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The effect of age and sex on the cervical range of motion A systematic review
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DOI: 10.1016/j.jbiomech.2018.04.047

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Review

The effect of age and sex on the cervical range of motion – A systematic
review and meta-analysis
Fumin Pan a, Rizwan Arshad a, Thomas Zander a, Sandra Reitmaier a, Arno Schroll b, Hendrik Schmidt a,⇑
a
Julius Wolff Institut, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
b
Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Cervical-flexibility examination is routinely performed in neck-pain patients. However, diagnosis of
Accepted 26 April 2018 cervical-flexibility impairment requires physiological reference values, which vary widely among the
population. Although there is a general understanding that the cervical range of motion (RoM) alters with
age and sex, the consolidated details of these variations remain lacking. A systematic review and meta-
Keywords: analysis was performed to evaluate the difference of cervical RoM in different age and sex populations.
Cervical The quality-assessment tool for quantitative studies was applied to assess methodological quality.
Range of motion
We identified 4,034 abstracts through a database search and 3 publications through a manual search.
Age
Sex
Thirty-four cross-sectional studies were selected for the systematic review and measuring technologies
Systematic review were identified. The difference in age descriptions was substantial and a strong discrepancy existed
Meta-analysis between the mobility measured by radiological and non-radiological devices. Therefore, only 11 non-
radiological studies with similar age descriptions were selected for meta-analysis. Cervical RoMs varied
considerably among the populations and generally decreased with age. However, this diminishment
started earlier and ended later in males, and was not continuous across age in both sexes. Females nor-
mally displayed a greater RoM than males, except in lateral bending. In young subjects, the difference
between males and females was not significant. For subjects in their 50s, males displayed a non-
significantly greater RoM than females.
The variability of cervical RoMs can be explained by different devices as well as age and sex. However,
the age-dependent reduction is not continuous and differs between males and females. These findings lay
the foundation for a better understanding of the incidence of age- and sex-dependent cervical disorders,
and may have important implications for the long-term success of different clinical interventions.
Ó 2018 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.1. Literature search and inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2. Methodological assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.3. Data extraction and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.4. Data synthesis and meta-analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3. Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.1. Search procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2. Characteristics and quality of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.3. Differences between radiological and non-radiological devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.4. Effect of age on the ‘‘half-cycle” RoM (sex not distinguished) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.5. Effect of age on the ‘‘full-cycle” RoM (sex distinguished). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.6. Effect of sex on the ‘‘full-cycle” RoM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

⇑ Corresponding author at: Julius Wolff Institut, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
E-mail address: hendrik.schmidt@charite.de (H. Schmidt).

https://doi.org/10.1016/j.jbiomech.2018.04.047
0021-9290/Ó 2018 Elsevier Ltd. All rights reserved.
14 F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27

3.7. Effect of age and sex on the couple RoM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
5. Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Appendix A. Supplementary material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1. Introduction
Observation of cervical motion is a basic component of the
physical examination of patients suffering from neck pain
(Dvorak et al., 1992; Hogg-Johnson et al., 2008; Hole et al., 1995;
Hoy et al., 2010), which is partly due to a common belief that cor-
recting motion aberrations and restoring functional capacity can
reduce pain (Gao et al., 2013). The examination typically includes
basic kinematic assessments, including the voluntary range of
motion (RoM) in flexion, extension, lateral bending, and/or axial
rotation. A multitude of studies report a reduced cervical RoM in
neck-pain patients (Falla et al., 2017; Machino et al., 2016;
Mohammad et al., 2015; Rutledge et al., 2013). However, the
reported measurements vary considerably (Doriot and Wang,
2006), mainly because of differences in inclusion criteria for symp-
tomatic and asymptomatic subjects, measurement instruments
(radiological or non-radiological), setups (constrained or uncon-
strained), protocols, and individual differences. When clinicians
aim to ‘normalize’ dysfunctional motion, however, an empirical
basis for differentiating between normal and dysfunctional motion
is needed, and in determining whether correction of dysfunctional
motion might reduce pain and activity limitation.
While the majority of the literature reports a reduced RoM with
increasing age (Lansade et al., 2009; Lind et al., 1989; Nilsson et al.,
1996; Seacrist et al., 2012; Swinkels and Swinkels-Meewisse,
2014), few failed to identify a significant age effect (Mayer et al.,
1993; Tommasi et al., 2009). Similar controversial results can be
seen for sex differences. Several studies stated that females have
a greater cervical RoM than males (Castro et al., 2000; Dvorak
et al., 1992; Kuhlman, 1993; Nilsson et al., 1996; Peolsson et al.,
2000; Schöps et al., 1997; Wolfenberger et al., 2002; Youdas
et al., 1992), whereas others reported no significant difference
between the sexes (Feipel et al., 1999; Hole et al., 1995; Mayer
et al., 1993; Trott et al., 1996; Walmsley et al., 1996). Therefore,
the influence of age and sex on the cervical RoM still merits discus-
sion. Consequently, a general inference on the impact of age and
sex could not be drawn until the present.
Functional x-rays have long been the gold standard for deter-
mining functional deficits, because they can directly expose
anatomical structures and provide objective and reliable RoM
results (except in the axial plane) (Liu et al., 2015; Machino
et al., 2016; Park et al., 2014; Wolfenberger et al., 2002; Yukawa
et al., 2012). However, a frequent use of this technology is ethically
illicit in both neck-pain patients for closed-meshed monitoring of a
treatment success and asymptomatic individuals for collecting
normative (reference) data. Therefore, multiple non-radiological
devices have been developed in recent years, including goniome-
ter, inclinometer, electromagnetic, ultrasonic, and optoelectronic
systems (Weerts et al., 2017; Williams et al., 2010). Here, the ques-
tion arises, whether these measurement instruments (radiological
and non-radiological) lead to comparable results of cervical RoMs
in different anatomical planes.
In this systematic review, we first aim to create a normative
(reference) database of cervical RoM data of asymptomatic individ-
uals and categorize them into different sex- and age-dependent
classes. Secondly, we analyze the differences in the outcome
between radiological and non-radiological methods. In a meta-
analysis, we further aim to determine the influence of age and
sex on the cervical RoM assessed by non-radiological methods.
2. Materials and methods
This review was performed in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) statement (Moher et al., 2009).
2.1. Literature search and inclusion criteria
The electronic databases PubMed, EMBASE and Web of Science
were searched using combinations of the terms shown in Fig. 1
from inception to April 2018. A manual search of bibliographies
and references was conducted to include possible studies not cap-
tured by the electronic search. The following criteria were applied

Fig. 1. Searching strategy.

