Orthotic Management for Cervical Pain.pptx

Mechanical and neurogenic neck pain is among the five most common musculoskeletal complaints worldwide. Across the lifespan it affects up to 70 % of adults for at least one short‐lived episode, and 10–20 % develop persistent or recurrent symptoms that impair work, driving and sleep. Orthoses—external devices that interface with the head, mandible, cervico-thoracic junction or trunk—remain a key non-invasive adjunct in both acute and chronic settings. Their value lies in modulating motion-related nociception, protecting healing tissues, redistributing load, and acting as biofeedback tools that promote safer posture. Yet the literature shows wide variation in what to prescribe, for how long, and to whom. The following review integrates biomechanics, clinical evidence and practical fitting guidance to equip clinicians with a structured approach to orthotic management of cervical pain.

2 Pathomechanics of painful neck conditions
Most non-specific neck pain originates in the functional spinal unit (FSU) of C2–T1—two vertebral bodies, the intervening intervertebral disc, uncovertebral joints, paired facet joints, and their enveloping ligaments and muscles. Disc degeneration reduces nucleus pulposus hydrostatic pressure, shifting compressive load anteriorly in flexion and straining the posterior annulus, joint capsules and ligamentum flavum. This micro-instability widens the neutral zone and makes previously pain-free movements provocative. Facet arthrosis adds capsular irritation and synovial impingement, often producing unilateral pain strengthened by extension and rotation.

Trauma introduces additional mechanisms: flexion-extension “whiplash” strains peri-articular tissues; fractures compromise the cortical ring; and surgical decompression, though curative for radiculopathy or myelopathy, leaves grafts and plates that are temporarily vulnerable to excessive micromotion. Each scenario can benefit, to varying degrees, from carefully selected external support.

3 Goals of orthotic intervention
Pain reduction through kinesthetic feedback or actual motion restriction.

Protection of injured or healing structures—capsular ligaments, fused segments, bone grafts or osteoporotic vertebral bodies.

Load redistribution from painful segments to the chin, occiput, sternum and thorax.

Promotion of optimal alignment to minimise compressive shear on ventral discs and facet joints.

Facilitation of early function by enabling upright mobility while tissues consolidate.

These goals are realised only if the device is matched to the pathology and worn consistently yet time-limited to avoid de-conditioning.

4 Biomechanics of cervical orthoses
Cervical motion occurs in three principal planes: flexion-extension (≈ 130°), axial rotation (≈ 80–90°) and lateral bending (≈ 45°). Orthoses limit movement by one or more of four mechanisms:

End-point control—using the mandible and occiput as cranial anchors and the sternum or thoracic shell as caudal anchors.

1. Seminar Presentation  : Orthotic Management for Cervical Pain Presenter: Rushikesh Rajgude MPO 2nd year Guide : Anupriya Tripathi Demonstrator, (DSMNRU, Lucknow) 1

2. Introduction: Definition : Cervical pain refers to discomfort or dysfunction in the neck due to muscle strain, degenerative changes, or nerve involvement. It is also known as cervicalgia. Causes : Poor posture, injuries (e.g., whiplash), degenerative disorders like spondylosis, or systemic conditions like rheumatoid arthritis 2 Cleveland Clinic. (n.d.). Neck Pain. Retrieved from https://www.clevelandclinic.org/health/diseases/22242-neck-pain

3. Anatomy of the Cervical Spine Components : 7 Vertebrae (C1–C7) Muscles (e.g., trapezius, levator scapulae) Ligaments and Intervertebral Discs Spinal Cord and Nerve Roots 3 Barnes, S. (2024, September 5). The Cervical Spine. Teach Me Anatomy. https://teachmeanatomy.info/neck/bones/cervical-spine/

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5. 5 CERVICAL LORDOSIS : It is due to wedge shape of I.V. disc & helps to hold the head in the upright position for a wide range of binocular vision . NORMAL CERVICAL LORDOSIS IS 31 – 40 DEGREE Lordosis Kyphosis Lordosis

