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EFEECTS OF WEARING HIJAB ON CERVICAL SPINE MOBILITY
Submitted by
Hajrah Mohammad Hafeez
In the partial Fulfillment for the Degree of
Doctor of Physical Therapy
SUPERVISOR:
Dr Umair Ahmed
Assistant Professor
University Institute of Physical Therapy
Faculty of Allied Health Sciences
THE UNIVERSITY OF LAHORE
2018
(Date font size 14)
The University of Lahore
Faculty of Allied Health Sciences
University Institute of Physical Therapy (UIPT)
Supervisory Committee
We the Supervisory Committee, certify that the contents and the form of thesis submitted by (Student Name) have been found satisfactory and recommend it for the evaluation of the External Examiner for the award of degree of M.Phil / PhD (Discipline)
Supervisor Dr Umair Ahmed
Assistant Professor
Co-Supervisor
Member
HOD, University Institute of Physical Therapy
Dr Ashfaq Ahmed
Dean Faculty of Allied Health Sciences
The University of Lahore
Faculty of Allied Health Sciences
University Institute of Physical Therapy (UIPT)
Examination Committee
The Thesis viva of Hajrah Mohammad Hafeez (DPT01133113) was held on at University Institute of Physical Therapy, The University of Lahore. The Supervisory and Examination Committee gave satisfactory remarks on the thesis and viva and were approved for the award of the degree of M.Phil / Ph.D (Discipline)

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HOD, University Institute of Physical Therapy (UIPT)

Dean Faculty of Allied Health Science
The University of Lahore
Faculty of Allied Health Sciences
University Institute of Physical Therapy (UIPT)
Undertaking
I Hajrah Mohammad Hafeez (DPT01133113) declare that the contents of my thesis entitled ” To determine the association of hijab on cervical mobility” are based on my own research findings and have not been taken from any other work except the references and has not been published before. I also undertake that I will be responsible for any plagerization in this thesis.

Hajrah M. Hafeez Student’s Name

The University of Lahore
Faculty of Allied Health Sciences
University Institute of Physical Therapy (UIPT)
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This is to certify that I have examined the Turnitin report of the thesis entitled”
The thesis contains no text that can be regarded as plagiarism.

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Supervisor
TABLE OF CONTENTS
Sr.No. Contents Page No.

1 INTRODUCTION 2 LITERATURE REVIEW 3 OBJECTIVES 4 OPERATIONAL DEFINITION 5 MATERIALS AND METHODS 6 DATA ANALYSIS 7 RESULS 8 DISCUSSION 9 CONCLUSION 10 RECCOMENDATIONS 11 LIMITATIONS 12 REFERENCES 13 APPENDIX ABSTRACT
Background and Introduction
Methods:
Results:
Conclusion:
Key Words:
1.INTRODUCTIONWearing the headscarf is an aspect of a basic religious practice by females in Islamic societies. The headscarf is alluded to the scarf that wraps up on the head and around the neck ADDIN EN.CITE <EndNote><Cite><Author>Haddad</Author><Year>2006</Year><RecNum>1</RecNum><DisplayText>(1)</DisplayText><record><rec-number>1</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533744338″>1</key></foreign-keys><ref-type name=”Book”>6</ref-type><contributors><authors><author>Haddad, Yvonne Yazbeck</author><author>Smith, Jane I</author><author>Moore, Kathleen M</author></authors></contributors><titles><title>Muslim women in America: The challenge of Islamic identity today</title></titles><dates><year>2006</year></dates><publisher>Oxford University Press</publisher><isbn>0195177835</isbn><urls></urls></record></Cite></EndNote>(1). Females in Islamic cultures wear the headscarf when they are in public and usually begin wearing it at the onset of puberty ADDIN EN.CITE <EndNote><Cite><Author>Ali</Author><Year>2007</Year><RecNum>2</RecNum><DisplayText>(2)</DisplayText><record><rec-number>2</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533744924″>2</key></foreign-keys><ref-type name=”Book”>6</ref-type><contributors><authors><author>Ali, Kecia</author><author>Leaman, Oliver</author></authors></contributors><titles><title>Islam: The Key Concepts: Islam: The Key Concepts</title></titles><dates><year>2007</year></dates><publisher>Routledge</publisher><isbn>1134155514</isbn><urls></urls></record></Cite></EndNote>(2). Muslims represent the second largest religious group in the world and are estimated to become the second largest religious group in the United States by the year 2040 ADDIN EN.CITE <EndNote><Cite><Author>Mohamed</Author><Year>2016</Year><RecNum>3</RecNum><DisplayText>(3)</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533745167″>3</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Mohamed, Besheer</author></authors></contributors><titles><title>A new estimate of the US Muslim population</title><secondary-title>Pew Research Center</secondary-title></titles><periodical><full-title>Pew Research Center</full-title></periodical><volume>6</volume><dates><year>2016</year></dates><urls></urls></record></Cite></EndNote>(3).
According to the Pew Research Center (2014), there are approximately 1.7 billion Muslims in the world ADDIN EN.CITE <EndNote><Cite><RecNum>5</RecNum><DisplayText>(4)</DisplayText><record><rec-number>5</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533746038″>5</key></foreign-keys><ref-type name=”Web Page”>12</ref-type><contributors></contributors><titles><title>http://www.pewresearch.org/topics/religion-and-government/page/9/ </title></titles><dates></dates><urls></urls></record></Cite></EndNote>(4). Estimating the total number of females worldwide who wear headscarves is difficult. Several Islamic countries mandate females to wear headscarves when out in public, while other countries have banned the use of headscarves in public. However, in the majority of the world’s countries, wearing headscarves is optional. For example, in the United States, where wearing of the headscarves are optional, 43% of Muslim females reported that they wear the headscarf, which makes for a total of 433,000 females ADDIN EN.CITE <EndNote><Cite><RecNum>7</RecNum><DisplayText>(5)</DisplayText><record><rec-number>7</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533747660″>7</key></foreign-keys><ref-type name=”Web Page”>12</ref-type><contributors></contributors><titles><title>Muslim Americans: Middle Class and Mostly Mainstream. http://www.pewresearch.org/files/old-assets/pdf/muslim-americans.pdf. Published May 22, 2007. Accessed October 14, 2016.</title></titles><dates></dates><urls></urls></record></Cite></EndNote>(5) .

