Normative data for neck muscles endurance in healthy Saudi males: foundations for precision health

Background: Distinctive cultural practices in Gulf countries, including Saudi Arabia such as wearing the shimagh and participating in traditional dances like the Ardah place considerable demands on neck muscle endurance. Insufficient endurance can contribute to or exacerbate neck pain. The absence of normative data for the Saudi population underscores a critical gap, emphasizing the need for data to guide prevention, diagnosis and culturally tailored interventions. The aim of this study was to establish normative data and assess both interrater and intrarater reliability for neck flexor and extensor muscle endurance in healthy Saudi males. Methods: Ninety healthy adults aged 20 years and older with no history of neck pain or injury participated in the study. Two raters (Rater 1 and Rater 2) assessed the endurance of the neck’s extensor and flexor muscles in each participant separately using a stopwatch across two sessions (day one and day 3). To mitigate order effects, a random number was assigned to each test for each participant. Participants rested for five minutes between the two readings and ten minutes between the two sets. Results: The standard error of measurement (SEM) and minimal detectable change (MDC) for neck flexor muscle endurance were 16.54 seconds and 45.84 seconds, respectively. For neck extensor muscle endurance, the SEM and MDC were 17.43 seconds and 48.31 seconds, respectively. The interrater and intrarater reliability for assessing the endurance of the neck flexor and extensor muscles ranged from good to excellent, with intraclass correlation coefficients (ICC2,1) value between 0.85 and 0.96. Conclusions: This study provides normative data for neck flexor and extensor muscle endurance, demonstarting good to excellent interrater and intrarater reliability. These benchmarks lay the groundwork for evaluating neck muscle function and clinically enable precise monitoring of endurance changes, guiding tailored interventions to prevent or manage neck pain, particularly in culturally relevant contexts.

Neck muscles; Intertester reliability; Intratester reliability; Physical endurance

[1] de Melo Castro Deligne L, Rocha MCB, Malta DC, Naghavi M, de Azeredo Passos VM. The burden of neck pain in Brazil: estimates from the global burden of disease study 2019. BMC Musculoskeletal Disorders. 2021; 22: 811.

[2] Alhakami AM, Madkhli A, Ghareeb M, Faqih A, Abu-Shamla I, Batt T, et al. The prevalence and associated factors of neck pain among ministry of health office workers in Saudi Arabia: a cross sectional study. Healthcare. 2022; 10: 1320.

[3] Al-Eisa E, Alghadir AH, Iqbal ZA. Measurement of physical activity in obese persons: how and why? A review. Journal of Physical Therapy Science. 2016; 28: 2670–2674.

[4] Alghadir A, Zafar H, Iqbal ZA, Al-Eisa E. Work-related low back pain among physical therapists in Riyadh, Saudi Arabia. Workplace Health & Safety. 2017; 65: 337–345.

[5] Colman D, Demoulin C, Vanderthommen M, Saive O, Durieux N, Cagnie B, et al. Exercise therapy including the cervical extensor muscles in individuals with neck pain: a systematic review. Clinical Rehabilitation. 2023; 37: 1579–1610.

[6] Fernández-de-Las-Peñas C, Cook C, Cleland JA, Florencio LL. The cervical spine in tension type headache. Musculoskeletal Science and Practice. 2023; 66: 102780.

[7] Hasan S, Bharti N, Alghadir AH, Iqbal A, Shahzad N, Ibrahim AR. The efficacy of manual therapy and pressure biofeedback‐guided deep cervical flexor muscle strength training on pain and functional limitations in individuals with cervicogenic headaches: a randomized comparative study. Pain Research and Management. 2023; 2023: 1799005.

[8] Wolff WL, Heinemann CM, Lipps DB. The influence of idiopathic chronic neck pain on upper trapezius and sternocleidomastoid muscle activity and elasticity during functional reaching: a cross-sectional study. Journal of Biomechanics. 2022; 141: 111223.

[9] Heredia-Rizo AM, Petersen KK, Arendt-Nielsen L, Madeleine P. Eccentric training changes the pressure pain and stiffness maps of the upper trapezius in females with chronic neck-shoulder pain: a preliminary study. Pain Medicine. 2020; 21: 1936–1946.

[10] González-Rueda V, López-de-Celis C, Bueno-Gracia E, Rodríguez-Sanz J, Pérez-Bellmunt A, Barra-López ME, et al. Short-and mid-term effects of adding upper cervical manual therapy to a conventional physical therapy program in patients with chronic mechanical neck pain. Randomized controlled clinical trial. Clinical Rehabilitation. 2021; 35: 378–389.

[11] Miranda IF, Neto ES, Dhein W, Brodt GA, Loss JF. Individuals with chronic neck pain have lower neck strength than healthy controls: a systematic review with meta-analysis. Journal of Manipulative and Physiological Therapeutics. 2019; 42: 608–622.

[12] Lourenço AS, Lameiras C, Silva AG. Neck flexor and extensor muscle endurance in subclinical neck pain: intrarater reliability, standard error of measurement, minimal detectable change, and comparison with asymptomatic participants in a university student population. Journal of Manipulative and Physiological Therapeutics. 2016; 39: 427–433.

[13] Reddy RS, Meziat-Filho N, Ferreira AS, Tedla JS, Kandakurti PK, Kakaraparthi VN. Comparison of neck extensor muscle endurance and cervical proprioception between asymptomatic individuals and patients with chronic neck pain. Journal of Bodywork and Movement Therapies. 2021; 26: 180–186.