6. 6 MOVEMENT CERVICAL THORACIC LUMBER FLEXION 60 15 40 EXTENSION 80 15 25 LATERAL FLEXION 45 + 45 = 90 15 + 15 = 30 20 + 20 = 40 ROTATION 75 + 75 = 150 40 + 40 = 80 5 + 5 = 10 Barnes, S. (2024, September 5). The Cervical Spine. Teach Me Anatomy. https://teachmeanatomy.info/bones/spine/

7. Animatic representation of cervical spine: 7 Veritas Health. (2022). Cervical Muscles Animation. [Video]. https://youtu.be/k_L6RdntJnk?si=J2N8CvHyYC-Nc7-L

8. Common Causes of Cervical Pain 8 J Orthop Sports Phys Ther. 2017;47(7):A1–A83. doi:10.2519/jospt.2017.0302

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10. 10 J Orthop Sports Phys Ther . 2017;47(7):A1–A83. doi:10.2519/jospt.2017.0302

11. Cervical Spondylosis 11 J Orthop Sports Phys Ther. 2017;47(7):A1–A83. doi:10.2519/jospt.2017.0302

12. 12 J Orthop Sports Phys Ther . 2017;47(7):A1–A83. doi:10.2519/jospt.2017.0302

13. Grade Description Details Grade 0 No Injury - No pain or signs of injury - No symptoms or effects Grade 1 Pain Only - Pain in the neck and surrounding areas - Stiffness when moving - Tenderness to being touched around the injury Grade 2 Pain and Physical Signs of Injury - Pain that radiates to nearby areas (head, face, shoulder, back) - Muscle spasms making it hard to move or turn the head and neck - Physical signs of injury, including: - Bruising - Swelling - Sensitivity to being touched around the injury Grade 3 Pain and Neurological Symptoms - Muscle weakness - Numbness or loss of sensation in the neck, upper back, shoulders, or upper arms - Burning, tingling, or "pins and needles" feeling (paresthesia) in the neck, upper back, shoulders, or upper arms - Headaches - Vision problems - Hoarseness or loss of voice (dysphonia) - Dizziness or vertigo (cervical vertigo) Grade 4 Severe Whiplash-Associated Disorders - All symptoms from Grade 3, with more severe neurological effects - May indicate a fractured neck vertebra and risk of damage to the spinal cord and its network of connected nerves 13

14. J Orthop Sports Phys Ther . 2017;47(7):A1–A83. doi:10.2519/jospt.2017.0302 14 Rheumatoid arthritis

15. 15 Classification Type Description Anderson and Montesano A Compression fracture with intact posterior ligamentous complex (PLC) B Compression fracture with disrupted posterior ligamentous complex (PLC) C Flexion distraction fracture with disrupted posterior ligamentous complex (PLC) Subaxial Injury Classification (SLIC) 1 Compression fracture 2 Flexion distraction fracture 3 Extension distraction fracture 4 Burst fracture 5 Translation fracture Anderson, P. A., & Montesano, P. X. (1988). Morphology and clinical correlation of specific patterns of cervical spine fracture. Clinical Orthopaedics and Related Research, 230, 159-169

16. Epidemiology: 16 Wang, H., Naghavi , M., Allen, C., Barber, R. M., Bhutta , Z. A., Carter, A., ... & GBD 2015 Mortality and Causes of Death Collaborators. (2016). Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet, 388(10053), 1459-1544.

