali Mohseni Bandpei c, d, Asghar Rezasoltani e, *, Anneli Peolsson f, Masumeh Mohammadi a a
Shahid Beheshti University of Medical Sciences, Physiotherapy Research Center, School of Rehabilitation, Department of Physiotherapy, Tehran, Iran University of Social Welfare and Rehabilitation Sciences, Department of Physiotherapy, Tehran, Iran Pediatric Neurorehabilitation Research Center, Department of Physiotherapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran d University Institute of Physical Therapy, Faculty of Allied Health Sciences, University of Lahore, Lahore, Pakistan e Shahid Beheshti University of Medical Sciences, Physiotherapy Research Centre, School of Rehabilitation, Tehran, Iran f €ping University, Department of Medical and Health Sciences, Physiotherapy, Linko €ping, Sweden Linko b c
a b s t r a c t Keywords: Cervical muscles Multifidus Neck pain Size Ultrasonography
Objective: The aim of the study was to compare the dimensions of cervical multifidus muscle (CMM) in different conditions. Methods: Twenty five women with neck pain and 25 healthy subjects participated in this study. The dimensions of the CMM were measured at rest, 50% and 100% maximum isometric voluntary contraction (MIVC) at six directions of neck movements, using ultrasonography. Results: The size of multifidus was smaller in patients than healthy individuals at rest state (P < 0.05). A significant smaller CMM dimension was found in the affected side compared with unaffected side in patients group (P < 0.05). The result of ANOVA for MLD showed a significant difference for contraction levels (P < 0.001) and neck movements (P < 0.001) in both groups. The MLD of the CMM was significantly different between CMM at rest and 50%, and 100% MIVC (P < 0.001). No significant differences were found between the groups at 50% and 100% MIVC (P > 0.05 in both instances). The most prominent CMM size change was observed during neck extension, flexion, ipsilateral lateral-flexion, and ipsilateral rotation, respectively (P < 0.05). Conclusions: Results of the present study indicate that the size of CMM was decreased in patients with neck pain in rest state. The size of CMM changes in all directions of neck movements, although the most prominent was during neck extension. This points out CMM stabilization role's in different directions of neck movements. © 2017 Elsevier Ltd. All rights reserved.
1. Introduction As an increasing musculoskeletal disorder worldwide, neck pain is experienced in about 67%e71% of people through their lifetime (Fejer et al., 2006; Cote et al., 1998). In cervical region, about 20% of the head weight is tolerated by bones and ligamentous structures, while the rest is tolerated by paraspinal muscles (Panjabi et al., 1998). Weakness and atrophy of segmental paraspinal muscles,
* Corresponding author. E-mail addresses: (A. Rezasoltani).
[email protected],
[email protected]
abnormal cervical lordosis, fat deposition, delayed muscular activity, compromised proprioception, and changes in muscular fibers type have been reported in patients with chronic neck pain (Uhlig et al., 1995; Kristjansson and Jonsson, 2002; Falla et al., 2004; Elliott ndez-de-las-Pen ~ as et al., 2008; et al., 2006; Wu et al., 2007; Ferna Lee et al., 2009; O'Leary et al., 2009; Chae et al., 2010; Rezasoltani et al., 2010; Javanshir et al., 2011; Amiri Arimi et al., 2016). Biomechanical models demonstrated that activity and function of the short and deep paraspinal muscles, especially the cervical multifidus muscle (CMM), is essential for spinal stability (Cholewicki and McGill, 1996; Panjabi et al., 1998; Kristjansson, 2004; Lee et al., 2007; Ward et al., 2009).