 F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27 15

to determine the eligibility of each study for inclusion in the sys-
tematic review: (1) having assessed asymptomatic subjects with-
out neck pain or stiffness; (2) having measured the cervical RoM
in different age and sex groups; (3) studies with adult participants
(
18 years); (4) studies concerning active cervical RoM (subject
controlled), which reflects the subject’s ability to move his/her
head with muscular effort. Passive RoM is tester controlled during
the measurement and reflects the limits of RoM set by passive
structures such as joint capsule, tendons, and bony structures.
Multiple studies have proved that the passive RoM is much greater
than the active RoM and depends on the applied force and pain-
tolerance level (Dvorak et al., 1992; Hakkinen et al., 2007;
Nilsson et al., 1996; Salo et al., 2009). For subsequent meta-
analysis, we only included papers with similar age descriptions
(20s, 30s, 40s, 50s and 60s).
Study eligibility was assessed by two independent authors. The
main difference of opinion for inclusion would be discussed and a
third review author facilitated consensus. No data was considered
more than once to avoid duplication.
2.2. Methodological assessment
Quality assessment of the included studies was performed inde-
pendently by two authors using the Effective Public Health Practice
Project (EPHPP), the quality assessment tool for quantitative stud-
ies (http://www.ephpp.ca/tools.html), developed by the Effective
Public Health Practice 2003, Canada (Jackson and Waters, 2005).
2.3. Data extraction and management
Data for means and standard deviations (SDs) of the cervical RoM
in different age groups, sex and sample size were extracted from
reported values or figures in selected studies. For the ‘‘full-cycle”
RoM (flexion plus extension, bilateral bending and biaxial rotation),
the data of males and females were separately collected. For the
‘‘half-cycle” RoM (only flexion, extension, left or right lateral bend-
ing, left or right axial rotation), we did not discriminate the sexes
because of a lack of a sufficient number of studies. Unpublished
data discussed in the text was requested from the original authors,

Records idenfied through

Idenficaon

database searching: PubMed Addional records idenfied

(1302), EMBASE (1763), Web of through other sources
science (969) (n = 3)

Records aer duplicates removed

(n = 2715)
Screening

Records screened Records with irrelevant topics

(n = 2715) excluded (n = 2523)

Full-text arcles excluded:

Full-text arcles assessed Have not separated age (98);
for eligibility
Eligibility

Irrelevant topic (48);

(n = 192) Studies on children (8);
Studies on passive RoM (3);
No full text (1).
Studies included in Total = 158
systemac review and
qualitave synthesis
(n = 34)
Included

Non-radiological studies
with similar age
descripons included in
quantave synthesis
(meta-analysis)
(n = 11)

Fig. 2. PRISMA flowchart for eligible study selection process.

Table 1

16
Characteristics of included studies for cervical range of motion (RoM) change with age and sex.

Author (year) Country n Sex Age Device Original Level Warm-up Gender Half- or Full- Primary Plane Coupled Result
Category Posture Exercise Seperated Cycle RoM Measured Motion
Measured
Lemmers et al. (2018) Netherlands 50 m 18–25 Electromagnetic Sitting Head- Y N Full & Half Sagittal Y Significant decrease in cervical
50f 26–35 system neutral Thorax Coronal RoM with age
36–45
46–55
56–65

66
a
Alahmari (2017) Saudi 233 m 10–19 Digital Sitting Head- NA Y Half Sagittal N Significant decrease in cervical
Arabia 20–29 inclinometer neutral Thorax Coronal RoM with age
30–39 Transverse
40–49
50–59
60–69
70–80
Machino et al. (2016) Japan 642 m 20–29 X-ray Standing C2-7 N Y Half Sagittal N Significant difference in cervical
383f 30–39 neutral RoM with sex;

F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27

40–49 Significant decrease in cervical
50–59 RoM with age
60–69
70–79
Niederer et al. (2015) Germany 64 m 20–29 Zebris Sitting Head- NA N Full Sagittal N Significant decrease in cervical
36f 30–39 neutral shoulder RoM with age
40–49
50–59
60–69