17. Classification of neck pain according to Firtz et.al. : 17

18. 18 Group Criteria Key Features Group 1 - No neurological symptoms- No red flags- No significant cervical spine dysfunction- Good cervical spine mobility - Minimal impairment- Suitable for conservative treatment, such as physical therapy and exercises. Group 2 - Neurological symptoms (e.g., numbness, tingling, weakness)- No red flags- Some cervical spine dysfunction- Reduced cervical spine mobility - Symptoms suggest possible nerve involvement.- Focus on nerve decompression and mobility improvement. Group 3 - Red flags (e.g., sudden onset of severe pain, constant/unrelenting pain)- Neurological symptoms- Significant cervical spine dysfunction- Reduced cervical spine mobility - Indicates serious underlying pathology.- Requires further diagnostic tests and urgent medical attention. Group 4 - Red flags- Neurological symptoms- Significant cervical spine dysfunction- Reduced cervical spine mobility- Other underlying conditions (e.g., infection, tumor) - Complex and potentially life-threatening.- Multidisciplinary management is crucial.

19. Diagnosis 19 Step 1: Medical History A healthcare provider will ask about previous neck injuries, work or activities that could strain your neck, and your pain, including: When it started Where it's located How long it lasts How intense it is Step 2: Physical Exam A healthcare provider will: Check your head and neck alignment Observe your range of motion when you move your neck Feel your neck and supporting muscles to check for tenderness and signs of strain Step 3: Imaging Tests (if necessary) X-rays: to show problems with bones or soft tissues Magnetic Resonance Imaging (MRI): to show problems with spinal cord, nerves, bone marrow, and soft tissue Computed Tomography (CT) scan: to show bone spurs and signs of bone deterioration

20. CONTD… 20 Additional Tests (if necessary) Electrodiagnostic tests: to check the function of nerves and muscle response Lab tests: to identify causes of neck pain other than musculoskeletal injuries

21. Goals of Orthotic Management 21 Weppner, J. L., & Alfano, A. P. (2024). Principles and components of spinal orthoses. In Atlas of limb orthoses (5th ed., pp. 69-72).

22. Biomechanical Principles: Cervical orthoses (COs) and cervico -thoracic orthoses (CTOs) are used to manage neck injuries, provide stabilization, and limit motion in the cervical spine. Their biomechanics involve the following key aspects: Motion Restriction : COs primarily restrict flexion, extension, lateral bending, and rotation in the cervical spine. Their efficacy varies with design; rigid collars provide better immobilization compared to soft collars . CTOs extend support to the thoracic region, significantly enhancing restriction, especially in flexion and extension. They provide a broader lever arm for immobilization, reducing intervertebral motion compared to cervical collars alone . Load Redistribution : Rigid CTOs, especially those with anterior struts, reduce axial compression forces and anterior shear stresses on the cervical spine. This biomechanical unloading is critical post-surgery or for fracture healing. Pressure Distribution : Properly fitted orthoses distribute pressure across bony landmarks (occiput, mandible, sternum, and thoracic spine), minimizing localized pressure sores while maintaining immobilization. 22 Ivancic, P. C. (2013). Effects of cervical orthoses on neck biomechanical responses during transitioning from supine to upright. Clinical Biomechanics, 28(3), 239-245.

23. CONTD… 4.SKELETAL FIXATION : It is a surgical procedure by which spine is stabilize by external device fitted on the skull . Pins are passed through the outer table of skull to stabilize cervical spine. They are connected to TC DLSO by means of uprights . Provide 95-100% stability .Very much effective for immobilization . 23

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25. Soft Collars Description : Made of polyurethane foam rubber covered in cloth Features : Flexible, easy to wrap, secured with Velcro Indications : Kinesthetic reminder post-surgery, gentle support after soft tissue injury, transition between rigid orthosis and no orthosis Biomechanical principle : Kinesthetic reminder. 25 Fisk, J. R., Lonstein, J. E., & Malas, B. S. (2017). Atlas of spinal orthotics. American Academy of Orthotists and Prosthetists. Cohen, S. P., & Hooten, W. M. (2017). Advances in the diagnosis and management of neck pain. BMJ, 358, j3221. https://doi.org/10.1136/bmj.j3221

