[

research report

Csar Fernndez-de-las-Peas, PT1,2 Marta Prez-de-Heredia, OT1

Alberto Molero-Snchez, MD1 Juan Carlos Miangolarra-Page, MD, PhD1

Performance of the Craniocervical Flexion

Test, Forward Head Posture, and Headache
Clinical Parameters in Patients With Chronic
Tension-Type Headache: A Pilot Study
t Design: Case-control, descriptive pilot study.

t Objective: To describe the differences in

the performance of the craniocervical flexion
test (CCFT) between individuals with chronic
tension-type headache (CTTH) and healthy
controls. To assess the relationship between the
CCFT, forward head posture, and several clinical
variables related to the intensity and temporal
profile of headache.

t Background: Musculoskeletal impairments of the craniocervical region might play

an important role on the pathogenesis of CTTH.
Deficits in the performance of the CCFT have
been reported in patients with cervicogenic
headache, nonspecific neck pain, and whiplash
injury, but not in individuals with CTTH.

t Material and methods: Ten patients

with CTTH and 10 comparable controls without
headache were studied. A headache diary was
kept for 4 weeks to substantiate the diagnosis
and to record the pain history. The CCFT was
performed with the subject supine and required
performing a gentle head-nodding action of
craniocervical flexion. The activation pressure
score (pressure that the subject can achieve
and hold for 10 seconds), the performance
pressure index (calculated by multiplying the
activation pressure score by the number of
successful repetitions), and the highest pressure
score (the highest level that each subject was
able to hold for 10 seconds from 20 to 30 mm

Hg) were measured. Side-view pictures of each

subject were taken in both sitting and standing
positions to assess forward head posture (FHP)
by measuring the craniovertebral angle. All
measures were taken by an assessor blinded to
the subjects condition.

t Results: Patients with CTTH had significantly lower values in both active pressure score and
performance pressure index (P,.001), but not in
the highest pressure score (P = .057), compared
to controls. Patients with CTTH had a smaller craniovertebral angle (mean 6 SD, 42.0 6 6.6),
indicating a more FHP than controls (48.8 6
2.5), in the standing position (P,.01); but not in
the sitting position (CTTH, 39 6 8.9; controls,
42.8 6 8.9, P = .10). No association between
FHP and any of the CCFT variables was found
(P..05). Headache intensity and frequency did
not seem to be related to the CCFT variables,
but there was a positive association between
headache duration and activation pressure score
(rs = 0.746, P = .02) and highest pressure score
(rs = 0.743, P = .02).
t Conclusions: These findings suggest
possible impairments of the musculoskeletal
system in individuals with CTTH, although it is
not possible to determine if these impairments
contributed to the etiology of CTTH or are as a
result of the chronic headache condition. J Orthop
Sports Phys Ther 2007;37(2):33-39. doi:10.2519/
jospt.2007.2401
t Key Words: cervical spine, head, neck, pain

eadache disorders are

one of the most common
problems seen in medical
practice. Among the
many types of headache disorders,
tension-type headache (TTH)
is the most frequent in adults.
Population-based studies suggest
1-year prevalence rates of 38.3%
for episodic TTH (less than
15 headaches per month) and
2.2% for chronic tension-type
headache (CTTH) (more than 15
headache attacks per month).33
Despite some advances, the pathogenesis
of TTH is not clearly understood. Cervical musculoskeletal abnormalities have
been traditionally linked to other types
of headaches.25,26,37 An excessive forward
head position, or forward head posture
(FHP), has been related to cervicogenic
headache (CeH),36 chronic tension-type
headache (CTTH),14 and unilateral migraine.15 FHP is usually associated with
shortening of the posterior cervical extensor muscles and weakening of the
anterior cervical flexor muscles. Our re-

Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Alcorcn, Madrid, Spain. 2Esthesiology Laboratory
of Universidad Rey Juan Carlos, Alcorcn, Madrid, Spain. The protocol for this study was approved by the Human Research Committee of the Universidad Rey Juan Carlos.
Address correspondence to Csar Fernndez-de-las-Peas, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas, 28922 Alcorcn, Madrid, Spain.
E-mail address: cesarfldp@yahoo.es

journal of orthopaedic & sports physical therapy | volume 37 | number 2 | february 2007 |

33

FIGURE 1. Inflatable air-filled pressure sensor

(Stabilizer; Chattanooga Group, Hixon, TN) used for the
craniocervical flexion test.

search group has recently demonstrated

that FHP was associated with referred
pain elicited by suboccipital muscle trigger points in individuals with CTTH.12
In addition, Hallgren et al16 and McPartland et al28 determined that subjects with
chronic neck pain showed atrophy and
fatty infiltration of the suboccipital muscles. Because the suboccipital muscles
have a greater concentration of muscle
spindles (36 spindles per g for rectus capitis posterior minor; 30.5 spindles per g
for rectus capitis posterior major)30 and
act as proprioception monitors of the
upper cervical spine, patients with CTTH
may show motor control dysfunction in
the deep neck flexor muscles.10
A low-load craniocervical flexion test
(CCFT) is clinically used to investigate
the anatomical action of the deep cervical flexors, particularly the longus colli
and longus capitis muscles. This clinical
test is typically used to assess a persons
ability to perform and hold a precise upper cervical flexion motion without flexion of the mid and lower cervical spine.
For that purpose, an inflatable air-filled
pressure sensor (Figure 1) is used to guide
an individual through 5 pressure stages
(20-30 mm Hg). The sensor is placed behind the neck and inflated to 20 mm Hg.
Clinical use of the test suggests that an
ideal controlled performance of the deep
cervical flexors can increase the pressure to 30 mm Hg and hold this pressure
for 10 seconds without any compensa-

research report
tion strategy.22 Different authors have
found, using this clinical test, deficits in
the performance of the CCFT in patients
with CeH,21 nonspecific neck pain,2,9 and
whiplash injury.20,23
This paper describes and compares
the differences in the performance of
the CCFT in patients with CTTH and
healthy controls. In addition, we assess the relationship between the CCFT,
FHP, and several clinical variables related
to the intensity and temporal profile of
headache.

METHODS
Subjects

total of 10 patients with CTTH

(2 men, 8 women; age range, 2945 years; mean 6 SD age, 38 6
5 years) and 10 comparable controls (3
men, 7 women; age range, 28-43 years;
mean 6 SD age, 36 6 5 years) without
headache history participated in this
study. Patients were recruited from the
Neurology Department of the Fundacin
Hospital Alcorcn and control subjects
were recruited from hospital staff. No
significant differences were found for
gender or age between groups. All subjects were right handed. Patients with
CTTH were diagnosed according to the
criteria of the International Headache
Society (IHS) by an experienced neurologist.18 Key elements of headache history
were ascertained, including family history, headache features, temporal profile,
and current and past medications. To be
included, patients had to report bilateral
pressing and tightening pain of mild to
moderate intensity (no more than 7 on
a 0-to-10 visual analogue scale [VAS]),
with no aggravation during routine physical activity. Patients with CTTH had to
have headaches for at least 15 days per
month. A headache diary was kept for 4
weeks to substantiate the diagnosis and
to record the pain history.32 Medication
overuse headache as defined by the International Headache Society18 was ruled out
in all cases. None of the patients received
physical therapy or took antidepressants

]
during the time of the study. Patients were
not allowed to take analgesics or muscle
relaxants 24 hours prior to the examination. All patients were examined on days
in which headache intensity was less than
4 on a 10-cm horizontal VAS. The health
status of all participants was clinically
stable, without current symptoms of any
other concomitant illness.
This study was supervised by the
Department of Physical Therapy, Occupational Therapy, Rehabilitation and
Physical Medicine, in collaboration with
the Esthesiology Laboratory, Universidad
Rey Juan Carlos. The protocol was approved by the Human Research Committee of the Universidad Rey Juan Carlos.
All subjects signed an informed consent
prior to participation.