http://dx.doi.org/10.1016/j.jbmt.2017.09.011 1360-8592/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Amiri Arimi, S., et al., Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.09.011
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Regarding the changes in muscle size as a measure of mechanical activity, ultrasonography is considered as a common reliable, valid, and available method to evaluate muscular atrophy or hypertrophy in different musculoskeletal conditions (Hides et al., ndez-de-las1995; Rezasoltani, 2003; Rankin et al., 2005; Ferna ~ as et al., 2008; Javanshir et al., 2010; Ghamkhar et al., 2011; Pen Rahmani et al., 2015). Cross-sectional area (CSA) of CMM has been reported to be smaller in patients with bilateral chronic neck ndez-de-las-Pen ~ as et al., pain compared to healthy subjects (Ferna 2008). As the correlation between CMM thickness and an isometric extension force of the head and neck is concerned, the most prominent change in CMM thickness was recorded when the effort was less than 50% of maximum isometric voluntary contraction (MIVC) (Lee et al., 2009). CMM is located in the posterior part of the cervical spine and appears to be active only during extension movement. Earlier studies were conducted on CMM during rest status or extension movement (Kristjansson, 2004; Rankin et al., 2005; Lee et al., 2007; ndez-de-las-Pen ~ as et al., 2008), while the CMM is 2009, Ferna regarded both as a static (Panjabi et al., 1998; Kristjansson and Jonsson, 2002; Ward et al., 2009) and dynamic stabilizer of the cervical spine (Lee et al., 2009). It seems that CMM is also active during other neck movements such as flexion, lateral flexion, and rotation in order to stabilize cervical spine. In the present study, we made an attempt to assess the size of CMM in women suffering from unilateral chronic non-specific neck pain compared to the asymptomatic subjects. Moreover, we evaluated the CMM size changes during isometric contraction in six different directions of head and neck movements, at three contractile levels (0%, 50%, and 100% MIVC) in all participants. 2. Methods
ethical approval from the Medical Sciences’ Ethical Committee at Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2.2. Procedure of ultrasonographic measurements In the present study, a SIUI ultrasound device with the 80 mm convex probe and 5 MHz frequency was used to assess CMM size. The participants were asked to sit on a chair and keep trunk upright, with head and neck in neutral position (Lee et al., 2007; Rezasoltani et al., 2010). Thoracic and pelvic girdle were fastened at the level of scapular spine and iliac crest, respectively (Rezasoltani et al., 2002). In all measurements, both hands were on the thighs, the knees were extended, and the feet were resting on a stool with 15 cm height (Fig. 1) (Rezasoltani et al., 2002; Lee et al., 2007). The size of CMM was assessed bilaterally at the rest, at the level of fourth cervical vertebrae that was defined using manual palpation by an experienced physiotherapist (Kristjansson, 2004; Lee et al., 2007). A probe was placed on one side of the C4 spinous process, perpendicular to the vertical axis of the neck and muscle ndez-de-las-Pen ~ as et al., 2008). CMM is located lateral fibers (Ferna to the junction of the vertebral lamina and spinous process, and anterior to the semispinalis cervices muscle (Lee et al., 2007). Anterior-posterior dimension (APD) and a lateral dimension (LD) were measured. Then, multiplied linear dimensions (MLD) (APD LD) (Rezasoltani et al., 2002, 2010), and shape ratio (LD/ APD) were computed (Kristjansson, 2004; Lee et al., 2007; ~ as et al., 2008; Rezasoltani et al., 2010). The Fern andez-de-las-Pen CMM size was first recorded at rest status. An experienced musculoskeletal operator (at least for 2 years) performed the ultrasound examination.