26. Rigid (Semi-Rigid) Collars 26

27. Types of Rigid Collars Philadelphia Cervical Collar : Description : Two pieces of Plastazote ® with Velcro fasteners, ventral and dorsal plastic struts Indications : Trauma situations, extrication collar. Biomechanical Principle : Motion restriction. 27 Fisk, J. R., Lonstein, J. E., & Malas, B. S. (2017). Atlas of spinal orthotics. American Academy of Orthotists and Prosthetists. Cohen, S. P., & Hooten, W. M. (2017). Advances in the diagnosis and management of neck pain. BMJ, 358, j3221. https://doi.org/10.1136/bmj.j3221

28. Miami J4 : Description : Firm plastic shell with padded inserts, anterior extension Indications : Increased restriction of cervical flexion Biomechanical Principle: Load redistribution 28 Fisk, J. R., Lonstein, J. E., & Malas, B. S. (2017). Atlas of spinal orthotics. American Academy of Orthotists and Prosthetists. Cohen, S. P., & Hooten, W. M. (2017). Advances in the diagnosis and management of neck pain. BMJ, 358, j3221. https://doi.org/10.1136/bmj.j3221

29. Aspen Collar : Description : Adjustable plastic shell with removable padded inserts, flexible plastic tabs, can be extended to cervico-thoracic orthosis Indications : Increased control of the cervico-thoracic junction 29 Fisk, J. R., Lonstein, J. E., & Malas, B. S. (2017). Atlas of spinal orthotics. American Academy of Orthotists and Prosthetists. Cohen, S. P., & Hooten, W. M. (2017). Advances in the diagnosis and management of neck pain. BMJ, 358, j3221. https://doi.org/10.1136/bmj.j3221

30. Malibu Brace : Description : Firm plastic shell with interior padding, adjustable straps Indications : General cervical immobilization 30 Fisk, J. R., Lonstein, J. E., & Malas, B. S. (2017). Atlas of spinal orthotics. American Academy of Orthotists and Prosthetists. Cohen, S. P., & Hooten, W. M. (2017). Advances in the diagnosis and management of neck pain. BMJ, 358, j3221. https://doi.org/10.1136/bmj.j3221

31. NecLoc and Stifneck Collars : NecLoc and Stifneck Collars : Description : Different designs for trauma extrications Indications : Trauma extrications 31 Fisk, J. R., Lonstein, J. E., & Malas, B. S. (2017). Atlas of spinal orthotics. American Academy of Orthotists and Prosthetists. Cohen, S. P., & Hooten, W. M. (2017). Advances in the diagnosis and management of neck pain. BMJ, 358, j3221. https://doi.org/10.1136/bmj.j3221

32. Cervico-thoracic Orthoses (CTOs) Description : Extend further down the trunk for greater stabilization Types : Minerva braces, sterna-occipital-mandibular immobilizer (SOMI), Aspen collar with thoracic extensions Indications : Greater levels of stabilization for cervico -thoracic region 32

33. Types of CTO's Minerva Brace/Jacket Description : Modern version provides higher comfort with padded plastic vest Uses : Stabilization in spinal trauma or infections Indications : Improved end-point control of the head Biomechanical Principles : Motion restriction, Pressure distribution. 33 Hsu, J. D., Michael, J. W., & Fisk, J. R. (2008). AAOS atlas of orthoses and assistive devices (5th ed.). Mosby/Elsevier

34. Sternal-Occipital-Mandibular Immobilizer (SOMI) Brace Description : Rigid three-post cervico -thoracic orthosis Features : Rigid ventral chest piece, shoulder supports, swivel-type occipital pad Indications : Treat stable fractures with minimal displacement, effective in limiting upper cervical spine flexion Biomechanical Principles : Motion restriction, Pressure distribution. 34 Hsu, J. D., Michael, J. W., & Fisk, J. R. (2008). AAOS atlas of orthoses and assistive devices (5th ed.). Mosby/Elsevier