70
Liu et al. (2015) China 84 m 20–29 X-ray Standing C2-7 N N Half Sagittal N Significant decrease in cervical
128f 30–39 neutral RoM with age
40–49
50–59
60–69
70–79
Hwang and Jung (2015) Korea 20f 20–29 VICON Standing Occ-T1 Y Y Full Sagittal N No significant difference in cervical
20 m 52–63 neutral Coronal RoM with sex;
Transverse Significant decrease in cervical
RoM with age
Swinkels and Swinkels- Netherlands 200f 20–29 CROM Sitting Head- Y N Half Sagittal N Mostly significant decrease in
Meewisse (2014) a 200 m 30–39 neutral Thorax Coronal cervical RoM with age
40–49 Transverse
50–59
Park et al. (2014) Korea 30 m 20–29 X-ray Standing C2-7 N N Half Sagittal N Significant decrease in cervical
74f 50–59 neutral RoM with age
Yukawa et al. (2012) Japan 616 m 20–29 X-ray Standing C2-7 N Y Half Sagittal N Mostly no significant difference in
614f 30–39 neutral cervical RoM with sex;
40–49 Significant decrease in cervical
50–59 RoM with age
60–69
70–79
 a
Ramiro et al. (2012) Netherlands 200 m 20–29 Goniometer Sitting Head- NA N Half Axial N Significant decrease in cervical
193f 30–39 neutral Thorax axial rotation with age
40–49
50–59
60–69
Whitcroft et al. (2010) UK 50 m <30 CROM Sitting Head- Y Y Overall RoM Sagittal N Mostly significant difference in
50f 30–40 neutral Thorax Coronal cervical RoM with sex;
40–50 Transverse Significant decrease in cervical
50–60 RoM with age
>60
Tommasi et al. (2009) Italy 63f 15–18 Optoelectronic Sitting Occ-T1 Y Y Full Sagittal Y No significant decrease in cervical
20–30 system neutral Coronal RoM with age
35–45 Transverse
a
Lansade et al. (2009) France 70f 20–29 Infra-red system Sitting Head- NA Y Full Sagittal Y Mostly no significant difference in
70 m 30–39 neutral Thorax Coronal cervical RoM with sex;
40–49 Transverse Significant decrease in cervical
50–59 RoM with age
60–69
70–79
>80
Demaille-Wlodyka et al. France 232 15–24 Zebris Sitting Head- N N Full Sagittal Y Significant decrease in cervical

F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27

(2007) 25–34 neutral shoulder Coronal RoM with age
35–44 Transverse
45–54
55–65
>65
Cagnie et al. (2007) Belgium 48 m 20–34 Zebris Sitting Head- Y Y Full Sagittal N No significant difference in cervical
48f 35–49 neutral shoulder Coronal RoM with sex;
50–64 Transverse Significant decrease in cervical
RoM with age
Malmstrom et al. Sweden 60f 20–29 Zebris Sitting Head- Y Y Half Sagittal Y Significant difference in cervical
(2006) a 60 m 30–39 neutral shoulder Coronal range of extension with sex;
40–49 Transverse Significant decrease in cervical
50–59 RoM with age except flexion
60–69
70–79
Doriot and Wang France 20f 20–35 VICON Sitting Head- NA Y Half Sagittal N No significant difference in cervical
(2006) 21 m 65–80 neutral Thorax Coronal RoM with sex;
Transverse Significant decrease in cervical
RoM with age
Wang et al. (2005) Taiwan 80 20–30 Zebris Sitting Head- NA N Half Sagittal N Significant decrease in cervical
40–65 neutral shoulder Coronal RoM with age
Transverse
Kalscheur et al. (2003) USA 25 m 65 Plastic Sitting Head- NA Y Half Sagittal N Significant difference in cervical
61f 70 goniometer neutral Thorax Coronal RoM with sex;
75 Transverse Significant decrease in cervical
80 RoM with age
85

(continued on next page)

17
 18
Table 1 (continued)

Author (year) Country n Sex Age Device Original Level Warm-up Gender Half- or Full- Primary Plane Coupled Result
Category Posture Exercise Seperated Cycle RoM Measured Motion
Measured
Wolfenberger et al. USA 66 m 20–29 Bubble gonimeter Sitting Head- NA Y Full Sagittal N Significant difference in cervical
(2002) a 39f 30–39 neutral Thorax RoM with sex;
40–49 Significant decrease in cervical
RoM with age
Sforza et al. (2002) Italy 70 m 15–16 Optoelectronic Sitting Head- NA Y Full & Half Sagittal Y Significant decrease in cervical
19–25 system neutral Thorax Coronal RoM with age
31–45 Transverse
Peolsson et al. (2000) Sweden 51 m 25–34 CMS device Sitting Head- NA Y Full & Half Sagittal N Significant difference in cervical
50f 35–44 neutral Thorax Coronal RoM with sex;
45–54 Transverse Significant decrease in cervical
55–64 RoM with age
a
Castro et al. (2000) Germany 86f 20–29 Zebris Sitting Head- NA Y Full Sagittal N Mostly significant difference in
71 m 30–39 neutral shoulder Coronal cervical RoM with sex;
40–49 Transverse Mostly significant decrease in
50–59 cervical RoM with age
60–69

F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27

70–79
>80
Feipel et al. (1999) Belgium 157 m 14–19 CA 6000 Sitting Head- NA Y Full & Half Sagittal Y No significant difference in cervical
93f 20–29 neutral Thorax Coronal RoM with sex;
30–70 Transverse Significant decrease in cervical
RoM with age
a
Schöps et al. (1997) Germany 115 m 20–29 Goniometer Sitting Head- NA Y Full Sagittal N Significant difference in cervical
105f 30–39 neutral Thorax Coronal RoM with sex;
40–49 Transverse Mostly significant decrease in
50–59 cervical RoM with age
60–69
>70
Walmsley et al. (1996) Canada 30 m 18–30 3 SPACE Isotrak Sitting Forehead- NA Y Full Axial N No significant difference in cervical
30f 50–65 system neutral Sternum RoM with sex;
Significant decrease in cervical
RoM with age
a
Trott et al. (1996) Australia 60f 20–29 3 SPACE Isotrak Sitting Forehead- NA N Half Sagittal Y Significant decrease in cervical
60 m 30–39 system neutral C7 Coronal RoM with age
40–49 Transverse
50–59
Schenkman et al. (1996) USA 31 m 20–40 CROM Sitting Head- NA N Half Sagittal N Significant decrease in cervical
26f 60–74 neutral Thorax Coronal RoM with age