2.1. Participants
2.3. Dynamometry
This cross-sectional study was performed on 25 women with unilateral chronic non-specific neck pain and 25 healthy women. They participated in this study voluntarily. The samples were recruited by a questionnaire and physical examination provided by a governmental organization. Both groups were computer users who worked for more than 4 h a day. In the patient group, individuals had experienced chronic unilateral non-specific neck pain lasting for at least 12 weeks. Mechanical or non-specific neck pain was defined as a pain in the neck or shoulder regions, elicited by the prolonged constant positioning of the neck, cervical movements, or ndez-de-las-Pen ~ as et al., palpating the local musculature (Ferna 2008). Exclusion criteria were history of any conditions such as bilateral neck pain, cervical radiculopathy, whiplash injury, fibromyalgia, myelopathy, severe osteoarthritis, cervical rib, spinal surgery, history of head and neck trauma or fracture, prior physical treatments during the previous six months, wound in the skin of the neck, systemic or autoimmune disease and pregnancy. The Spurling test (Cleland et al., 2005), as well as X-rays, were used to exclude those with any referred pain or evident degenerative findings. All participants were asked to refrain from any extra physical activity for three days before the test. The control group also performed their overall healthy and daily activities without pain in the last year. The aims and methods of the study were explained to all the participants. All the participants signed a consent form. Demographic data were collected through a general questionnaire. Additionally, in the patient group, the visual analogue scale (VAS) (Jensen et al., 1999; Bijur et al., 2001) and the neck disability index (NDI) (Hains et al., 1998; Mousavi et al., 2007; Cleland et al., 2008) were used to assess the pain intensity and functional disability, respectively. The present study also received
The maximum isometric force of the cervical flexor, extensor, left and right lateral flexors, and left and right rotator muscles were assessed using the isometric measurement device designed for the purpose of the study. It is notable that the high reliability of the
Fig. 1. Experimental set up of the study.
Please cite this article in press as: Amiri Arimi, S., et al., Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.09.011
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device had been already reported (Rezasoltani et al., 2006). The participant was asked to sit in a similar position, and exert maximum effort against the load cell from frontal, occipital, temporal, and maxillary prominence regions, for flexor, extensor, lateral flexor, and rotator muscles, respectively. The load cell was fixed to the bars placed on the wall, but the subjects' position was changed and adjusted to the apparatus. In order to perform the best effort on the load cell, the position of the participant was changed along with the direction during each movement. All participants were allowed to warm up by 2e3 sub-maximal contractions and then were asked to contract at maximum force for three times (Rezasoltani et al., 2006). The highest value was recorded and considered as MIVC of the same direction of the movement (Rezasoltani et al., 2010). During contraction, subjects were asked to relax their trunk and upper limbs. Participants were asked to perform 50% and 100% of their maximum force similar to the previous stage while receiving visual feedback. During two levels of MIVC, the examiner simultaneously imaged the CMM on the dominant side. The right side was dominant side in all participants. The mean value of two ultrasonography measurements was used for data analysis (Rezasoltani et al., 2010). The order for examination of the movements was randomly assigned for each subject. 2.4. Statistical analysis Descriptive statistics were reported for all variables. Normal distribution of the data was assessed with Kolmogorov-Smirnov test. A paired t-test was used to compare the variables within groups, and also an independent t-test was used to compare the variables between the two groups. The Analysis of variance ANOVA test was utilized to assess the variability in the size of CMM at three contraction levels (rest, 50% and 100% MIVC) and six directions of the head and neck movements (flexion, extension, left and right lateral flexion, and left and right rotation) in both groups. The Bonferroni test was used to compare differences between contraction levels and neck movements. A P < 0.05 was considered significant. Data were analyzed using SPSS-16.