FHP
A picture of the lateral view of each subject was taken to objectively assess FHP.
The base of the camera was set at the
height of the subjects shoulder. The tragus of the ear was clearly marked and a
plastic pointer was taped to the skin overlying the spinous process of the seventh
cervical vertebra (C7). The picture was
used to measure the craniovertebral angle: the angle between the horizontal line
passing through C7 and a line extending
from the tragus of the ear to C7 (Figure 2).1
A smaller craniovertebral angle is associ-

TRAGUS OF THE EAR

C7 Vertebrae

FIGURE 2. The craniovertebral angle was assessed

directly from a side-view picture using a protractor and a
straight edge.

34 | february 2007 | volume 37 | number 2 | journal of orthopaedic & sports physical therapy

ated with a greater FHP. High reliability

of this procedure (ICC = 0.88) has been
previously reported.31 FHP was assessed
in a relaxed sitting and a relaxed standing position. Details of this protocol can
be found elsewhere.12,14 A picture of the
lateral view of each subject was taken in
both positions.

CCFT
An inflatable air-filled pressure biofeedback sensor (Stabilizer; Chattanooga
Group, Hixon, TX) was used to assess
the performance of the deep neck flexors
of the cervical spine (Figure 1). The sensor
is placed behind the neck and is inflated
to 20 mm Hg, which is sufficient to fill
the space between the testing surface
and the neck, without pushing the neck
into a lordosis. The pressure sensor is
used to monitor the slight flattening of
the cervical lordosis that occurs with the
contraction of the deep neck flexors27
particularly the longus colli muscleand
registers the muscular effort and associated small movement of the cervical spine
as an increase in pressure. Any unwanted
head lift or general cervical flexion results
in a decrease in pressure.
The CCFT is performed with the subject supine. The subject performs a gentle
head-nodding action of craniocervical
flexion (an action indicating yes) for 5
incremental stages of increasing range
(2 mm Hg each stage), each stage being
held for 10 seconds. A suggested ideal
controlled performance of the deep cervical flexors should increase the pressure
to 30 mm Hg (an increase of 10 mm Hg).
The linear relationship between the incremental pressure targets of the CCFT
and the craniocervical flexion range of
motion has been demonstrated, supporting the clinical use of this test.6 Moreover, Falla et al7 demonstrated that each
stage of the CCFT was accompanied by
increased electromyography amplitude
in the deep cervical flexor muscles. Such
increase in the EMG activity of the deep
cervical flexors did not occur during other
neck or jaw movements, supporting the
muscle specificity of this test.8

The pressure that the subject can

achieved and hold in a steady manner for
10 seconds is called the activation pressure score.21 The tonic capacity of the deep
neck flexors is assessed by monitoring the
subjects ability to sustain the upper cervical flexion position at the achievable
pressure (activation pressure score) in a
preset task of attempting 10 repetitions
of 10-set holds. The holding capacity is
judged by the number of successful 10set holds the subject can achieve (performance pressure index). Loss of pressure
of greater than 20% of the target (usually 2 mm Hg of pressure) is regarded as
failure, and the number of repetitions to
that point is used in the calculation of the
holding capacity.
The holding capacity is presented as
a performance pressure index, which is
calculated by multiplying the target pressure achieved (activation pressure score)
by the number of successful repetitions.
For example, if a subject can achieve an
increase in pressure of 8 mm Hg with the
upper cervical flexion action (activation
pressure score) and repeat this performance 10 times, the subject will receive
a performance pressure index of 80. A
recent study17 found intraexaminer reliability (ICC) of 0.78 and an interexaminer (ICC) of 0.54 for the performance
pressure index, and an intraexaminer reliability of 0.78 and an interexaminer of
0.57 for the activation pressure score.
The hand dial of the pressure sensor
was mounted on a stand to provide the
subject with visual feedback to target the
desired pressure levels during testing
(Figure 3).