75 Transverse
a
Hole et al. (1995) UK 44 m 20–29 CROM Sitting Head- Y Y Half Sagittal N No significant difference in cervical
40f 30–39 neutral Thorax Coronal RoM with sex;
–4950– Transverse Significant decrease in cervical
59 RoM with age
60–69
Netzer and Payne USA 55 m 6–8 Two-dimensional Sitting Head- N Y Half Coronal N No significant difference in cervical
(1993) 55f 12–15 video system neutral Thorax Axial RoM with sex;
20–30 Mostly significant decrease in
40–50 cervical RoM with age
60–80
 Mayer et al. (1993) USA 28 m 50% Electronic Sitting Occ-T1 NA Y Half Sagittal N No significant difference in cervical
30f young inclinometer neutral Coronal RoM with sex;
50% old Transverse No significant decrease in cervical
RoM with age
Kuhlman (1993) Scotland 33 m 20–30 Gravity Sitting Head- NA Y Half Sagittal N Significant difference in cervical
40f 70–90 goniometer neutral Thorax Coronal RoM with sex;
Transverse Significant decrease in cervical
RoM with age
a
Youdas et al. (1992) USA 171f 11–19 CROM Sitting Head- NA Y Half Sagittal N Mostly significant difference in
166 m 20–29 neutral Thorax Coronal cervical RoM with sex;
30–39 Transverse Mostly significant decrease in
40–49 cervical RoM with age
50–59
60–69
70–79
80–89
90–97
Lind et al. (1989) Sweden 35 m 12–19 X-ray & Compass Sitting occiput-C7 N Y Half & Full Sagittal N No significant difference in cervical
35f 20–29 neutral Coronal RoM with sex;
30–39 Transverse Mostly significant decrease in
40–49 cervical RoM with age

F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27

50–59
60–69
70–79

n: Number of subjects
a
Studies included for meta-analysis; CROM: Cervical range of motion device; CMS: Cervical measurement device; m: Males; f: Females; NA: Not available; Y:Yes; N: No

19
20 F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27

Table 2
Quality of studies (n = 34) based on the quality assessment tool for quantitative studies (Jackson and Waters, 2005).

Study Selection Study Confounders Blinding Data Withdrawls Measurement Analysis

Bias design collection and drop-outs integrity
Sample size Significant Appropriate
methods
calculation difference statistic
Lemmers et al. (2018) S M M W W S Y Y Y Y
Alahmari (2017) a M M W W S S Y Y Y Y
Machino et al. (2016) S M M W S S Y Y Y Y
Niederer et al. (2015) S M S W S S Y Y Y Y
Liu et al. (2015) S M M W S S Y Y Y Y
Hwang and Jung W M S W S S Y Y Y Y
(2015)
Swinkels and S M W W M S Y Y Y Y
Swinkels-
Meewisse (2014)a
Park et al. (2014) S M M M S S Y Y Y Y
Yukawa et al. (2012) S M M W S S Y Y Y Y
Ramiro et al. (2012)a M M W W S S Y Y Y Y
Whitcroft et al. (2010) M M S W S S Y Y Y Y
Tommasi et al. (2009) M M S W S S Y Y Y Y
Lansade et al. (2009) a M M W W S S Y Y Y Y
Demaille-Wlodyka S M S W W S Y Y Y Y
et al. (2007)
Cagnie et al. (2007) M M S W S S Y Y Y Y
Malmstrom et al. M M S W S M Y Y Y Y
(2006)a
Doriot and Wang M M S W S S Y Y Y Y
(2006)
Wang et al. (2005) M M W W S S Y Y Y Y
Kalscheur et al. (2003) M M W W W S Y Y Y Y
Wolfenberger et al. M M W W M S Y Y Y Y
(2002)a
Sforza et al. (2002) M M M W W S Y Y Y Y
Peolsson et al. (2000) W M M W S S Y Y Y Y
Castro et al. (2000)a S M S W S S Y Y Y Y
Feipel et al. (1999) S M W W S S Y Y Y Y
Schöps et al. (1997)a M M M W S S Y Y Y Y
Walmsley et al. (1996) M M W W S S Y Y Y Y
Trott et al. (1996)a M M W W S S Y Y Y Y
Schenkman et al. M M M W W S Y Y Y Y
(1996)
Hole et al. (1995)a M M W W S S Y Y Y Y
Netzer and Payne M M W W S S Y Y Y Y
(1993)
Mayer et al. (1993) M M W W M S Y Y N Y
Kuhlman (1993) M M W W W S Y Y Y Y
Youdas et al. (1992)a S M W W S S Y Y Y Y
Lind et al. (1989) M M W W S S Y Y Y Y

Selection bias – Were the selected participants likely to be representative of the target population? Study design – Was the study design method appropriate? Confounders –
Were there important differences between groups prior to the intervention? Blinding – Were the study participants and examiners aware of the research question? Data
collection methods – Was reliability or validity been reported? Withdraws and drop-outs – Were withdrawals and drop-outs reported? Measurement Integrity – Did all
participants undergo the consistent measurement? Statistical Analysis – Were the statistical methods appropriate for the study design?
a
Studies included for Meta-analysis. S: Strong; M: Moderate; W: Weak; Y: Yes; N: No.

