J Manipulative Physiol Ther 2009 (Oct); 32 (8): 625—634
Sue A. Weber Hellstenius, DC, MSc
Anglo-European College of Chiropractic/Bournemouth University in England, UK. firstname.lastname@example.org
OBJECTIVE: To identify if there were differences in the cervical biomechanics in preadolescents who had recurrent neck pain and/or headaches and those who did not.
METHODS: A controlled comparison study with a convenience sample of 131 students (10-13 years old) was performed. A questionnaire placed students in the no pain group or in the neck pain/headache group. A physical examination was performed by a doctor of chiropractic to establish head posture, active cervical rotation, passive cervical joint functioning, and muscle impairment. The unpaired t test and the chi(2) test were used to test for differences between the 2 groups, and data were analyzed using SPSS 15 (SPSS Inc, Chicago, Ill).
RESULTS: Forty percent of the children (n = 52) reported neck pain and/or recurrent headache. Neck pain and/or headache were not associated with forward head posture, impaired functioning in cervical paraspinal muscles, and joint dysfunction in the upper and middle cervical spine in these subjects. However, joint dysfunction in the lower cervical spine was significantly associated with neck pain and/or headache in these preadolescents. Most of the students had nonsymptomatic biomechanical dysfunction of the upper cervical spine. There was a wide variation between parental report and the child's self-report of trauma history and neck pain and/or headache prevalence.
CONCLUSION: In this study, the physical examination findings between preadolescents with neck pain and/or headaches and those who were symptom free differed significantly in one of the parameters measured. Cervical joint dysfunction was a significant finding among those preadolescents complaining of neck pain and/or headache as compared to those who did not.
From the FULL TEXT Article:
There was a 40% prevalence of neck pain and/or headache reported by the preadolescents in this study. This statistic is difficult to compare with results from other studies because the prevalence of either or both neck pain and/or headaches in preadolescents had not been measured before. There was an even sex distribution among the students who reported having neck pain and/or headache who were between 10 and 12 years of age. This is in agreement with other reported data for this age group. [4, 28] Students between 12 and 13 years of age must be considered periadolescent and interestingly, in this group, there was an increase in prevalence of neck pain and/or headaches among both boys and girls, and a clear shift in sex distribution with female preponderance. The increase in prevalence of neck pain and/or headache with a female sex shift in adolescence has been noted previously in the literature. [5, 14, 19, 23, 27, 28, 76, 77]
Students in this study reported having a fairly high level of pain and that it affected some students in their ability to participate in daily activities. Twenty percent reported that they have pain 1 to 2 times a week. It is interesting that very few parents reported that their child had neck pain and/or headache. There was a discrepancy between parents' report of their child's neck pain and/or headache occurring “often” (6%) and children (31%) who reported having pain “often.” These discrepancies may reflect the weakness of questionnaires in assessing pain in preadolescents and highlight the need gathering data prospectively with daily recording of symptoms as well as through interviews with parents and children. The results otherwise support the findings of Lundqvist et al  which indicated that parents not uncommonly underestimate headaches in their children.
There was also discrepancy between parental report and child self-report in regards to the incidence of head trauma. It is feasible that children do not always tell that they have hurt themselves, so interviews with both children and parents would have improved the accuracy of this question. Considering that 60% of the students reported head trauma and more than half of the students had dysfunction in the upper cervical spine, the possible relationship between the two should be investigated more closely.
The present study is to our knowledge the first cross-sectional observational study to evaluate whether pre-adolescents with recurrent neck pain and/or headache differed from peers not complaining of neck pain and/or headache in physical examination findings, specifically, forward head posture, active cervical rotation, CJD, and the presence of focal areas of tension in the cervical paraspinal muscles.
Forward head posture is associated with neck pain, cervicogenic headache, tension-type headache and migraine headache in adults. [51, 54, 55, 56, 70] In our study, the group of students with neck pain and headaches did not have an associated forward head posture suggesting that in this group of adolescents forward head posture is not yet a significant associated factor. It is of interest that most of the students examined had forward head posture both in standing and sitting. Further studies are needed to investigate if this is a predisposing factor for the increase in neck pain and headache prevalence observed in adolescence.