Study Protocol
All subjects, controls, and patients had
2 appointments within a 4-week period.
At the first visit assessor 1 gave a headache diary to the patients with CTTH.
Each patient registered on the diary daily
headache intensity on a 10-cm horizontal
VAS19 (range, 0 [no pain] to 10 [maximum pain]), the headache duration (in
hours per day), and the number of days
with headache. This headache diary was

FIGURE 3. Position of the subjects at the beginning of the

craniocervical flexion test.

kept for 4 weeks. Assessor 1 also informed

control subjects about physical therapy
and headache, but did not give them a
headache diary. A second assessor, blinded to the subjects condition, took 2 pictures of each subject, 1 in sitting and 1 in
standing.
At the second visit 4 weeks later, the
second assessor repeated the same head
posture assessment and examined the performance on the CCFT as follows. Subjects
were explained how to perform the CCFT
by taking a 5-minute training session. The
subject was positioned in supine. The cervical spine was supported in a neutral position, which was determined visually by
maintaining a horizontal plane between
the forehead and the chin, ensuring that a
line bisecting the neck longitudinally was
parallel to the treatment plinth.6,20,21 The
pressure biofeedback unit was placed behind the neck and inflated to a baseline of
20 mm Hg (Figure 3). Subjects were taught
the action of a slow and gentle head flexion
as though nodding to indicate yes and to
hold the end position. A trained examiner
observed and corrected any substitution
movement to insure that all subjects could
perform the test correctly. Signs of incorrect performance, such as jerking the chin
down with a fast movement or performing
a chin retraction action to push the neck
onto the sensor, were corrected during
the instruction phase. Each subject was
reminded to relax the neck musculature
and to concentrate on performing a gentle head-nodding movement.

journal of orthopaedic & sports physical therapy | volume 37 | number 2 | february 2007 |

35

[
TABLE 1

research report

CCFT in Patients With Chronic Tension-Type

Headache (n = 10) and Controls (n = 10)

CTTH (Mean 6 SD)

Control (Mean 6 SD)

6.6 6 2.3

12.6 6 4.3

,.001

Performance pressure index

32.4 6 15.8

66.8 6 23.5

,.001

Highest pressure score (mm Hg)

25.8 6 3.6

28.4 6 1.8

Activation pressure score (mm Hg)

P Value*

.057

Abbreviations: CCFT, craniocervical flexion test; CTTH, chronic tension-type headache.

*
Differences between groups using an unpaired Student t test.

Nonsignificant.

The CCFT was divided into 2 phases.

In the first phase, the pressure increase
that the subject could achieve and hold
with a controlled upper cervical flexion
action was assessed (activation pressure
score). This pressure was then used as the
target pressure for the subject to achieve
10 repetitions of a 10-second hold (performance pressure index). A 30-second
rest was provided between each repetition. Subjects viewed the dial of the pressure sensor to target the desired pressure
level (Figure 3).
In the second phase, 10 minutes later,
each subject was instructed to perform
the CCFT at 5 different pressure levels
(22, 24, 26, 28, and 30 mm Hg) and to
hold each level for 10 seconds. A 45-second rest was provided between each pressure level. The testing procedure ended
when the subject could not hold a specific pressure level for 10 seconds (loss of
pressure greater than 20% of the targeted
pressure, that is, 2 mm Hg) or the maximum pressure score of 30 mm Hg was
achieved. The highest pressure score each
subject could achieve was recorded.
A VAS (range, 0 [no pain] to 10 [maximum pain]) was used to assess head
or neck pain evoked during the performance of the CCFT in both patients and
controls.
Finally, subjects with CTTH returned
the headache diary to the first assessor,
who calculated the following variables:
(1) headache intensity, which was calculated from the mean of the VAS of the
days with headache; (2) headache frequency, which was calculated dividing
the number of days with headache by

4 weeks (days per week); and (3) headache duration (hours per day), which was
calculated dividing the sum of the total
hours of headache by the number of days
with headache (hours per day).