if necessary omitted (O’Driscoll and Tomenson, 1982). For two stud-
ies (Hole et al., 1995; Youdas et al., 1992), which presented data for
the ‘‘half-cycle” RoM of both, males and females, we calculated the
mean values (m) and SDs of the pooled sample using the formulas
recommended by the Cochrane Handbook for Systematic Reviews
of Interventions (Higgins and Green, 2011):
m1 n1 þ m2 n2
m¼
n1 þ n2
sffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
ðn1  1ÞSD21 þ ðn2  1ÞSD22 þ nn11þn
SD ¼
2.4. Data synthesis and meta-analysis
Mean values of the cervical RoM as well as the sample size in
each age and sex group were pooled using Review Manager Soft-
ware (RevMan5.3, Copenhagen: The Nordic Cochrane Centre, The
Cochrane Collaboration). The meta-analysis was performed using
a random-effect model for consideration of heterogeneity (incon-
sistency) among studies due to different study designs, methods
and populations. Statistical heterogeneity was evaluated based
on the inconsistency (I2) index, which estimates the percentage
of total variation across studies that is ascribed to heterogeneity;
n2
ðm21 þ m22  2m1 m2 Þ <25% indicates low, 25% to 75% medium and >75% high hetero-
2

n1 þ n2  1 geneity (Higgins et al., 2003). Mean pooled differences ±95% confi-

dence interval (CI) in the cervical RoM between different age and
where mi, ni and SDi (i = 1, 2) are the mean values, numbers of sex groups were presented, with statistical significance defined
subjects and SDs of each sex group. as p < 0.05 calculated by Z-test.
 F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27 21

Fig. 3. Cervical ranges of motion in the sagittal plane of asymptomatic subjects, and comparison between radiological and non-radiological results. a. Cervical Range of
Flexion (RoF), b. Cervical Range of Extension (RoE), c. Cervical Range of Flexion plus Extension (RoFE).

3. Results ‘‘half-cycle” RoM, 10 studies presented the ‘‘full-cycle” RoM, 5

3.1. Search procedure
4034 hits were yielded from database search and 3 from other
sources. In total, 3845 papers were rejected after a duplication
check and title-abstract screening, 192 papers remained. After
reading the full texts, 34 papers met the inclusion criteria and were
included for systematic review. The differences in the description
of the age groups were substantial. Radiological studies usually
measured cervical RoM from C2-7 in the sagittal plane, however,
non-radiological studies measured from head to thorax in all three
anatomical planes. Due to the small number of radiological studies
with heterogeneous age descriptions, only 11 non-radiological
studies with similar age descriptions (20s, 30s, 40s, 50s and 60s)
were included in the meta-analysis. (Fig. 2). The entire body of lit-
erature of the included studies was provided in the Appendix 1.
3.2. Characteristics and quality of studies
The general characteristics of the 34 included studies are
described in Table 1. These studies were conducted in 15 countries,
mostly in Europe (19 studies). The sample size in each study ran-
ged from 40 to 1230, with a total of 6667 participants. 24 studies
have separated sexes. Additionally, 18 studies presented the
studies presented both and one presented the overall RoM. The
quality assessment results are presented in Table 2. All the
included studies were cross-sectional cohort studies with a moder-
ate study design quality. 22 studies described either the reliability
or validity of the measuring devices. The eleven non-radiological
studies in the data pool for meta-analysis showed heterogeneity
(I2) ranging from 0 to 94%, with 11% of all displaying substantial
heterogeneity (I2
75%) and a mean I2 of 31.3%.
3.3. Differences between radiological and non-radiological devices
29 studies used non-radiological devices to assess cervical
RoMs in three planes, whereas only five studies utilized X-ray to
assess cervical RoMs in the sagittal plane. The radiological devices
were usually used to assess RoM from C2-7, however, non-
radiological devices were usually used to assess cervical RoM
between the head and thorax, which might have caused the large
difference between these two categories of devices as shown in
Fig. 3. Furthermore, radiological devices could only measure cervi-
cal RoM in sagittal or coronal planes. Due to these reasons, we con-
sidered only measurements obtained with non-radiological
devices in the following meta-analysis. A database created from
these radiological and non-radiological studies with similar age
descriptions was given in Appendix 2, which was age- and sex-
dependent.
22 F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27

3.4. Effect of age on the ‘‘half-cycle” RoM (sex not distinguished)

<0.00001
<0.00001

<0.00001
<0.00001
<0.00001
<0.00001
<0.0001
p-Value

0.0005

0.001
The results from seven studies were pooled for the age effect on

0.11
the ‘‘half-cycle” RoM (Alahmari, 2017; Hole et al., 1995;
Malmstrom et al., 2006; Ramiro et al., 2012; Swinkels and
Mean ± 95% CI Swinkels-Meewisse, 2014; Trott et al., 1996; Youdas et al., 1992)

11.74 ± 1.95
13.06 ± 1.93
3.39 ± 1.56
8.95 ± 1.59

2.41 ± 1.35

5.19 ± 1.77
8.96 ± 1.95
0.99 ± 1.23

7.81 ± 1.30

4.08 ± 2.50
(Table 3, Fig. 4). Flexion decreased both from the 20s to 30s and
from the 40s to 50s age ranges (p < 0.05). Extension and both-
Right

sides lateral bending decreased continuously from the 20s to the

60s (p < 0.05). Axial rotation did not display any decrease from
the 20s to the 30s. However, it decreased continuously from the
<0.00001
<0.00001

<0.00001
<0.00001

<0.00001
<0.00001
p-Value

30s to the 60s (p < 0.05). With an increase in age of up to two dec-
0.002

0.002
0.11

0.01
ades, the ‘‘half-cycle” cervical RoMs in all three planes decreased
significantly (p < 0.05).
Mean ± 95% CI
Axial rotation

3.5. Effect of age on the ‘‘full-cycle” RoM (sex distinguished)

14.38 ± 2.61

11.94 ± 3.37
1.52 ± 1.89
5.62 ± 3.54
8.43 ± 1.66

3.65 ± 2.34

3.21 ± 2.46
7.95 ± 2.93
7.08 ± 1.42

5.18 ± 2.04

For both males and females, the results from four studies
Left

(Castro et al., 2000; Lansade et al., 2009; Schöps et al., 1997;