[14] Jull G, Kristjansson E, Dall’Alba P. Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Manual Therapy. 2004; 9: 89–94.

[15] Alqahtani B, Elnaggar RK, Alshehri MM, Khunti K, Alenazi A. National and regional prevalence rates of diabetes in Saudi Arabia: analysis of national survey data. International Journal of Diabetes in Developing Countries. 2023; 43: 392–397.

[16] Kocur P, Choszczewski D, Lewandowski J, Goliwąs M. Assessment of stiffness of the superficial neck muscles in female office workers with impaired endurance of deep neck flexors: a case-control study. Physiotherapy Quarterly. 2023; 31: 114–120.

[17] Edmondston SJ, Wallumrød ME, MacLéid F, Kvamme LS, Joebges S, Brabham GC. Reliability of isometric muscle endurance tests in subjects with postural neck pain. Journal of Manipulative and Physiological Therapeutics. 2008; 31: 348–354.

[18] Harris KD, Heer DM, Roy TC, Santos DM, Whitman JM, Wainner RS. Reliability of a measurement of neck flexor muscle endurance. Physical Therapy. 2005; 85: 1349–1355.

[19] Jarman NF, Brooks T, James CR, Hooper T, Wilhelm M, Brismée J-M, et al. Deep neck flexor endurance in the adolescent and young adult: normative data and associated attributes. PM&R. 2017; 9: 969–975.

[20] Parazza S, Vanti C, O’Reilly C, Villafañe JH, Tricás Moreno JM, Estébanez De Miguel E. The relationship between cervical flexor endurance, cervical extensor endurance, VAS, and disability in subjects with neck pain. Chiropractic & Manual Therapies. 2014; 22: 10.

[21] Alghadir A, Anwer S, Iqbal ZA, Alsanawi HA. Cross-cultural adaptation, reliability and validity of the Arabic version of the reduced Western Ontario and McMaster Universities Osteoarthritis index in patients with knee osteoarthritis. Disability and Rehabilitation. 2016; 38: 689–694.

[22] Peolsson A, Almkvist C, Dahlberg C, Lindqvist S, Pettersson S. Age-and sex-specific reference values of a test of neck muscle endurance. Journal of Manipulative and Physiological Therapeutics 2007; 30: 171–177.

[23] Alsanawi HA, Alghadir A, Anwer S, Roach KE, Alawaji A. Cross-cultural adaptation and psychometric properties of an Arabic version of the shoulder pain and disability index. International Journal of Rehabilitation Research. 2015; 38: 270–275.

[24] Fayers PM, Machin D. Quality of life: the assessment, analysis and interpretation of patient-reported outcomes. 3rd edn. John Wiley & Sons: Chichester. 2016.

[25] Mayo NE, Aburub A, Brouillette MJ, Kuspinar A, Moriello C, Rodriguez AM, et al. In support of an individualized approach to assessing quality of life: comparison between patient generated index and standardized measures across four health conditions. Quality of Life Research. 2017; 26: 601–609.

[26] Olson LE, Millar AL, Dunker J, Hicks J, Glanz D. Reliability of a clinical test for deep cervical flexor endurance. Journal of Manipulative and Physiological Therapeutics. 2006; 29: 134–138.

[27] Edmondston S, Björnsdóttir G, Pálsson T, Solgård H, Ussing K, Allison G. Endurance and fatigue characteristics of the neck flexor and extensor muscles during isometric tests in patients with postural neck pain. Manual Therapy. 2011; 16: 332–338.

[28] Painkra JP, Kumar S, Anwer S, Kumar R, Nezamuddin M, Equebal A. Reliability of an assessment of deep neck flexor muscle endurance test: a cross-sectional study. International Journal of Therapy and Rehabilitation. 2014; 21: 227–231.

[29] Marijančić V, Grubić Kezele T, Peharec S, Dragaš-Zubalj N, Pavičić Žeželj S, Starčević-Klasan G. Relationship between physical activity and sedentary behavior, spinal curvatures, endurance and balance of the trunk muscles-extended physical health analysis in young adults. International Journal of Environmental Research and Public Health. 2023; 20: 6938.

[30] Mikkelsson LO, Nupponen H, Kaprio J, Kautiainen H, Mikkelsson M, Kujala UM. Adolescent flexibility, endurance strength, and physical activity as predictors of adult tension neck, low back pain, and knee injury: a 25 year follow up study. British Journal of Sports Medicine. 2006; 40: 107–113.

[31] Blangsted AK, Søgaard K, Hansen EA, Hannerz H, Sjøgaard G. One-year randomized controlled trial with different physical-activity programs to reduce musculoskeletal symptoms in the neck and shoulders among office workers. Scandinavian Journal of Work, Environment & Health. 2008; 34: 55–65.

[32] Hidaka T, Kakamu T, Endo S, Masuishi Y, Kasuga H, Hata A, et al. Associations of endurance, muscle strength, and balanced exercise with subjective sleep quality in sedentary workers: a cross-sectional study. Work. 2024; 78: 761–770.

[33] Sebastian D, Chovvath R, Malladi R. Cervical extensor endurance test: a reliability study. Journal of Bodywork and Movement Therapies. 2015; 19: 213–216.

[34] Juul T, Langberg H, Enoch F, Søgaard K. The intra- and inter-rater reliability of five clinical muscle performance tests in patients with and without neck pain. BMC Musculoskeletal Disorders. 2013; 14: 339.