35. Poster Orthoses Description : Control the head with padded mandibular and occipital supports Features : Two to four rigid metal uprights, adjustable leather straps Indications : General head control. Biomechanical Principles : Motion restriction, Pressure distribution. 35 Hsu, J. D., Michael, J. W., & Fisk, J. R. (2008). AAOS atlas of orthoses and assistive devices (5th ed.). Mosby/Elsevier

36. Halo Vests (Casts) Description : Provides greatest immobilization of cervical orthoses Features : Invasive and noninvasive fixation to the skull, modern versions made of titanium and carbon fiber Indications : Immobilization in spinal trauma, tumors, infections, congenital malformations, surgical arthrodesis O nly if stable fracture pattern (intact posterior ligaments & no significant kyphosis). Biomechanical Principles : Skeletal Fixation, Load Redistribution, Motion restriction. 36 Hsu, J. D., Michael, J. W., & Fisk, J. R. (2008). AAOS atlas of orthoses and assistive devices (5th ed.). Mosby/Elsevier

37. Recent advancements in Cervical Orthoses 37

38. 3-D printed Cervical Fixation Orthosis 38 A new design for personalized cervical fixation orthosis was developed using 3D printing technology to provide cervical spine stability and comfort. The orthosis was designed to limit cervical spine movement in any plane, ensuring safety and stability of the cervical spine. The device was created using a combination of 3D scanning and 3D printing technologies, allowing for a customized fit and improved comfort. The orthosis was tested on a 53-year-old woman who had undergone cervical spine surgery and showed no signs of pain or discomfort during wear. The device's advantages include low cost, quick manufacturing time, high precision, and attractive appearance. Xu Y, Li X, Chang Y, Wang Y, Che L, Shi G, Niu X, Wang H, Li X, He Y, Pei B, Wei G. Design of Personalized Cervical Fixation Orthosis Based on 3D Printing Technology. Appl Bionics Biomech . 2022 Apr 30;2022:8243128. doi : 10.1155/2022/8243128. PMID: 35535322; PMCID: PMC9078801.

39. Benefits and Limitations 39

40. 40 Biomechanical Evaluation of Cervical Orthoses

41. Biomechanical analysis of cervical orthoses in flexion and extension: a comparison of cervical collars and cervical thoracic orthoses Gavin, T. M., Carandang , G., Havey, R., Flanagan, P., Ghanayem , A., & Patwardhan, A. G. (2003). Biomechanical analysis of cervical orthoses in flexion and extension: a comparison of cervical collars and cervical thoracic orthoses. Journal of rehabilitation research and development, 40(6), 527–537. https://doi.org/10.1682/jrrd.2003.11.0527 41 Cervical orthoses are devices used to immobilize and protect the cervical spine after injuries or post-operatively. The biomechanics of cervical orthoses involve understanding how they restrict motion and provide stability to the cervical spine. According to the article , the biomechanical analysis of cervical orthoses in flexion and extension was performed using 20 normal volunteer subjects. The study compared the efficacy of two current cervical collars (Aspen and Miami J) and two current CTOs (Aspen 2-post and Aspen 4-post) in reducing the cervical intervertebral and gross range of motion in flexion and extension.

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43. 43 Technique to calculate vertebral angular motion. (a) Digitization of C4 vertebra in neutral posture and (b) digitization of C4 vertebra in fully flexed posture. Angular motion of each of four-line segments between two postures was first calculated. Then four angles were averaged to calculate angular motion of C4 vertebra from neutral to full-flexed posture. Translational motion of each cervical vertebra in (a) extension and (b) flexion. VF allowed continuous tracking of cervical spine throughout complete range of motion. Centroidal motion was measured in millimeters

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45. CONTD. 45

46. Evidence based practice (Case Studies, Research Articles, Pilot studies, Reviews) 46

47. Key Takeaways:- Adding a 3D posture corrective orthotic to a multimodal program is feasible, compliant, and safe for treating chronic nonspecific neck pain. Population: Participants with chronic nonspecific neck pain (CNSNP) Sample size:24 Duration:10 weeks Methods: Randomized Controlled Pilot Study Outcomes: Feasibility, recruitment, adherence, safety, neck pain intensity, neck disability, cervical range of motion, 3D posture parameters. Results: The 3D posture corrective orthotic improved neck disability index scores. 47 Custom 3D Posture Corrective Orthoses