Table 2 The mean, standard deviation, and range of CMM size at rest in patients (n ¼ 25) and control (n ¼ 25) groups. Dimensions
APD(cm) LD(cm) MLD(cm2) Shape ratio
Control(n ¼ 25)
Mean ± SD (min-max)
Mean ± SD (min-max)
0.86 ± 0.12 (0.63e1.13) 1.76 ± 0.14 (1.48e2.15) 1.53 ± 0.31 (0.96e2.32) 2.06 ± 0.26 (1.66e2.58)
0.91 ± 0.10 (0.77e1.15) 1.87 ± 0.13 (1.64e2.15) 1.69 ± 0.27 (1.28e2.34) 2.07 ± 0.21 (1.74e2.46)
P-value
0.13 0.01* 0.03* 0.89
significant for LD (P ¼ 0.01) and MLD (P ¼ 0.038) at rest (Table 2). The patients group showed a significant smaller CMM in the affected side (P ¼ 0.001 for APD and MLD; P ¼ 0.004 for LD; P ¼ 0.014 for shape ratio) than unaffected side. In control group, the size of CMM was different between the right and left sides of the neck (the muscle was larger on the right side as the dominant side), but the mean different percentage (Rezasoltani et al., 2012a) between the two sides was smaller in control group than patients group, particularly for APD (P ¼ 0.036) and MLD (P ¼ 0.048). 3.2. Maximum isometric force of cervical muscles Although the maximum isometric force of the cervical muscles in the patient's group was smaller in all directions than the control Table 3 The mean, standard deviation and range of maximum isometric strength of neck muscles in Newton in patients (n ¼ 25) and control (n ¼ 25) groups. Max. Strength (N)
Flexion
The mean, standard deviation and the range of the anthropometric variables for both groups are presented in Table 1. No significant differences were found between the groups for anthropometric variables (P > 0.05 in all instances).
Extension R Lateral-flexion L Lateral-flexion R Rotation L Rotation
Table 2 presents CMM's dimensions at rest for a basic comparison between the groups. The size of the CMM was smaller in the patient's group than the control group. This difference was
Patients(n ¼ 25)
* The level of significance, P < 0.05. APD: Anterior-Posterior Dimension. LD: Lateral Dimension. MLD: Multiplied Linear Dimension.
3. Results
3.1. Cervical multifidus muscle dimensions at rest
3
Patients(n ¼ 25)
Control(n ¼ 25)
Mean ± SD (min-max)
Mean ± SD (min-max)
42.06 ± 14.35 (22.56e73.58) 54.89 ± 18.72 (21.58e91.23) 40.33 ± 12.95 (21.58e78.48) 42.14 ± 13.00 (23.54e68.67) 38.41 ± 11.96 (19.62e76.52) 38.29 ± 13.22 (20.60e74.56)
48.89 ± 16.27 (23.54e83.38) 63.13 ± 16.82 (25.51e98.10) 46.20 ± 16.47 (22.07e83.38) 49.08 ± 17.14 (24.53e88.29) 42.41 ± 12.86 (22.56e73.58) 45.12 ± 16.08 (19.62e83.38)
P-value
0.12 0.1 0.16 0.11 0.26 0.1
R: Right. L: Left.
Table 1 Demographic characteristics of the participants (n ¼ 50). Mean ± SD (min-max) Groups
N
Age(years)
Weight(kg)
Height(m)
BMI(kg/m2)
VAS(cm)
NDI(%)
Patients
25
Control
25
33.6 ± 7.05 (25e47) 31.8 ± 5.56 (25e47)
65.36 ± 10/63 (45e85) 64.96 ± 9.47 (50e85)
1.60 ± 0.05 (1.48e1.70) 1.61 ± 0.05 (1.50e1.70)
25.35 ± 3.07 (20.16e29.78) 24.95 ± 3.08 (20.08e29.82)
4.4 ± 1.29 (2e7) e
23.19 ± 11.33 (4.44e44.44) -
BMI: Body Mass Index. VAS: Visual Analogue Scale. NDI: Neck Disability Index.