Pakistan has no laws banning or enforcing the ?ij?b. In Pakistan, most women wear shalwar kameez, a tunic top and baggy or skintight trouser set which covers their legs and body. Depending on the societal status and city, a loose dupatta scarf is worn around the shoulders and upper chest or just on the shoulder. Women are not expected to wear a hijab or scarf in public, but many women in Pakistan wear different forms of the hijab and it varies for rural and different urban areas. For example, in the Khyber Pakhtunkhwa province and the Federally Administered Tribal Areas a minority of the women wear the full head-to-toe black burqa/chador while in the rest of the provinces, including Azad Kashmir, most of the women wear the dupatta (a long scarf that matches the woman’s garments).Burqas are mainly worn in the Swat Valley and tribal areas, however, they can be seen throughout the country including in urban population centers.

In Contrast Saudi Arabia, a country that mandates the wearing of headscarves, all females over the age of 15 are expected to wear headscarves, which makes for 9,210,133 females ADDIN EN.CITE <EndNote><Cite><RecNum>8</RecNum><DisplayText>(6)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533747937″>8</key></foreign-keys><ref-type name=”Web Page”>12</ref-type><contributors></contributors><titles><title>Contact CIA. Central Intelligence Agency. https://www.cia.gov/library/publications/the-world-factbook/fields/2010.html. Accessed November 14, 2016</title></titles><dates></dates><urls></urls></record></Cite></EndNote>(6).In such cultures, females start wearing headscarves at an early age and for extended periods of time daily. Consequently, routine wearing of headscarves may have an influence on cervical range of motion (ROM) and cervical proprioception. Cervical spine mobility is maintained by the unique bony and soft tissue structures of the cervical spine that allow for multidirectional movements of the head. A majority of the movements occur in the upper cervical spine at the craniocervical junction, which allows for three-dimensional movements while maintaining the horizontality of visual gaze ADDIN EN.CITE <EndNote><Cite><Author>An</Author><Year>1999</Year><RecNum>9</RecNum><DisplayText>(7)</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533748345″>9</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>An, Howard S</author><author>Wise, Jeffrey J</author><author>Xu, Rongming</author></authors></contributors><titles><title>Anatomy of the cervicothoracic junction: a study of cadaveric dissection, cryomicrotomy, and magnetic resonance imaging</title><secondary-title>Journal of spinal disorders</secondary-title></titles><periodical><full-title>Journal of spinal disorders</full-title></periodical><pages>519-525</pages><volume>12</volume><number>6</number><dates><year>1999</year></dates><isbn>0895-0385</isbn><urls></urls></record></Cite></EndNote>(7). Hence, cervical range of motion (ROM) is an important assessment that is commonly used to classify patients with neck pain with mobility deficits and neck pain with headaches, according to the International Classification of Function (ICF) ADDIN EN.CITE <EndNote><Cite><Author>Childs</Author><Year>2008</Year><RecNum>10</RecNum><DisplayText>(8)</DisplayText><record><rec-number>10</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533748424″>10</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Childs, John D</author><author>Cleland, Joshua A</author><author>Elliott, James M</author><author>Teyhen, Deydre S</author><author>Wainner, Robert S</author><author>Whitman, Julie M</author><author>Sopky, Bernard J</author><author>Godges, Joseph J</author><author>Flynn, Timothy W</author><author>Delitto, Anthony</author></authors></contributors><titles><title>Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association</title><secondary-title>Journal of Orthopaedic &amp; Sports Physical Therapy</secondary-title></titles><periodical><full-title>Journal of Orthopaedic &amp; Sports Physical Therapy</full-title></periodical><pages>A1-A34</pages><volume>38</volume><number>9</number><dates><year>2008</year></dates><isbn>0190-6011</isbn><urls></urls></record></Cite></EndNote>(8).
Wearing protective headgear has been shown to decrease active cervical ROM. McCarthy et al studied the effects of wearing an American football helmet on active cervical ROM and proprioception. Fifteen American football player with their age matched control participated. Cervical ROM and head repositioning accuracy were measured during cervical flexion and extension. The results indicated that wearing the helmet significantly decreased cervical extension in both groups. Head-repositioning accuracy was similar between the groups without the helmet. However, when wearing the helmet American football players appeared to be more accurate in head repositioning 5 accuracy than controls ADDIN EN.CITE <EndNote><Cite><Author>McCarthy</Author><Year>2015</Year><RecNum>11</RecNum><DisplayText>(9)</DisplayText><record><rec-number>11</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533751033″>11</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>McCarthy, Peter