Cervical Spine Motion in the Elderly
Condition: Cervical Spine Degeneration; Movement, Abnormal; Aging
MeSH terms: Dyskinesias
Study type: Interventional

Summary: 
      Rationale:

      Physiological motion of the cervical spine is a subject of interest for medical specialists.
      Segmental range of motion (sROM) has been most commonly used to define motion but inter- and
      intra-variability is large. Therefore, a sequence of segmental contributions in the lower
      cervical spine during the second half of extension has been defined in healthy participants
      (uniform in 80-90%). The mean age of these participants was 23 years. Since cervical
      degenerative disc disease (CDDD) occurs more often in elderly patients, it is of paramount
      importance to study whether this sequence remains present during aging, regardless of losing
      0.11 degrees of sROM each year.

      Objective:

      To investigate if the normal sequence of segmental contributions in the lower cervical spine
      during the second half of extension (C4-C5 followed by C5-C6, and then C6- C7) is also
      present in asymptomatic participants between 55 and 70 years of age by using cinematographic
      recordings.

      Study design:

      Fundamental research

      Study population:

      Eleven asymptomatic participants between 55 and 70 years of age, without a medical history of
      neck problems, with a score of 4 or less on the Neck Disability Index (NDI), and without
      severe degenerative changes based on a score of 3 or less on the radiological Kellgrens'
      classification.

      Intervention:

      Two flexion and extension cinematographic recordings of the cervical spine with a two-week
      interval between recordings.

      Main study parameters/endpoints:

      Primary endpoint: Defining the cervical spines' physiological motion pattern by analysing the
      normal sequence of segmental contributions in the lower cervical spine (C4-C5 followed by
      C5-C6, and then C6-C7) during the second halfof extension in asymptomatic participants
      between 55 and 70 years of age.

      Secondary endpoint: Determine sROM of C4-C5, C5-C6, and C6-C7 by analysing the flexion and
      extension cinematographic recordings in asymptomatic participants between 55 and 70 years of
      age.

      Nature and extent of the burden and risks associated with participation, benefit and group
      relatedness: Participants receive cinematographic recordings twice. There will be no
      follow-up.
    

Detailed description: 
      INTRODUCTION AND RATIONALE Physiological motion of the cervical spine is a subject of
      interest for medical specialists. Although the term 'physiological motion' is commonly used,
      a proper definition has been lacking for a long time. Segmental range of motion (sROM, e.g.
      the amount of sagittal rotation in a segment between maximal flexion and maximal extension
      position of the entire cervical spine) is most commonly used to study motion. SROMs, however,
      suffer from large intra- and interindividual variability. Therefore, in the lower cervical
      spine, Boselie et al have recently described a consistent sequence of segmental contribution
      in sagittal rotation during flexion and extension in 20 healthy participants. This was based
      on historic reports. The mean age of the healthy participants was 23 years (SD 2.65, range
      18-55 years). They showed that the sequence of segmental contributions in the lower cervical
      spine during the second half of extension of the entire cervical spine and head was uniform
      in 80-90% of the healthy participants. The sequence of segmental contributions was C4-C5
      followed by C5-C6, and then C6-C7. Also, they described a group of single level cervical
      degenerative disc disease (CDDD) patients in which this sequence was present in only one
      patient (10%). This is the first method described which can reliably differentiate between
      normal or abnormal movement of the cervical spine in an individual subject. CDDD is
      degeneration of a cervical intervertebral disc and/or the adjoining vertebral bodies leading
      to cervical radiculopathy and/or myelopathy. CDDD occurs more often in elderly patients (> 50
      years of age) and due to aging of the population this will become a larger problem in the
      future. Age has been shown to be associated with a 0.11 degree decrease of sROM per year,
      independent of degeneration. Given that there are five levels in the subaxial cervical spine,
      there is an associated five degrees decrease in motion of the total subaxial cervical spine
      for every 10 years of ageing. It remains unclear whether the normal sequence of segmental
      contributions in the lower cervical spine is also present in asymptomatic elderly. By
      confirming the normal sequence in this group, this can be used to determine abnormal motion
      in elderly patients suffering from CDDD. The intention is to use this in future research in
      patients with cervical myelopathy or radiculopathy undergoing surgery to compare the outcomes
      of different types of surgery (e.g. cervical arthroplasty or anterior cervical discectomy
      with fusion) and to compare the influence of the type of surgery on normal motion.

      2. OBJECTIVES Primary Objective: To investigate whether the normal sequence of segmental
      contributions in the lower cervical spine during the second half of extension (C4-C5 followed
      by C5-C6, and then C6-C7), which is present in young asymptomatic controls, is similar in
      asymptomatic participants between 55 and 70 years of age by using cinematographic recordings.

      Secondary objective: To determine sROM of C4-C5, C5-C6, and C6-C7 by analysing the flexion
      and extension cinematographic recordings in asymptomatic participants between 55 and 70 years
      of age.