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group, this was not statistically significant between the two groups (Table 3). 3.3. Change in muscle dimensions during contractions The result of ANOVA for MLD showed a significant difference for contraction levels (P < 0.001) and neck movements (P < 0.001) in both groups. The MLD of the CMM was increased associated with raising the contraction levels (from 0% to 100%) in all participants. The MLD of the CMM was significantly different between CMM at rest and 50%, and 100% MIVC (P < 0.001). There were no significant differences between the groups in MLD changes of the CMM at 50% and 100% MIVC (P ¼ 0.79). The shape ratio was also changed associated with the increase in the level of force, but the difference was not significant for both groups (Table 4). The result of Bonferroni analysis revealed that the mean MLD of the CMM at flexion was smaller than extension (P < 0.001), lateral flexion (right, P ¼ 0.018; left, P ¼ 0.134), and rotation (right, P ¼ 0.017; left, P ¼ 0.021). In other words, during the contraction of the cervical flexor muscles, CMM size was decreased, while during cervical extension, CMM size significantly increased compared to the other neck movements (P < 0.001). The ANOVA for shape ratio showed a significant effect for neck movements (P < 0.001) in patients group. The results of Bonferroni analysis showed significant differences in shape ratio of the CMM, only between extensioncontraction and the other neck movements (P < 0.01) (Table 5). 4. Discussion The results of this study demonstrated that the size of CMM at rest and the strength of cervical muscles in all directions were smaller in women with unilateral chronic non-specific neck pain than the control group. This is consistent with previous studies conducted on the neck semispinalis capitis, longus colli, and multifidus muscles size in patients with chronic neck pain compared to ndez-de-las-Pen ~ as et al., 2008; Rezasoltani control group (Ferna et al., 2010; Javanshir et al., 2011). The results also revealed that the muscle size was significantly smaller on the painful side than the non-painful side in the patients group. A similar result for the size of the lumbar multifidus muscle has already been reported in patients with chronic low back pain (Hides et al., 2008; Nabavi
et al., 2014). It is believed that the strength generated by a group of muscles is directly related to the size of these muscles (Rezasoltani et al., 2002, 2010; O'Leary et al., 2009; Rezasoltani et al., 2010). In the present study, the MIVC of cervical muscles was also lower in all directions of the movements in the patient group compared to the control group. Previous studies have also reported that isometric strength of cervical muscles is significantly lower in patients with chronic neck pain compared with the control groups (Ylinen et al., 2004a; Rezasoltani et al., 2010; Lindstrøm et al., 2011), which seems to be attributed to the pain and discomfort. Ylinen et al. reported that pain is associated with the decreased force generation of cervical muscles in patients with chronic neck pain (Ylinen et al., 2004b). They suggested that pain may prevent full effort during strength tests and also the generation of maximal force. Accordingly, muscle impairment, atrophy, the neural inhibition induced by pain, may affect the size and muscle contractibility and prevent the MIVC of the muscle (Falla, 2004; Ylinen et al., 2004a; O'Leary et al., 2009; Lindstrøm et al., 2011). Therefore, chronic neck pain may lead to paraspinal muscles weakness and also increase musculoskeletal dysfunctions during routine and repetitive activities at work and ndez-de-las-Pen ~ as et al., 2008; Rezasoltani et al., daily life (Ferna 2010). Most of the previous studies conducted on the CMM size have been performed at the rest of the muscle (Kristjansson, 2004; ndez-de-las-Pen ~ as Rankin et al., 2005; Lee et al., 2007; Ferna et al., 2008). To the knowledge of the authors of this study, it seems that this is the first study in which the CMM changes during isometric contraction of flexion, lateral flexion and rotation movements were investigated. Also, the size of CMM was measured during three levels of isometric contraction of neck muscles at six different directions of head and neck movements, in order to detect the level of contribution of this muscle as a function of providing the spinal stability. The maximum change in muscle dimensions was observed during neck extension indicating the main function of this muscle to be head and neck extension. The minimum size of CMM was seen during neck flexion (reduction in APD and increase in LD). It is assumed that CMM stabilizes cervical spine by exerting compression force between vertebrae as a synergistic effect with neck flexors (Rezasoltani et al., 2012a,b). Although the size of the muscle was increased during neck ipsilateral lateral flexion and
Table 4 Mean of MLD and shape ratio of the CMM at different contractile levels (rest, 50 and 100% MIVC) in patients (n ¼ 25) and control (n ¼ 25) groups. Contraction Levels
Rest 50% 100%
Mean MLD
Mean Shape ratio
Patients(n ¼ 25)
Control(n ¼ 25)
Patients(n ¼ 25)
Control(n ¼ 25)
1.53 1.70 1.72
1.69 1.74 1.75
2.06 2.06 2.07
2.07 2.09 2.08
MLD: Multiplied Linear Dimension.