W</author><author>Hume, Phillip J</author><author>Heusch, Andrew I</author><author>Lark, Sally D</author></authors></contributors><titles><title>Wearing American Football helmets increases cervicocephalic kinaesthetic awareness in “elite” American Football players but not controls</title><secondary-title>Chiropractic &amp; manual therapies</secondary-title></titles><periodical><full-title>Chiropractic &amp; manual therapies</full-title></periodical><pages>32</pages><volume>23</volume><number>1</number><dates><year>2015</year></dates><isbn>2045-709X</isbn><urls></urls></record></Cite></EndNote>(9). Additionally soft neck collars significantly reduced cervical spine rotation ADDIN EN.CITE <EndNote><Cite><Author>Podolsky</Author><Year>1983</Year><RecNum>12</RecNum><DisplayText>(10)</DisplayText><record><rec-number>12</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533751255″>12</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Podolsky, Sherman</author><author>Baraff, Larry J</author><author>Simon, Robert R</author><author>Hoffman, Jerome R</author><author>Larmon, Baxter</author><author>Ablon, Wendy</author></authors></contributors><titles><title>Efficacy of cervical spine immobilization methods</title><secondary-title>The Journal of trauma</secondary-title></titles><periodical><full-title>The Journal of trauma</full-title></periodical><pages>461-465</pages><volume>23</volume><number>6</number><dates><year>1983</year></dates><isbn>0022-5282</isbn><urls></urls></record></Cite></EndNote>(10).Therefore, it is reasonable to assume that other headdresses, including headscarves, may also influence cervical ROM.
The wearing of headscarves may also influence cervical proprioception especially when worn for an extended time period. To the best of our knowledge, there is only one study that investigated the effect of wearing headscarves on cervical proprioception. Alqabbani et al.reported greater joint position error in females wearing headscarves compared to females with no headscarves. The findings of this pilot study indicated the need to further explore the influence of wearing the headscarves on cervical proprioception and cervical mobility and to investigate other factors related to the wearing of headscarves ADDIN EN.CITE <EndNote><Cite><Author>Alqabbani</Author><Year>2016</Year><RecNum>13</RecNum><DisplayText>(11)</DisplayText><record><rec-number>13</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533751659″>13</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Alqabbani, Samiah F</author><author>Johnson, Eric G</author><author>Daher, Noha S</author><author>Gaikwad, Shilpa B</author></authors></contributors><titles><title>THE EFFECT OF WEARING HEADSCARVES ON CERVICAL SPINE PROPRIOCEPTION</title><secondary-title>Internation Journal of Physiotherapy and Research</secondary-title></titles><periodical><full-title>Internation Journal of Physiotherapy and Research</full-title></periodical><pages>1389-1393</pages><volume>4</volume><number>2</number><dates><year>2016</year></dates><urls></urls></record></Cite></EndNote>(11).

The primary objectives of this dissertation were to determine the effects of wearing the headscarf on cervical spine range of motion. Among females who wear the headscarf, a secondary aim was to analyze the influence of age at onset of wearing the headscarf and duration of hours per day wearing the headscarf on cervical ROM.

2.LITERATURE REVIEW
Alqabbani et al conducted a study to investigate the effect of wearing headscarves on cervical ROM in females who wear headscarves compared with females who don’t wear headscarves. Fifty-two females with mean age 28.1±3.1 years were divided into two groups, Headscarf group and no-scarf group. Cervical range of motion was measured in a seated position for flexion, extension, right lateral flexion, left lateral flexion, right rotation and left rotation. Results: The headscarf group reported a significant limitation in cervical ROM in all six directions. Moreover, females in the headscarf group who wore the headscarf for more or equal to 6 hours had significantly less left rotation compared to those who wear it for less than 6 hours ADDIN EN.CITE <EndNote><Cite><Author>Alqabbani</Author><Year>2018</Year><RecNum>14</RecNum><DisplayText>(12)</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533753009″>14</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Alqabbani, Samiah F</author><author>Bains, Gurinder S</author><author>Johnson, Eric G</author><author>Lohman, Everett B</author><author>Daher, Noha S</author></authors></contributors><titles><title>EFFECTS OF WEARING HEADSCARVES ON CERVICAL SPINE MOBILITY</title><secondary-title>INTERNATIONAL JOURNAL OF PHYSIOTHERAPY</secondary-title></titles><periodical><full-title>INTERNATIONAL JOURNAL OF PHYSIOTHERAPY</full-title></periodical><pages>113-118</pages><volume>5</volume><number>3</number><dates><year>2018</year></dates><isbn>2349-5987</isbn><urls></urls></record></Cite></EndNote>(12).