Reliability of the CCFT

Reliability of the CCFT was determined
on 10 additional healthy subjects (5 females and 5 males, aged 30 to 50 years
[mean 6 SD age, 39 6 6 years]). The activation pressure score, the performance

TABLE 2

tistical package (Version 12.0). A normal

distribution of quantitative data was
assessed by means of the KolmogorovSmirnov test. Quantitative data without a
normal distribution (ie, headache intensity, duration, and frequency) were analyzed with nonparametric tests, whereas
quantitative data with a normal distribution (ie, FHP, activation pressure score,
performance pressure index, and highest
pressure score) were analyzed with parametric tests. Differences in both FHP and
the 3 CCFT variables between groups
were assessed with an unpaired Student
t test. A Pearson correlation test (r) was
used to analyze the association between
the craniovertebral angle (FHP) and
the CCFT variables (activation pressure
score, performance pressure index, highest pressure score) in both patient and
control groups. Finally, the Spearman rho
(rs) test was used to analyze the association between the 3 CCFT variables and
the clinical variables relating to headache

Highest Pressure Score During the CCFT

Achieved for Each Subject
Number of Subjects Able to Achieve Target Pressure (%)

Pressure Level

CTTH Group

Control Group

22 mm Hg

4 (40%)

0 (0%)

24 mm Hg

0 (0%)

0 (0%)

26 mm Hg

2 (20%)

3 (30%)

28 mm Hg

1 (10%)

2 (20%)

30 mm Hg

3 (30%)

5 (50%)

Abbreviation: CCFT, craniocervical flexion test; CTTH, chronic tension-type headache.

pressure index, and the highest pressure

score were tested twice by the same assessor, with a 1-week interval between
testing sessions. The intraclass correlation coefficient (ICC2,1) was calculated for
each variable. The results showed a high
degree of intraexaminer reliability for the
3 CCFT variables (ICC = 0.84 for the activation pressure score, ICC = 0.90 for the
performance pressure index, and ICC =
0.88 for the highest pressure score).

Statistical Analysis
Data were analyzed with the SPSS sta-

(headache intensity, frequency, or duration) in the headache group. A P value

less than .05 was considered statistically
significant.

RESULTS
Headache Diary
History of CTTH ranged from 2 to 18
years (mean 6 SD duration, 9.4 6 5.3
years). Headache frequency during the
4-week study period ranged from 4 to 6
days per week (mean 6 SD, 4.7 6 0.7).
The mean duration of headache episodes

36 | february 2007 | volume 37 | number 2 | journal of orthopaedic & sports physical therapy

was 7.3 hours (range, 4-10 hours), and

the mean intensity (VAS) was 6 (range,
4-7). Patients with CTTH were examined on days in which headache intensity was less than 4 on the VAS (mean 6
SD, 3.0 6 0.4). No correlation was found
between headache history and the other
headache clinical parameters.

CCFT
The CTTH group had significantly lower
values in both active pressure score and
performance pressure index as compared to the control group (P,.001).
The highest pressure score was not statistically significant different between
groups (P = .057). The activation pressure score, the performance pressure
index, and the mean highest pressure
score for each group are detailed in Table 1. Table 2 summarizes the percentage
of subjects in each group who achieved
each of the pressure levels (22, 24, 26,
28, or 30 mm Hg) as their highest pressure score during the CCFT.

FHP
To verify if the head posture remained
stable during the study, 2 separate sets
of pictures were taken from each subject
with a 4-week interval. No differences
were found between the 2 measurements
(paired Student t test) (seated: P = .60,
ICC = 0.90; standing, P = .7, ICC = 0.95).
Therefore, data for further analysis were
derived from the average of the 2 values
corresponding to each position.
Patients with CTTH showed a smaller
craniovertebral angle (mean 6 SD, 42 6
6.6), indicating a more FHP than healthy
controls (mean 6 SD, 48.8 6 2.5) in the
standing position (P,.01). There was no
significant difference between groups
for the craniovertebral angle in the sitting position (CTTH mean 6 SD angle,
39 6 8.9 versus 42.8 6 8.9; P = .10).
The control group showed a more FHP
in standing as compared to sitting (mean
6 SD angle, 48.8 6 2.5 versus 42.8 6
8.9; P = .001). No difference in FHP between positions was found in the CTTH
group (standing mean 6 SD angle, 42 6

6.6 versus sitting, 39 6 8.9; P = .10).