Wolfenberger et al., 2002) were pooled for flexion plus extension
and from three studies (Castro et al., 2000; Lansade et al., 2009;
<0.00001
<0.00001
<0.00001

<0.00001
<0.0001

<0.0001
p-Value
0.0001

0.0003

Schöps et al., 1997) for lateral bending and axial rotation (Table 4,
0.002
0.004

Fig. 5). From the 20s to the 30s, the cervical RoM of males
decreased significantly in all directions except lateral bending (p
< 0.01). With a single decade increase from the 30s to the 40s
Mean ± 95% CI

12.92 ± 4.50

and from the 40s to the 50s, males displayed no significant

3.43 ± 1.76
6.39 ± 1.67
9.31 ± 2.33

2.97 ± 1.34

2.23 ± 1.41
5.33 ± 3.61
3.58 ± 1.95
5.54 ± 2.05
8.60 ± 4.06

decrease of the cervical RoM in all three planes. The greatest

Right

decrease of the cervical RoM in males occurred from the 50s to

the 60s in all directions (p < 0.0001). Interestingly, from the 20s
to the 30s, there was no significant decrease in the sagittal or coro-
<0.00001
<0.00001
<0.00001

<0.00001

<0.00001

nal planes in females, which was the same from the 50s to the 60s.
<0.0001
p-Value
0.0005

0.005

0.001

0.007

Both from the 30s to the 40s and the 40s to the 50s, the cervical
Mean and 95% confidence interval (CI) difference (°) of ‘‘half-cycle” cervical range of motion between two age groups.

RoM in females decreased significantly in all directions (p < 0.05).

The range of axial rotation decreased continuously in females (p
Lateral bending

Mean ± 95% CI

< 0.05). The greatest decrease of the cervical RoM in females

13.31 ± 5.81
3.78 ± 2.13
5.86 ± 1.94

5.31 ± 1.57

3.13 ± 1.88
6.24 ± 2.72
4.39 ± 3.21
9.40 ± 2.74

1.99 ± 1.40

9.11 ± 4.09

occurred from the 40s to the 50s in all directions (p < 0.05). For
both sexes, with an increase in age of up to two decades, the cer-
Left

vical RoM decreased significantly except for flexion–extension in

males between their 30s and 50s (p < 0.05).
<0.00001
<0.00001
<0.00001

<0.00001
p-Value

3.6. Effect of sex on the ‘‘full-cycle” RoM

0.0004
0.0003

0.003
0.002

0.17
0.03

Results from four studies were pooled for ‘‘full-cycle” cervical

RoM differences between males and females in each age group
Mean ± 95% CI

21.67 ± 11.88

(Castro et al., 2000; Lansade et al., 2009; Schöps et al., 1997;

11.52 ± 2.85

12.82 ± 8.47
15.30 ± 3.96

3.18 ± 1.71

2.77 ± 1.78

4.81 ± 6.85
8.45 ± 3.09

6.05 ± 1.78

9.30 ± 8.36
Extension

Wolfenberger et al., 2002) (Table 5, Fig. 6). Males and females in

their 20s displayed no significant difference in all planes. In both
the 30s and 40s age groups, males displayed a smaller RoM of flex-
ion–extension and axial rotation than females (p < 0.05). By con-
<0.00001
<0.00001

<0.00001
<0.00001

trast, males in their 50s displayed a greater RoM than females in

p-Value

all three planes, although not statistically significant. Males in their

0.002
0.001

0.004
0.92

0.11
0.01

60s again displayed a smaller RoM than females in the sagittal

plane (p < 0.05).
Flexion-extension

Mean ± 95% CI

3.7. Effect of age and sex on the couple RoM

9.34 ± 3.49

3.69 ± 1.51

3.25 ± 2.21
4.60 ± 2.96

2.09 ± 2.58
8.18 ± 2.60

5.27 ± 2.07

4.22 ± 3.20
0.08 ± 1.53
4.99 ± 3.00
Flexion

Eight studies have investigated the effect of age and sex on the
coupled RoM as shown in Table 1 and Appendix 3. Results of these
studies are substantial different. Primary movement in the sagittal
Group 2

plane was accompanied with slight coupled lateral bending or

30s
40s
50s
60s
40s
50s
60s
50s
60s
60s

axial rotation. Some studies found that coupled motion was most
evident during primary movements in the coronary and transvers
Age group