Mccarthy et al conducted a study that aimed to quantify the kinesthetic and movement effects of the American football helmet. Fifteen British Collegiate American football players (mean age 22.2, SD 1.9; BMI kg.m2 26.3, SD 3.7) were age and size matched to 11 non-American football playing university students (mean age 22.5, SD 3.6; BMI 24.3, SD 3.3 kg.m2). Both groups had their active cervical range of motion and head repositioning accuracy measured during neck flexion/extension using a modified cervical range of motion device and a similarly modified football helmet. Result indicated Wearing American football helmets significantly reduces the active cervical range of motion in extension, along with a change in the neutral head position. American footballers have a greater accuracy in repositioning their head from flexion (potentially enhanced proprioception) when wearing a helmet ADDIN EN.CITE <EndNote><Cite><Author>McCarthy</Author><Year>2015</Year><RecNum>11</RecNum><DisplayText>(9)</DisplayText><record><rec-number>11</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533751033″>11</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>McCarthy, Peter W</author><author>Hume, Phillip J</author><author>Heusch, Andrew I</author><author>Lark, Sally D</author></authors></contributors><titles><title>Wearing American Football helmets increases cervicocephalic kinaesthetic awareness in “elite” American Football players but not controls</title><secondary-title>Chiropractic &amp; manual therapies</secondary-title></titles><periodical><full-title>Chiropractic &amp; manual therapies</full-title></periodical><pages>32</pages><volume>23</volume><number>1</number><dates><year>2015</year></dates><isbn>2045-709X</isbn><urls></urls></record></Cite></EndNote>(9).

Cervical ROM can be a predictive outcome measure for neck-pain related conditions. Kasch et al ADDIN EN.CITE <EndNote><Cite><Author>Kasch</Author><Year>2008</Year><RecNum>15</RecNum><DisplayText>(13)</DisplayText><record><rec-number>15</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533762865″>15</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Kasch, H</author><author>Qerama, E</author><author>Kongsted, Alice</author><author>Bendix, Tom</author><author>Jensen, Troels Staehelin</author><author>Bach, Flemming Winther</author></authors></contributors><titles><title>Clinical assessment of prognostic factors for long?term pain and handicap after whiplash injury: a 1?year prospective study</title><secondary-title>European journal of neurology</secondary-title></titles><periodical><full-title>European journal of neurology</full-title></periodical><pages>1222-1230</pages><volume>15</volume><number>11</number><dates><year>2008</year></dates><isbn>1351-5101</isbn><urls></urls></record></Cite></EndNote>(13)prospectively investigated the ability of active cervical mobility, cervical pain, and non-pain complaints as predictors of handicap following whiplash injury. Subjects who had initial limitation in cervical ROM were 4.6 times at higher risk for disability following whiplash injury. Therefore, it was suggested that reduced cervical ROM is one of the prognostic factors for increased disability after acute whiplash.
Dall’Alba et al ADDIN EN.CITE <EndNote><Cite><Author>Dall’Alba</Author><Year>2001</Year><RecNum>16</RecNum><DisplayText>(14)</DisplayText><record><rec-number>16</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533763154″>16</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Dall’Alba, Paul T</author><author>Sterling, Michele M</author><author>Treleaven, Julia M</author><author>Edwards, Sandra L</author><author>Jull, Gwendolen A</author></authors></contributors><titles><title>Cervical range of motion discriminates between asymptomatic persons and those with whiplash</title><secondary-title>Spine</secondary-title></titles><periodical><full-title>Spine</full-title></periodical><pages>2090-2094</pages><volume>26</volume><number>19</number><dates><year>2001</year></dates><isbn>0362-2436</isbn><urls></urls></record></Cite></EndNote>(14)examined the ability of cervical ROM to discriminate between asymptomatic subjects and those with persistence whiplash associated disorders. The finding indicated that cervical ROM successfully discriminates between subjects with whiplash-associated disorder (WAD) and an asymptomatic control group. Therefore, it was proposed that cervical ROM could be used as an indicator of physical impairments.