Reduced cervical rotation has been recorded in adults with cervicogenic headache and thought to be a result of cranio-CJD reducing rotation at the C0-C1 joint. [58, 71, 72] Unlike adults with cervicogenic headache, the group of preadolescents in this study with neck pain and/or headaches did not have associated upper CJD nor did they have reduced cervical rotation. The group of students with neck pain and/or headache did have a significant associated right lower CJD. This could be an important finding which may help to guide the implementation of treatment strategies for those preadolescents with neck pain and/or headaches who have associated joint dysfunction in the cervical spine.
Unlike adults, the preadolescents in this study with neck pain and/or headaches did not have associated focal areas increased tension in cervical paraspinal muscles. However, when evaluating the physical examination findings from all of students combined, 60% had focal areas of tension in the suboccipital muscles, 53% had forward head posture, and 46% had upper CJD. It is the combination of these factors which has been found in adult patients with dysfunctional mechanics of the cervical spine contributing to neck pain and headache. Our results indicate that there may be a pattern of dysfunctional mechanics in the upper cervical spine in the majority of the preadolescents examined but that not everyone is symptomatic.
Prolonged static postures were found to initiate or exacerbate neck pain and/or headache episodes in the preadolescent students who reported pain and were participating in this study. One quarter reported that neck movements initiated or exacerbated neck pain and/or headache episodes. This is similar to what has been found in adolescents. [5, 46, 49, 70, 74, 76-80]
A longitudinal prospective study, following a cohort of preadolescents through adolescence and ideally into young adulthood, would provide more information as to whether those individuals with asymptomatic faulty head posture, upper CJD and focal areas of tension in suboccipital muscles are more commonly represented among those who develop neck pain and/or headache and are responsible for the increase in prevalence of neck pain and/or headache in adolescence and adulthood. 
This was a pragmatic study of students in their own school setting. A pragmatic study is useful for its real world implications, but also has some weaknesses. Despite a high participation rate the study sample was small so only trends may be observed. The study sample, a convenience sample, represents students from one school only which introduces bias. The study sample was intended to be preadolescent. In Sweden, groups of students are commonly categorized by the year they are born. A miscalculation was made when estimating the ages of the students in grade 6.
Although the students were estimated to be 12 years old, they were turning thirteen during the school year and therefore periadolescent. However, this gave us a chance to see the transition into adolescence. Although widely used, the instruments selected to measure forward head posture and cervical rotation have not been validated in previous studies. Forward head posture may be measured more specifically but requires taking pictures of the students, and this could have resulted in a lower participation rate. Social desirability bias may have influenced students' posture and how they answered questions. Another limitation in the study concerns the method of gathering data; questionnaires introduce recall bias and are not as accurate as diaries in studies concerning children with pain. [29-31] As well, the questionnaire, although prepared from widely used surveys, was not validated for use with children.
There are different opinions in the literature as to the validity of using palpation to assess musculoskeletal impairment of the spine, but experience is considered mandatory for reliability of the findings. [58, 81, 82, 83] At the same time, chiropractors are extensively trained in this and base their work on their ability to assess and treat just these problems. An important parameter of this study was that the examiner was blinded as to whether students had neck pain and/or headaches. Because of this, TPs could not be accurately assessed in relation to the area of pain. In order to define a focal point of increased tension in a taut band of muscle as a TP, one needs to know if it refers pain to a distant site. Because the study design required that the examiner refrain from obtaining historical information from the students, the presence of TPs could not be established, but instead, the examiner evaluated whether the student had nodules in taut bands of muscle.
Forty percent of the preadolescents in this study had recurring neck pain and/or headache which was initiated or exacerbated by prolonged static activities. Among those students with neck pain and/or headache, there was an even sex distribution in those clearly preadolescent and an increase in neck pain and/or headache prevalence as students transitioned into adolescence as well as a sex shift with female preponderance. There was a discrepancy between parental report and child self-report in regards to the occurrence of head trauma and the prevalence of neck pain and/or headache. One parameter, CJD, was found significantly more often among those preadolescents complaining of neck pain and/or headache as compared to those who were symptom free.
- Children and parents may report different views of the clinical history
- Prolonged static postures can initiate and/or aggravate neck pain and/or headaches in children
- Dysfunction of the cervical spine may contribute to recurrent neck pain and/or headache in pre-adolescents