planes. During lateral bending or axial rotation, age usually

Group 1

showed a significant effect on coupled RoM (p < 0.05) but not

Table 3

20s

30s

40s

50s

sex. However, the effect of age was not continuous and differed
among studies.
 F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27
Fig. 4. The effect of age on ‘‘half-cycle” cervical ranges of motion in three planes. r Mean pooled difference (°); Whiskers: 95% confidence interval (°); * p < 0.05.
4. Discussion
This literature review aimed to collect information concerning
cervical spine kinematics of asymptomatic subjects. Given suffi-
cient homogenous data with similar age descriptions, a meta-
analysis was conducted. The results show a strong discrepancy in
the obtained RoMs between radiological and non-radiological
measurements. For example, when females aged 20–29 years per-
formed a flexion, radiological devices result in an up to 35° smaller
RoM than non-radiological devices (Fig. 3a), mainly because that
radiological measurements normally assessed the RoM from C2–
7, whereas non-radiological devices mostly assess the cervical
RoM between the head and thorax. However, whether there are
other additional factors could not be clarified because no study
in this review used both radiological and non-radiological devices
within the same cohort or measured at the same spinal levels to
allow a direct comparison.
Radiological studies can only assess the cervical RoMs in the
sagittal or coronal planes, but not in the axial plane, and are rela-
tively laborious in a clinical setting. Furthermore, the radiation
exposure limits the usage of these devices. Therefore, it is very
important to generate a normative reference database of cervical
RoMs assessed by non-radiological devices for asymptomatic indi-
viduals as well as for neck-pain patients during follow-up. In this
study, we created such a database and categorized them into dif-
ferent sex- and age-dependent classes, which is given in Appendix
2. This database can be used as a reference tool to diagnose dys-
functional motion in patients with neck diseases and to evaluate
whether a surgical or non-surgical correction reduces the dysfunc-
tional motion.
As reported, age and sex are two main factors influencing the
cervical RoM and have been investigated over many decades
(Castro et al., 2000; Chen et al., 1999; Demaille-Wlodyka et al.,
2007; Dvorak et al., 1992; Feipel et al., 1999; Hole et al., 1995;
Lansade et al., 2009; Liu et al., 2015; Machino et al., 2016;
Malmstrom et al., 2006; Netzer and Payne, 1993; Niederer et al.,
2015; Nilsson et al., 1996; Schenkman et al., 1996; Schöps et al.,
1997; Sforza et al., 2002; Swinkels and Swinkels-Meewisse,
23
2014; Trott et al., 1996; Wang et al., 2005; Whitcroft et al., 2010;
Youdas et al., 1992; Yukawa et al., 2012). Chen et al. (1999) in their
review indicated a consistent tendency for the cervical RoM to
decrease with age. However, the authors did not present quantita-
tive data to confirm whether this tendency is continuous with age
and differs between sexes. Furthermore, there remains consider-
able disagreement over the effect of sex on the cervical RoM
(Cagnie et al., 2007; Hwang and Jung, 2015; Kalscheur et al.,
2003). In the present study, we provided consolidated details on
the change in the cervical RoM with age and sex. We demonstrated
that across the 20s to 60s age categories, both the ‘‘half-cycle” and
‘‘full-cycle” cervical RoMs displayed a decrease in RoMs in all
planes, which might arise from spine degeneration with aging
(Machino et al., 2016; Okada et al., 2009; Simpson et al., 2008;
Yukawa et al., 2012). However, the decrease of the ‘‘full-cycle” cer-
vical RoM in both males and females was not continuous with age.
There were two neighbor age groups that displayed no significant
differences in the RoM between each other and age groups that
displayed a large significant reduction in the RoM (up to 15°).
These findings may result from a variety of factors, including dif-
ferent occupational patterns (e.g., females on average work fewer
hours per job than males) (Locke et al., 2014), anatomical structure
(e.g., males have smaller upper cervical lordosis and greater lower
cervical lordosis than females) (Been et al., 2017), and daily activ-
ities (e.g., males spend more time than females in moderate and
vigorous physical activity) (Hagstromer et al., 2007) between
males and females.
Regarding the effect of sex on the cervical RoM, there was no
significant difference in the 20s age group, because the youngest
age group in most populations displayed the greatest mobility.
Males in their 30s and 40s displayed less mobility than females
in sagittal and axial motions. It is interesting to note, that males
in their 50s displayed greater mobility, although not significant,
than females. It could be hypothesized that the females during this
age range underwent menopause, which could decrease spine
mobility (Cunha-Henriques et al., 2011; Kyllonen et al., 1998).
After this period, females in their 60s again displayed greater cer-
vical mobility than males.
 24 F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27

The coupled motion results differed a lot among studies.

<0.00001
<0.00001

<0.00001
p-Value Primary movement in the sagittal plane was only accompanied

0.0006
0.003
0.007

0.009
0.007
wth slight coupled motion, but not in the coronary and trans-

0.93
0.1
vers planes. Sex usually did not alter coupled motion behaviors
but age did. However, we could not quantify the effect of age on
Mean ± 95% CI

coupled motion in this review due to heterogeneous data. In

13.27 ± 9.59
15.59 ± 4.71
23.32 ± 4.36

17.40 ± 4.86
5.49 ± 3.58

9.83 ± 5.64

7.52 ± 5.62
7.69 ± 5.64
0.25 ± 5.87
6.84 ± 8.20 several studies, the younger and older subjects tended to have
greater coupled motion than the mid-aged subjects did
Male

(Demaille-Wlodyka et al., 2007; Feipel et al., 1999; Malmstrom

et al., 2006; Sforza et al., 2002; Trott et al., 1996). This might
be because the younger subjects showed least stiffness in the
<0.00001
<0.00001
<0.00001

<0.00001
<0.00001

<0.0001
p-Value

musculoskeletal system and could perform the largest motion

0.009

0.006

0.02

0.02

in all planes. One possible explanation for changes in the elderly

is a more pronounced flexed cervical spine and, thereby, more
coupled flexion (Panjabi et al., 1993). The authors also assume
Mean ± 95% CI
Axial rotation

that the elderly subjects showed less stability of the whole

14.25 ± 4.76
21.83 ± 5.87

22.15 ± 7.35
30.76 ± 9.03

15.07 ± 6.06

16.08 ± 7.80
5.58 ± 4.17

7.97 ± 5.64

7.23 ± 6.26
8.30 ± 6.95

body. During the movement to one plane, the subjects have to

Female

perform compensating movement to the other planes for global

balance.
A number of limitations may have influenced our conclusions.
Inevitably, we could not avoid the risk of an incomplete literature
<0.00001
<0.00001
<0.00001
p-Value

0.0005

search and publication bias. Secondly, there was considerable vari-

0.62

0.13
0.09

0.05
0.03

0.04

ation in the devices used for non-radiological measurements,

including in their reliability and validity, we could not quantify
the difference because of a limited number of studies for a single
Mean ± 95% CI

15.67 ± 14.24

11.79 ± 6.61
18.32 ± 5.05
25.39 ± 5.01
3.07 ± 12.06
12.09 ± 5.04

device, and could only assign them to two categories (radiological

7.62 ± 8.72

8.75 ± 8.71

6.61 ± 6.25
5.03 ± 6.46

and non-radiological). Furthermore, a major source of uncertainty

Male

is in the cervical RoM levels that have been determined in different

studies. An additional possible source of error is that the measure-
ment protocols among studies were different like the original
<0.00001
<0.00001