Mikael et al investigated the effects of restrained cervical mobility on pursuit eye movements (PEMs), voluntary sac-cades and postural control, as measured by posturography, were studied in 11 healthy subjects whose cervical spine movement had been restrained for 5 days by means of a rigid neck-collar. at day 5 mean peak velocity of voluntary saccades at amplitudes of 40° and 60° was significantly reduced, as was mean peak gain of PEMs at a stimulus velocity of 50°; the variance of body position in vibration-induced body sway was significantly increased, but there was no difference in variance of galvanically-induced body sway or in velocity of vibration-induced body sway. the results suggest that restriction of cervical movements per se affects voluntary eye movements, a conclusion also consistent with findings in patients with tension headache. Restriction of cervical movement only marginally affects postural control ADDIN EN.CITE <EndNote><Cite><Author>Karlberg</Author><Year>1991</Year><RecNum>17</RecNum><DisplayText>(15)</DisplayText><record><rec-number>17</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533824443″>17</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Karlberg, Mikael</author><author>Magnusson, Måns</author><author>Johansson, Rolf</author></authors></contributors><titles><title>Effects of restrained cervical mobility on voluntary eye movements and postural control</title><secondary-title>Acta oto-laryngologica</secondary-title></titles><periodical><full-title>Acta oto-laryngologica</full-title></periodical><pages>664-670</pages><volume>111</volume><number>4</number><dates><year>1991</year></dates><isbn>0001-6489</isbn><urls></urls></record></Cite></EndNote>(15).
Kourosh et al conducted a study to investigate the Effect of Soft and Rigid Cervical Collars on Head and Neck Immobilization in Healthy Subjects. Twenty-nine healthy subjects aged 18–26 participated in this study. Data were collected using a three-dimensional motion analysis system and six infrared cameras. This study showed that different cervical collars have different effects on neck motion. Rigid and soft cervical collars used in the present study limited the neck motion in both directions. All motion significantly decreased when subjects used soft collars (p<0.01). According to the obtained data, flexion and lateral rotation experienced the maximum (39%) and minimum (11%) immobilization in all six motions using soft collars. Rigid collars caused maximum immobilization in flexion (59%) and minimum immobilization in the lateral rotation (18%) and limited all motion much more than the soft collar ADDIN EN.CITE <EndNote><Cite><Author>Barati</Author><Year>2017</Year><RecNum>18</RecNum><DisplayText>(16)</DisplayText><record><rec-number>18</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533830654″>18</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Barati, Kourosh</author><author>Arazpour, Mokhtar</author><author>Vameghi, Roshanak</author><author>Abdoli, Ali</author><author>Farmani, Farzad</author></authors></contributors><titles><title>The effect of soft and rigid cervical collars on head and neck immobilization in healthy subjects</title><secondary-title>Asian spine journal</secondary-title></titles><periodical><full-title>Asian spine journal</full-title></periodical><pages>390-395</pages><volume>11</volume><number>3</number><dates><year>2017</year></dates><isbn>1976-1902</isbn><urls></urls></record></Cite></EndNote>(16).

To the best of our knowledge, not much previous investigations into the effects of
wearing headscarves on cervical spine mobility have been conducted. Therefore, the
primary aim of the present study was to investigate the effects of wearing headscarves on
cervical ROM in females who wear headscarves compared with females who do not wear
headscarves. Among females who wore the headscarf, a secondary aim was to compare
cervical ROM measures by time spent per day wearing the headscarf (?5hours versus >5
hours) and age at onset of wearing the headscarf. We also examined the relationship between outcome variables and age at onset of wearing the headscarf, number of years worn, and time spent per day wearing the hijab.
3.OBJECTIVESThe objective is to assess the association of hijab with cervical mobility.

4.MATERIALS AND METHODS
Study Design: Case control
Setting: Data was collected from University of Lahore, Main campus and surrounding area.

Duration of study was completed within 6 months after the approval of synopsis
Sample size: Sample size of 70
Population size:
Margin of Error: A percent that tells how much Women can expect this survey results to reflect the views of overall population. The smaller the margin of error, the closer results are to having the exact answers at the given confidence level. The margin of error was 5% therefore 70 Women were needed for this survey.

N= Population Size
e= Margin of error (percentage in decimal form)
z= z-score. The z-score is the number of standard deviation a given proportion is away from the mean.

Sample Technique: Individuals were readily available to the researcher for the data collection of this survey.

Sample selection criteria
Inclusion Criteria:
Age 20-30
Wearing Hijab For atleast 4-5 years
Exclusion Criteria:
Cervical pain for less than 6 months
Neck injury/ trauma
Tenderness/ muscle spasm in cervical region
METHODOLOGY
Subjects:
60 females with mean age 27 years participated in the study.
Subjects were divided into two groups (headscarf group: Thirty five females who
routinely wore headscarves; control group: Thirty five females who never wore
headscarves). Individuals who met the inclusion criteria ranged from 20-40 years of age, had been wearing the headscarf for a minimum of Four years, and began wearing the headscarf around teen years of age. Subjects were excluded if they had cervical pain for less than six months, or if they had tenderness or muscle spasm in the cervical area. Subjects were recruited from University of lahore and the surrounding area of lahore.

Universal Inclinometer:
The Universal Inclinometer replaces the goniometer for quick and easy measurements. The inclinometer is fluid dampened to permit fast, accurate readings without waiting for oscillations to damp out. The inclinometer is easily adjusted to zero at the initial position so the final reading is the range of motion. A short base is provided for measuring curved surfaces like the spine.

A long base works well for placement on long flat surfaces such as the arm (when measuring elbow range of motion) or the leg (when measuring knee range of motion). The long arm is also easy to grasp for measurements such as wrist rotation and shoulder rotation.