Table 5 Mean of MLD and shape ratio of the CMM at different directions of neck movements in patients (n ¼ 25) and control (n ¼ 25) groups. Directions
Mean MLD
Mean Shape ratio
Patients(n ¼ 25)
Control(n ¼ 25)
Patients(n ¼ 25)
Control(n ¼ 25)
Flexion Extension R Lateral-flexion L Lateral-flexion R Rotation L Rotation
1.51 1.91 1.65 1.59 1.65 1.63
1.52 1.95 1.71 1.62 1.66 1.65
2.14 1.95 2.08 2.08 2.09 2.06
2.18 1.94 2.09 2.08 2.10 2.08
R: Right. L: Left.
Please cite this article in press as: Amiri Arimi, S., et al., Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.09.011
S. Amiri Arimi et al. / Journal of Bodywork & Movement Therapies xxx (2017) 1e6
rotation contractions, this was less than that of extension. The size change was almost similar in both movements. A mild increase or decrease in CMM size was also shown in contra-lateral isometric contraction, of both lateral flexion and rotation. It is possible that the CMM is less involved in these movements and the slight observed changes are may be attributed to the co-activation or stabilization effects of the muscle. In this regard, no significant difference was seen between the patients and the control groups. The greatest variability in the size of the CMM in both groups was detected between the 0% and 50% MIVC, and the 0% and 100% MIVC. Although the size of the muscle was improved from 50% to 100% of MIVC, this difference was not statistically significant, which is consistent with the result of previous studies (Hodges et al., 2003; Lee et al., 2009). Lee et al. assessed the contraction pattern of the CMM during progressive isometric extension of the neck using ultrasonography, and reported that the greatest change in the thickness may occur in the contraction of less than 50% MIVC, while at higher levels of the contraction, muscle thickness remained unchanged or reduced (Lee et al., 2009). Hodges et al. also demonstrated that at the lower contractile levels (less than 20e30% MIVC), small changes in muscular function is associated with significant changes in its structure. In contrast, at the higher contractile levels, the structure of the muscle does not change greatly (Hodges et al., 2003). They concluded that the structural changes of muscles at low contractile levels can be detected using ultrasonography but it cannot be used at moderate to high contractile levels (Hodges et al., 2003). In fact, it is consistent with the postural and tonic role of the CMM (Ward et al., 2009). CMM mainly consists of type one fibers and has many muscle spindles indicating the low load and tonic activity of this muscle, that is essential for segmental spinal stability (Boyd-Clark et al., 2002). In the present study, the echogenicity of the CMM did not measure, but it would be useful to include this kind of measurements in future studies. 5. Conclusion Results of the present study indicate that the CMM size was smaller in women with chronic non-specific neck pain compared to the control group at rest. Also, it was observed that in the patient group, the CMM size on the painful side was smaller than on the non-painful side. Although the size of CMM was changed in all directions of neck movements, the most prominent change was observed during neck extension, in descending order, associated with flexion, ipsilateral lateral flexion, and ipsilateral rotation, respectively. The greatest change in the CMM size occurred from 0 to 50% MIVC contraction levels in both groups. The results of this study can be beneficial to clinicians when prescribing therapeutic exercises for patients with chronic non-specific neck pain. It seems that specific exercise therapy, particularly those involving neck extension may strengthen the CMM. Exercises focusing on the stabilization of the neck in different directions of movement, at low contractile levels are recommended. Ethical approval The Shahid Beheshti University of Medical Sciences, approved the study. Funding This study did not receive funding from any organization. Conflict of interest No conflict of interests have been reported by the authors or by
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Please cite this article in press as: Amiri Arimi, S., et al., Multifidus muscle size changes at different directions of head and neck movements in females with unilateral chronic non-specific neck pain and healthy subjects using ultrasonography, Journal of Bodywork & Movement Therapies (2017), http://dx.doi.org/10.1016/j.jbmt.2017.09.011