48. The photographs taken using the Global Posture System (GPS). ( A ) Anterior and posterior views. ( B ) Sagittal plane or lateral views. The six reflective markers used in the analysis are: acromion, anterior superior iliac spine, posterior The photographs taken using the Global Posture System (GPS). ( A ) Anterior and posterior views. ( B ) Sagittal plane or lateral views. The six reflective markers used in the analysis are: acromion, anterior superior iliac spine, posterior superior iliac spine, glabella, tragus, C7, and middle sternal notch.superior iliac spine, glabella, tragus, C7, and middle sternal notch. 48

49. Three-dimensional postural parameters of the head region in relation to the thoracic region. Postural rotations ( Rx ,  Ry ,  Rz ). Postural translations ( Tx ,  Tz ). Three-dimensional PCO to perform the mirror image therapy (reverse posture training) while the patient was walking on motorized treadmill. 49

50. Comprehensive review on Spinal Orthotics Cervical orthotics are used to provide initial immobilization of cervical injuries prior to formal evaluation and radiographs. Some injuries, depending on the degree of instability, may be treated with an orthotic device. Common orthotic devices and their indications are reviewed. Many patients treated surgically use postoperative orthotics; controversy exists about whether more extensive stabilization surgery should be done to eliminate the need for post-op bracing and to facilitate acute rehabilitation. Key takeaway: Cervical orthotics can effectively immobilize cervical spine injuries, but extensive stabilization surgery may be necessary for optimal rehabilitation and avoidance of post-operative bracing. Methods: Comprehensive Review 50 Whitcroft , K. L., Masani, L., & Steele, N. (2019). Cervical orthoses: A review of their use, effects and recent developments. Journal of Back and Musculoskeletal Rehabilitation, 32(2), 201-209

51. Experimental study on Sagittal Cervical Posture Corrective Orthotic Device Study Findings: The addition of a Sagittal Cervical Posture Corrective Orthotic Device to a multimodal rehabilitation program improved short- and long-term outcomes in patients with discogenic cervical radiculopathy. Key Benefits: The study suggests that this orthotic device can provide significant benefits for patients with cervical radiculopathy, including improved short- and long-term outcomes. Study Population: The study focused on patients with discogenic cervical radiculopathy, a condition characterized by pain and discomfort in the neck and arm due to disc degeneration. Rehabilitation Program: The study involved a multimodal rehabilitation program, which likely included a combination of physical therapy, exercise, and other interventions 51 Moustafa, I. M., Diab, A. A., Taha, S., & Harrison, D. E. (2016). Addition of a Sagittal Cervical Posture Corrective Orthotic Device to a Multimodal Rehabilitation Program Improves Short- and Long-Term Outcomes in Patients With Discogenic Cervical Radiculopathy.  Archives of physical medicine and rehabilitation ,  97 (12), 2034–2044. https://doi.org/10.1016/j.apmr.2016.07.022

52. 52 Moustafa, I. M., Diab, A. A., Taha, S., & Harrison, D. E. (2016). Addition of a Sagittal Cervical Posture Corrective Orthotic Device to a Multimodal Rehabilitation Program Improves Short- and Long-Term Outcomes in Patients With Discogenic Cervical Radiculopathy.  Archives of physical medicine and rehabilitation ,  97 (12), 2034–2044. https://doi.org/10.1016/j.apmr.2016.07.022

53. 53 Moustafa, I. M., Diab, A. A., Taha, S., & Harrison, D. E. (2016). Addition of a Sagittal Cervical Posture Corrective Orthotic Device to a Multimodal Rehabilitation Program Improves Short- and Long-Term Outcomes in Patients With Discogenic Cervical Radiculopathy.  Archives of physical medicine and rehabilitation ,  97 (12), 2034–2044. https://doi.org/10.1016/j.apmr.2016.07.022