Procedure: The Universal Inclinometer was used to measure flexion/extension, lateral flexion, and rotation for each subject. The subjects were seated on a comfortable chair with their feet
resting on the floor and their backs against the chair and their arms resting on their laps and Supine lying for rotation measurement with Inclinometer placed on the forehead.
Any jewelry, hats, and glasses were removed before placing the Inclinometer on the
subject’s head. Subjects who wore the headscarves were asked to remove them before
the measurements. First, the investigator explained the cervical movements to
the subjects and indicated that all movements should be performed to the end range.
Second, subjects performed a practice trial in each direction to ensure familiarization
when moving their heads with the Inclinometer. Then, subjects performed the neck
movements in the following order: right rotation, left rotation, flexion, extension, right
lateral bending, and left lateral bending. Each movement was repeated for two trials.
For the flexion/extension and lateral flexion movements, the investigator recorded
the value of the relevant inclinometer indicating the starting position. At the end of each
movement, the investigator recorded the value of the inclinometer again, indicating the
end position the dial of the inclinometer was manually set to zero before the movement. The value after the movement directly indicated the amount of movement.
5.DATA ANALYSIS
The Statistical Product and Service Solutions (SPSS) for Windows variant 21.0 (IBM Corp., Armonk, New York) was utilized to investigate the information. An example size of 70 subjects was expected to get the information. Information was abridged utilizing frequencies and relative frequencies for clear cut factors and means ± standard deviation (SD) for quantitative factors. Mean age and BMI(Kg/m2) of females in the hijab wearing group and those in the control amass were looked at utilizing Independent-test. Mean result factors (cervical ROM right rotation, left rotation, flexion, Extension, right lateral flexion, left lateral flexion) by time spent every day wearing the headscarf (?5 hours versus > 5 hours) and Subject group were looked at utilizing independent-test. Mean outcome variables by time spent every day wearing the headscarf (?5 hours versus > 5 hours) and age at beginning of wearing the headscarf were surveyed utilizing Independent t test. The level of significance was set at a p-value of ?0.05.

6. RESULTS:
Table I Age
Mean 26.60
Std. Deviation 5.817
Minimum 20
Maximum 40

Fig1: The mean age was 26.60±5.81
Table II BMI
Mean 23.1456
Std. Deviation 3.33547
Minimum 18.15
Maximum 30.20

Fig 2: The mean BMI was 23.14±3.33
Table III Height
Mean 5.4071
Std. Deviation .12663
Minimum 5.20
Maximum 5.80

Fig3: The mean height was 5.4±0.12

Table IV Weight
Mean 62.9000
Std. Deviation 9.53430
Minimum 49.00
Maximum 88.00

Fig4: The mean weight was 62.90±9.53
Table V Frequency Valid Percent
yes 35 50.0
no 35 50.0
Total 70 100.0
Mean 1.50 Std. Deviation 0.504

Fig5:
Table VI Frequency Valid Percent
Right Handed 65 92.9
Left Handed 5 7.1
Total 70 100.0
Mean 1.07
Std. Deviation 0.259

Fig6: Among the groups 92.9% were right handed and remaining 7.1% were left handed
Table VII Frequency Percent
Less than 5 hours a days 20 57.1
More than 5 hours a day 15 42.9
Total 35 100.0

Fig7: It was observed that 57.1% of hijab’s wore hijab for less than 5 hours a day and 42.9% wore it for more than 5 hours.

How many years has it been since u started wearing hijab?
Table VIII
Mean 8.23
Std. Deviation 4.766
Minimum 4
Maximum 20

Fig8:
Right Rotation
Table IX Right Rotation
Mean 83.2143
Std. Deviation 3.98509
Minimum 74.00
Maximum 90.00

Fig9: The mean for right rotation was 83.21±3.98
Left Rotation

Table X Left Rotation
Mean 81.0714
Std. Deviation 3.6646
Minimum 71.00
Maximum 85.00

Fig10: The mean for left rotation was 81.07±3.66
Flexion
Table XI Flexion
Mean 57.8571
Std. Deviation 2.6772
Minimum 53.00
Maximum 62.00

Fig11: The mean cervical flexion was 57.85±2.67
Extension
Table XII Extension
Mean 67.500
Std. Deviation 2.7333
Minimum 62.00
Maximum 73.00

Fig12: The mean cervical extension was 67.50±2.73
Right lateral Flexion
Table XIII Right Lateral Flexion
Mean 46.6714
Std. Deviation 2.28873
Minimum 40.00
Maximum 50.00

The mean for right lateral flexion was 46.67±2.28
Left lateral Flexion
Table XIV Left Lateral Flexion
Mean 44.5286
Std. Deviation 2.28239
Minimum 40.00
Maximum 48.00