<0.00001
<0.00001

starting position. For example, Kuhlman (1993) utilized a gravity

<0.0001

<0.0001
p-Value

0.0002

goniometer to define the anatomical zero position. Malmstrom

0.27

0.43
0.02
Mean and 95% confidence interval (CI) difference (°) of ‘‘full-cycle” cervical range of motion between two age groups.

et al. (2006) asked the subjects to assume a posture in which the

center of mass was projected near tuber ischia. Cagnie et al.
Lateral bending

Mean ± 95% CI

(2007) defined the zero position as the anatomical position of the

17.78 ± 5.48
19.88 ± 6.49

12.32 ± 5.91
22.56 ± 5.01
10.43 ± 4.72
20.48 ± 4.39

10.47 ± 5.57
7.36 ± 5.99

2.24 ± 5.54
2.30 ± 4.06

head (vertically upright without rotation), and was subjectively

Female

determined by each subject. Some studies asked the subjects to

look straight ahead (Lansade et al., 2009; Sforza et al., 2002). All
of the limitations above could together cause the large range of
heterogeneity in our study. We must be aware that all the included
<0.00001

<0.00001

<0.00001
p-Value

studies are cross-sectional studies. Due to the heterogeneity

0.007

0.008

0.001
0.67
0.35

0.55
0.01

among population, the most reliable results concerning the effect

of age on cervical RoM should be from a longitudinal study with
a large homogenous cohort and a long follow-up. Thus, further
Mean ± 95% CI

22.82 ± 16.96
19.20 ± 13.99
13.01 ± 10.14

34.10 ± 10.44

18.44 ± 5.82
14.55 ± 8.88
5.92 ± 12.34
2.90 ± 13.18

studies need to be conducted.

7.73 ± 3.24

2.38 ± 7.80

Despite these limitations, a greater understanding of our find-

ings could provide clinicians with insights into the following
Male

points: There are major differences of measured cervical RoMs

between radiological and non-radiological devices. Loss of cervi-
<0.00001
<0.00001

cal RoM in healthy individuals with aging could also be expected.

<0.0001
p-Value

0.003

0.002

Cervical RoMs determined at a given point in age can now be

0.36

0.76
0.04

0.02
0.02

used to predict mobility for decade age increments within each

Flexion-extension

sex category. Evidence from this review demonstrates age-

Mean ± 95% CI

related reductions in cervical mobility, albeit in a non-

21.88 ± 18.52
22.17 ± 10.93

12.48 ± 10.71
14.12 ± 9.21
26.49 ± 5.27

14.16 ± 8.86
1.55 ± 10.15
30.00 ± 7.94
3.90 ± 8.36

9.03 ± 8.83

continuous manner, most evident after approximately 40 years

of age for females and after 50 years for males. These patterns
Female

of cervical RoM reduction with age could serve for distinguishing

pathological or aging degeneration, for evaluation of impairment,
for evaluation of treatment efficacy, and for determining inter-
Group 2

vention outcome as well as for generating computational models

30s
40s
50s
60s
40s
50s
60s
50s
60s
60s

and developing spinal implants. However, it remains unknown

whether such decreases in the RoM are inevitable or irreversible
Age group

and further research could focus on maintaining or enhancing

Group 1

cervical mobility with aging through appropriate exercise or

Table 4

20s

30s

40s

50s

therapy
 F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27 25

Fig. 5. The effect of age on ‘‘full-cycle” cervical ranges of motion in three planes. r Mean pooled difference (°); Whiskers: 95% confidence interval (°); * p < 0.05.

Table 5
Mean and 95% confidence interval (CI) difference (°) of ‘‘full-cycle” cervical range of motion (RoM) between males and females.

Age Group Flexion-extension Lateral bending Axial rotation

Mean ± 95% CI p-Value Mean ± 95% CI p-Value Mean ± 95% CI p-Value
20s 0.86 ± 4.15 0.68 0.34 ± 2.76 0.81 -4.74 ± 5.45 0.09
30s 9.16 ± 3.56 <0.00001 -2.59 ± 4.30 0.24 -6.18 ± 4.53 0.007
40s 5.75 ± 4.92 0.02 -2.65 ± 6.43 0.42 -5.47 ± 5.45 0.05
50s 5.47 ± 12.53 0.39 3.24 ± 5.73 0.27 1.68 ± 6.10 0.59
60s 7.39 ± 6.32 0.02 -1.63 ± 6.15 0.6 3.50 ± 11.72 0.56

If mean difference <0°, it represents males have a smaller RoM than females; if mean difference >0°, it represents males have a larger RoM than females.

Fig. 6. The effect of sex on ‘‘full-cycle” cervical ranges of motion (RoM) in three planes. r Mean pooled difference (°); Whiskers: 95% confidence interval (°); * p < 0.05.

5. Conclusions (4) a significant reduction of RoMs with an one-decade age

increase exists in males from their 20s to 30s and 50s to
This review/meta-analysis shows that 60s and in females from their 30s to 40s and 40s to 50s,
(5) an age- and sex-dependent database concerning cervical
(1) a strong discrepancy exists in obtained RoMs between radi- RoMs was created and further functional diagnoses of cervi-
ological and non-radiological measurements, cal spine should be age and sex controlled.
(2) a significant difference of RoMs between sexes only exists
for the age ranges 30s and 40s,
Conflict of interest
(3) a significant reduction of RoMs with up to a two-decades age
increase exists both in males and females,
The authors declare that they have no conflict of interest.
26 F. Pan et al. / Journal of Biomechanics 75 (2018) 13–27

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