54. Systemic Review study (2013) 54 Rogers, E. J., & Rogers, R. C. (2016). A review of cervical orthoses and their effectiveness in managing cervical spine conditions. Prosthetics and Orthotics International, 40(1), 89-95

55. A comfort assessment of existing cervical orthoses Existing cervical orthoses cause discomfort influenced by design and duration of wear, with design being the more significant factor in discomfort experienced. Population: Healthy adults Sample size:34 Duration:4 hours Methods: Controlled experimental study Outcomes: Discomfort levels and location. Results: Stro II orthosis caused significantly less discomfort than Headmaster and Philadelphia orthoses. 55 Langley, J., Pancani , S., Kilner , K., Reed, H., Stanton, A., Heron, N., Judge, S., McCarthy, A., Baxter, S., Mazzà , C., & McDermott, C. J. (2018). A comfort assessment of existing cervical orthoses. Ergonomics, 61(2), 329–338. https://doi.org/10.1080/00140139.2017.1353137

56. 56 Langley, J., Pancani , S., Kilner , K., Reed, H., Stanton, A., Heron, N., Judge, S., McCarthy, A., Baxter, S., Mazzà , C., & McDermott, C. J. (2018). A comfort assessment of existing cervical orthoses. Ergonomics, 61(2), 329–338. https://doi.org/10.1080/00140139.2017.1353137

57. Conclusion Cervical orthoses, when integrated into multimodal treatment programs, can significantly improve outcomes for patients with specific cervical conditions such as CNSNP, CR, and CGH. However, challenges related to patient discomfort and the varying effectiveness of orthoses across different conditions necessitate careful patient selection and customization of orthotic devices. Further research is needed to optimize orthosis design and expand the evidence base for their use in diverse clinical scenarios. 57

58. References: Hsu, J. D., Michael, J. W., & Fisk, J. R. (2008). AAOS atlas of orthoses and assistive devices (5th ed.). Mosby/Elsevier. Lusardi, M. M., Jorge, M., & Nielsen, C. C. (2020). Orthotics and prosthetics in rehabilitation (4th ed.). Elsevier. Fisk, J. R., Lonstein, J. E., & Malas, B. S. (2017). Atlas of spinal orthotics. American Academy of Orthotists and Prosthetists. Cohen, S. P., & Hooten, W. M. (2017). Advances in the diagnosis and management of neck pain. BMJ, 358, j3221.  https://doi.org/10.1136/bmj.j3221 Whitcroft , K. L., Masani, L., & Steele, N. (2019). Cervical orthoses: A review of their use, effects and recent developments. Journal of Back and Musculoskeletal Rehabilitation, 32(2), 201-209. Rogers, E. J., & Rogers, R. C. (2016). A review of cervical orthoses and their effectiveness in managing cervical spine conditions. Prosthetics and Orthotics International, 40(1), 89-95. Young, I. A., Dunning, J., Butts, R., & Cleland, J. A. (2019). Reliability, construct validity, and responsiveness of the neck disability index and numeric pain rating scale in patients with mechanical neck pain without upper extremity symptoms. Physiotherapy Theory and Practice, 35(12), 1328-1335. Karimi, M. T., & Kamali, M. (2016). The effectiveness of cervical orthoses on cervical spine disorders: A systematic review. Journal of Rehabilitation Sciences and Research, 3(1), 1-6. Langley, J., Pancani , S., Kilner , K., Reed, H., Stanton, A., Heron, N., Judge, S., McCarthy, A., Baxter, S., Mazzà , C., & McDermott, C. J. (2018). A comfort assessment of existing cervical orthoses.  Ergonomics ,  61 (2), 329–338. https://doi.org/10.1080/00140139.2017.1353137 58