The mean for left lateral flexion was 44.52±2.2
TableXV  Do you wear scarf on regular basis? N Mean Std. Deviation t test p-value
Right Rotation yes 35 80.89 4.13 -6.003 <0.001
  no 35 85.54 1.99   Left Rotation yes 35 79.08 3.96 -5.371   no 35 83.06 1.86   Flexion yes 35 56.00 2.04 -8.053   no 35 59.71 1.80   Extension yes 35 66.31 2.60 -4.006   no 35 68.68 2.33   Right lateral Flexion yes 35 46.31 2.71 -1.312 0.194
  no 35 47.02 1.74   Left lateral Flexion yes 35 44.00 2.52 -1.978 0.052
  no 35 45.05 1.90  
No significant difference in right and left lateral flexion because p value more than 0.05
And significant difference in all other ranges because p value less than 0.05
Table XVI
Do you wear scarf on regular basis? N Mean Std. Deviation Std. Error Mean
Age yes 35 27.11 6.187 1.046
no 35 26.09 5.463 .923
BMI yes 35 23.7075 3.35946 .56785
no 35 22.5837 3.26219 .55141
No significant difference of BMI and age in both the groups.

Table XVII
how long do you wear scarf? N Mean Std. Deviation
Lft_Rotationless than 5 hours a days 20 81.1500 2.43386
more than 5 hours a day 15 76.3333 3.97612
Rt_Roatationless than 5 hours a days 20 83.0000 3.24443
more than 5 hours a day 15 78.0667 3.51460
Flexion less than 5 hours a days 20 57.0000 1.65434
more than 5 hours a day 15 54.6667 1.75933
Rt_latFlexionless than 5 hours a days 20 47.6000 2.01050
more than 5 hours a day 15 44.6000 2.61315
Extension less than 5 hours a days 20 67.4500 2.03845
more than 5 hours a day 15 64.8000 2.56905
Lft_latFlexionless than 5 hours a days 20 45.2000 1.85245
more than 5 hours a day 15 42.4000 2.44365
Mean ranges are reduced for those who wore hijab more than 5 hours a day.

7. DISCUSSION
In this investigation a sum of 70 females with mean age 26.60± 5.81 years took an interest. Among them 35 females were those that wore hijab on a regular premise and the other 35 were those that didn’t wear hijab. The mean of age, weight list (BMI) in Kg/m2 was around typical in both the groups. There was no critical contrast in mean BMI between the hijabi group and control group (23.70±3.35 versus 22.58± 3.26) and hand predominance was (right given 92.9% ) and (left gave 7.1%) among the females. In the hijabi group, the mean number of years of wearing the hijab was 8.23±4.7 years, The Hijabi group assembled 57.1% of females wore hijab for under 5 hours per day and 42.9% of females wore it for over 5 hours per day
.

There was a significant difference in mean± standard deviation (SD) in range of motion
in all directions apart from right and left lateral flerxion between the two groups (Table 15) . Females in the Hijab wearing group had a huge decrease in CROM for right (80.89±4.1 versus 85.±1.99, p<0.001),left rotation (79.08±3.96 versus 83.06±1.86, p<0.001), flexion (56.0±2.04 versus 59.71±1.8, p<0.001), Extension (66.31±2.6 versus 68.68±2.33, p<0.001),There was no critical decrease in right lateral flexion (46.31±2.71 versus 47.02±1.74, p=0.194), and left lateral flexion (44.00±2.52 versus 45.05±1.9, p=0.052).

In addition, there was a significant difference in mean cervical ROM in all directions by the hours per day spent wearing the headscarf (Table 17).

Podolsky et al. ADDIN EN.CITE <EndNote><Cite><Author>Podolsky</Author><Year>1983</Year><RecNum>12</RecNum><DisplayText>(10)</DisplayText><record><rec-number>12</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533751255″>12</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Podolsky, Sherman</author><author>Baraff, Larry J</author><author>Simon, Robert R</author><author>Hoffman, Jerome R</author><author>Larmon, Baxter</author><author>Ablon, Wendy</author></authors></contributors><titles><title>Efficacy of cervical spine immobilization methods</title><secondary-title>The Journal of trauma</secondary-title></titles><periodical><full-title>The Journal of trauma</full-title></periodical><pages>461-465</pages><volume>23</volume><number>6</number><dates><year>1983</year></dates><isbn>0022-5282</isbn><urls></urls></record></Cite></EndNote>(10) uncovered a noteworthy cervical revolution impediment when utilizing a delicate neckline. Additionally, McCarthy et al. ADDIN EN.CITE <EndNote><Cite><Author>McCarthy</Author><Year>2015</Year><RecNum>11</RecNum><DisplayText>(9)</DisplayText><record><rec-number>11</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533751033″>11</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>McCarthy, Peter W</author><author>Hume, Phillip J</author><author>Heusch, Andrew I</author><author>Lark, Sally D</author></authors></contributors><titles><title>Wearing American Football helmets increases cervicocephalic kinaesthetic awareness in “elite” American Football players but not controls</title><secondary-title>Chiropractic &amp; manual therapies</secondary-title></titles><periodical><full-title>Chiropractic &amp; manual therapies</full-title></periodical><pages>32</pages><volume>23</volume><number>1</number><dates><year>2015</year></dates><isbn>2045-709X</isbn><urls></urls></record></Cite></EndNote>(9) detailed confinement in cervical augmentation related with protective cap wearing found in American football players. In any case, no impediments were identified when estimating cervical ROM without the head protector. As opposed to this investigation, all estimations of cervical ROM were performed without the hijab. Alqabani et al ADDIN EN.CITE <EndNote><Cite><Author>Alqabbani</Author><Year>2018</Year><RecNum>14</RecNum><DisplayText>(12)</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533753009″>14</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Alqabbani, Samiah F</author><author>Bains, Gurinder S</author><author>Johnson, Eric G</author><author>Lohman, Everett B</author><author>Daher, Noha S</author></authors></contributors><titles><title>EFFECTS OF WEARING HEADSCARVES ON CERVICAL SPINE MOBILITY</title><secondary-title>INTERNATIONAL JOURNAL OF PHYSIOTHERAPY</secondary-title></titles><periodical><full-title>INTERNATIONAL JOURNAL OF PHYSIOTHERAPY</full-title></periodical><pages>113-118</pages><volume>5</volume><number>3</number><dates><year>2018</year></dates><isbn>2349-5987</isbn><urls></urls></record></Cite></EndNote>(12) examined an examination and discovered noteworthy decrease in each of the six headings also she found that females who wore hijab for over 6 hours daily had critical decrease in CROM as compared to the individuals who wore it for under 6 hours.
This study revealed a significant decrease in cervical ROM in all directions except for right and left cervical flexion. Our subjects wore the headscarf for an expanded period. In the subject group 57.1% of females wore hijab for under 5 hours per day and 42.9% of females wore it for over 5 hours every day and the mean number of years worn was years 8.23 ±4.7.