We also assessed the degree of association between the 3 variables of the CCFT
and FHP (Table 3). No significant association was found (P..05).

TABLE 3

found in studies of patients with chronic

neck pain2,9,20,23 but in 1 exception.17 Surprisingly, we found that patients with
CTTH with longer headache duration
performed better on the CCFT. These

Pearson Correlation Coefficients Between the

Variables of the Craniocervical Flexion Test

performance pressure index highest pressure score

Activation pressure score

r = .93; P,.001

Performance pressure index

Headaches
Headache intensity and frequency were
not associated with any of the CCFT variables; but there was a positive association
between headache duration and both activation pressure score (rs = 0.746; P =
.02) and the highest pressure score (rs =
0.743; P = .02): the greater the values of
the CCFT, the greater the headache duration. Further, the craniovertebral angle
in the sitting position was negatively related to length of headache disease (rs =
0.645; P = .04): the lesser the craniovertebral angle, the greater the FHP and the
greater the headache history (ie, the more
chronic were the symptoms).
Finally, 9 patients with CTTH (90%)
reported head pain during the CCFT
(mean 6 SD, 4.3 6 2.1), whereas no
control subject reported pain during the
test (P,.001). In 8 of these 9 patients
with CTTH (89%), the pain evoked
during the CCFT was recognized as
their usual headache pain. In addition,
the pain elicited during the CCFT was
spread to the posterior part of the neck
in all patients (n = 9), and to the dorsal
region (interscapular area) in 4 of 9 patients (45%).

DISCUSSION

ur results are very similar to

those previously reported, in
which authors found impairment
of deep neck flexor muscles in a group
of individuals with CeH.21 Deficits in the
performance of the CCFT have also been

r = .87; P,.001
r = .80; P,.001

findings are in contrast with the findings

from Jull et al,21 in which an association
between duration of headache and scores
on the CCFT was not found. One possible
reason for this contradictory result could
be that CeH, but not CTTH, is usually increased by neck movement.18
In the present study, 3 (30%) patients
with CTTH reached the maximum pressure score (of 30 mm Hg), in contrast to
none of the patients with chronic neck
pain in the study by Chiu et al.2 It may be
that chronic neck pain can have a more
direct influence on muscle endurance of
the neck flexors than CTTH.
Previous studies analyzing the CCFT
in chronic conditions have evaluated the
electromyographic (EMG) activity of the
superficial neck flexor muscles. 9,20,23 Patients with chronic neck pain showed significantly higher EMG amplitude in the
sternocleidomastoid and anterior scalene
muscles as compared to healthy subjects,
probably as a strategy to compensate for
dysfunction of the deep neck flexors.9,20,23
It is known that nociceptive inputs can
alter motoneuron pool net excitability,
which could modify motor unit recruitment and EMG amplitude.4 We have
recently demonstrated that the referred
pain elicited by manual exploration of
trigger points in the sternocleidomastoid
muscle share similar characteristics with
CTTH.11 Because trigger points are responsible for the liberation of algogenic
substances (ie, bradykinin, calcitonin
gene-related peptide, substance P, tumor necrosis factor-, interleukin-1,

journal of orthopaedic & sports physical therapy | volume 37 | number 2 | february 2007 |