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ADDIN EN.CITE.DATA (17-19) and also with subjects with neck pain ADDIN EN.CITE <EndNote><Cite><Author>Dall’Alba</Author><Year>2001</Year><RecNum>16</RecNum><DisplayText>(14)</DisplayText><record><rec-number>16</rec-number><foreign-keys><key app=”EN” db-id=”ex2e55e57sd2d7ez9x3paa9k2fezapzs9v5d” timestamp=”1533763154″>16</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Dall’Alba, Paul T</author><author>Sterling, Michele M</author><author>Treleaven, Julia M</author><author>Edwards, Sandra L</author><author>Jull, Gwendolen A</author></authors></contributors><titles><title>Cervical range of motion discriminates between asymptomatic persons and those with whiplash</title><secondary-title>Spine</secondary-title></titles><periodical><full-title>Spine</full-title></periodical><pages>2090-2094</pages><volume>26</volume><number>19</number><dates><year>2001</year></dates><isbn>0362-2436</isbn><urls></urls></record></Cite></EndNote>(14). In our example, the mean age for the subjects was 26.1± 35.81 years, which speaks to a moderately youthful populace. In any case, inside this age run, a critical decrease in cervical ROM was identified. It is sensible to anticipate that, inside the number of inhabitants in females who wear headscarves, the confinement in cervical ROM may have a tendency to be more prominent as they become more established. In this manner, future examinations ought to explore more established grown-up females who wear headscarves.

8.CONCLUSION:
In this study, the differences in active cervical ROM between females who
routinely wore the hijab and females who never wore the hijab were investigated. The findings indicated that the headscarf group reported a significant limitation in cervical ROM in all directions except for right and left cervical flexion. Additionally, females in the hijab group who wore the hijab for five hours or more a day had significantly less CROM as compared to those who wore it for less than five hours a day.

9.RECOMMENDATIONSWearing the hijab is a basic religious practice by females in Islamic societies. General wear of the headscarf may impact cervical range of motion. Moreover, wearing it for five hours or more may result in additionally decay of cervical ROM. In this manner, it is proposed that females limit the measure of time spent wearing the headscarf, if convenient to them. In addition, to keep up cervical motion, execution of consistent scope of movement practices such as stretching and range of motion exercise of cervical spine is suggested, particularly for females whose day by day schedules expect them to wear the headscarf for over five hours.

10. LIMITATIONS
The study had some potential limitations. Firstly, the study was done on small sample size, only subjects with age range from 20-40 years were included. Further research is warranted to include a wider age range to investigate the influence of age on cervical range of motion. Secondly we considered three factors related to
headscarves: age, hours worn per day, and the number of years worn.
Future research should include factors such as styles and textures of headscarves.
In addition, further studies should be done to investigate the effect of interventions to improve cervical muscle flexibility and range o motion.

11. APPENDIX
Questionnaire
CERVICAL ROM EVALUATION FORM
Subject No: Age:
Height: Weight:
Hand Dominance:
Right
left
Subject group:
Q1) Do you Wear Hijab daily?
Yes
No
Q2) How many years has it been since you started wearing hijab?

Q3) What is you Daily duration of wearing the Hijab?
Less than five hours
More than five hours
Examiner Name:
Cervical Range of Motion:

1 2 Average
Right rotation Left rotation Flexion Extension Right lateral flexion Left lateral flexion
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http://www.pewresearch.org/files/old-assets/pdf/muslim-americans.pdf. Published
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https://www.cia.gov/library/publications/the-world-factbook/fields/2010.html.

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