37

[
serotonin, and norepinephrine)34 it is
possible that superficial neck flexors may
inhibit deep neck flexors in patients with
CTTH. In the present study we did not
include EMG analysis of the superficial
neck flexors. In future studies it would
be interesting to assess if patients with
CTTH show greater EMG amplitude in
the superficial neck flexors during the
performance of the CCFT.
In addition, the performance of the
CCFT evoked usual head pain in 8 out
of our 10 patients (80%). In our previous work, we found that manual palpation of the suboccipital muscles elicited a
referred pain with similar pain characteristics as headache attacks in patients with
CTTH.12 It is plausible that suboccipital
muscle stretching that occurs during the
craniocervical flexion action elicited the
patients' usual head pain. O'Leary et al29
demonstrated that both healthy subjects
and patients with neck pain performing
the CCFT exert a similar dorsal head contact force during testing. It is possible
that the dorsal head force likely exerted
during the CCFT in our sample of patients could have stimulated the suboccipital and other posterior neck muscles,
eliciting referred pain to the head. It is
also possible that the observed difference
in performance on the CCFT between
patients and controls was due to pain
during the test procedure in the CTTH
group, muscle inhibition from long-lasting pain in the area, or tightness of the
dorsal structures such as facet joints,
muscles, or ligaments.
We also found that patients with
CTTH had a greater FHP than control
subjects in standing, but not in sitting.
In the sitting position, the more FHP
noted in the CTTH group was not statistically significant (P = .10), likely due to
the small sample size. FHP has been previously associated with other headache
disorders.14,15,36 Some authors suggest that
poor postural habits,14 pain (headache),
and low-force repetitive overuse14 could
all contribute to chronic pain.3 We also
found that FHP changed less from standing to sitting in the CTTH group as com-

research report
pared to controls, which may indicate
less neck flexibility of the patients with
CTTH. This possible lack of neck flexibility may affect the ability to perform the
CCFT and explain our results. The relationship between FHP and deep cervical
flexor strength has not been previously
investigated in individuals with CTTH.
Our preliminary results only showed a
certain degree of correlation between the
CCFT and headache duration, but not between the CCFT, FHP, and the remaining headache clinical parameters. But the
CTTH group's significantly greater FHP
in standing and reduced holding capacity
on the CCFT may imply an association,
despite the nonsignificant correlation
coefficient. It is possible that motor control dysfunction, interpreted as decreased
neck flexor endurance, can be a contributing factor for CTTH. Whether motor
control dysfunction contributes to the
perpetuation of CTTH must be verified
by future research.
Finally, as a result of several clinical
studies, low-load therapeutic exercises
emphasizing motor control rather than
muscle strength has been advocated for
effective management of patients presenting with nonspecific neck pain5 and
CeH.24 However, there are no studies
analyzing the effectiveness of these lowload therapeutic exercises in patients
with CTTH.13 Determination of the clinical significance of the musculoskeletal
impairments identified in this study in
individuals with CTTH and the most
effective intervention to correct these
impairments would require the development and testing of specific physical
therapy programs.
There are some limitations to our
study. First, only patients with CTTH
were included. Hence, our results cannot
be extrapolated to the episodic form of
TTH or to other headache disorders. It
would certainly be interesting to repeat
the same procedure with patients suffering from other headache conditions. The
second limitation was the small sample
size. To definitely establish a link between
motor control dysfunction, head posture,

]
and headache clinical parameters in patients with CTTH, our findings must be
confirmed in a larger sample. Finally,
the assessment of physical therapy interventions targeting the deep neck flexors
muscles might eventually help elucidate
the influence of neck posture and deep
neck flexors endurance in the clinical
course of CTTH.

CONCLUSIONS

atients with CTTH showed reduced holding capacity of the

deep neck flexor muscles, assessed
by the CCFT, as compared to healthy
subjects. In addition, 8 (80%) patients
with CTTH reported that the CCFT
evoked their usual head pain. Patients
with CTTH showed greater FHP in the
standing position, than healthy subjects.
These findings suggest possible impairments of the musculoskeletal system in
individuals with CTTH although it is
not possible to determine if these impairments contributed to the etiology of
CTTH or are as a result of the chronic
headache condition. t

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