      3. STUDY DESIGN This is a fundamental research project in which asymptomatic elderly
      participants without neck pain or severe degenerative changes will be included. Participants
      will be recruited at Zuyd Hogeschool Sittard/Heerlen and Zuyderland Medical Center Sittard-
      Geleen/Heerlen by using posters notifying about the study. They can contact the researcher by
      email, who will inform them verbally and in writing. Informed consent will be signed if they
      meet the in- and exclusion criteria and if they are willing to participate. Flexion and
      extension of the cervical spine has been analysed through sagittal cinematographic recordings
      before. This was done in two groups with ten healthy participants in each group, from which
      an adequate analysis could be performed. Taking a possible loss to follow up of 10% into
      account, our study population will consist of 11 participants. No interim analysis will be
      performed. Each participant receives flexion and extension cinematographic recording twice to
      determine reproducibility and consistency of sequence between the two time points (T1 and
      T2). Recordings will be performed with an interval of two weeks, resulting in 22
      cinematographic recordings. Inclusion is expected to take approximately three months.
      Possible participants have to complete the Neck Disability Index (NDI), participants scoring
      above 4/50 points will be excluded (which means they would be no longer be classified as 'no
      disability due to neck problems'). A lateral X-ray of the cervical spine will be made, which
      will be scored using Kellgrens' classification by two neurosurgeons to avoid inclusion of
      participants with severe degenerative changes. Participants with a Kellgren score (KS) of
      four will be excluded. A KS score of four indicates severe degenerative changes such as
      severe narrowing of the disc space, severe sclerosis of the vertebral plates, or multiple
      large osteophytes. Participants with KS between zero and three will be included, indicating
      no, minimal, or moderate degenerative changes.

      4. STUDY POPULATION Population (base) Male and female participants between 55 and 70 years of
      age, without a history of neck complaints, an NDI score of 4 or less and a KS of 3 or less
      will be included. Participants will be recruited using posters in Zuyd Hogeschool
      Sittard/Heerlen and Zuyderland Medical Center Sittard- Geleen/Heerlen.

      Sample size calculation Sample size calculation is based on previous articles using the same
      method of cinematographic recordings to analyse motion of the cervical spine. Our study
      population will consist of 11 participants, assuming a possible loss to follow-up of 10%.
      Flexion and extension cinematographic recordings are acquired twice for each participant with
      an interval of two weeks in order to determine reproducibility and consistency of sequence of
      motion between two time points (T1 and T2). If there is no loss to follow-up and all
      cinematographic recordings are of good quality in the first 10 participants, the study will
      be ended.

      5. TREATMENT OF SUBJECTS 5.1 Investigational product/treatment Cinematographic recordings
      during flexion and extension of the cervical spine in asymptomatic elderly participants.

      5.2 Use of co-intervention Not applicable.

      5.3 Name and description of investigational product Not applicable.

      5.4 Summary of findings from non-clinical studies Not applicable.

      5.5 Summary of findings from clinical studies

      Initially, a method was developed to determine the ROM in the sagittal plane of the cervical
      spine using a fluoroscopy video of flexion-extension movement. The total ROM (tROM) and the
      sROM in 10 healthy participants (19-22 years) was investigated. The tROM for anteflexion is
      118.1 degrees and 114.3 degrees for retroflexion. Several new and very important insights
      have been published in this study. The maximum sROM is not necessarily reflected comparing
      the position of the vertebra in full flexion to its position in full extension. Moreover,
      sROM differs depending on execution of the motion from flexion to extension or the other way
      around and sROM can differ with time. A difference in excess of five degrees for the same
      segment in the same individual can be recorded. The cadence of movement in the cervical spine
      was also described. During flexion and extension, motion of the cervical vertebrae follows a
      general pattern which is complex and counter- intuitive. They conclude that tROM and sROM are
      unsuitable to be used as a parameter of cervical spine mobility.

      A review that systematically addressed contemporary knowledge about the mechanical behaviour
      of cervical vertebrae and soft-tissue of the cervical spine, under conditions that result in
      minor of major injuries. The results are collected from multiple studies that have measured
      sROM of individual joints of the cervical spine. It is emphasised that, even under normal
      conditions, sROM is not consistent either in time or according to the direction of motion.

      sROM and KS with flexion/ extension radiographs were assessed and the relation to clinical
      variables in 195 patients was determined (age 15-93 years, 62 males and 133 females).
      Interobserver reliabilities for assessing KS (intraclass correlation coefficient 0.81) and
      sROM (intraclass correlation coefficient 0.72) were good to excellent. Age had a significant
      negative association with sROM at C2-C3, C3-C4, C4-C5, and C5-C6, amounting to a total of
      five degrees decrease in subaxial cervical ROM every 10 years. KS at the level of interest
      had a significant negative association with sROM at C2-C3, C3-C4, C4- C5, C5-C6, and C6-C7.
      KS at the inferior segment had a significant positive association with sROM at C2-C3, C3-C4,
      and C4-C5. For every point increase in KS at a given level, there was an associated 1.2
      degrees decrease in sROM at that level, and 0.8 degrees increase in sROM at the level above.
      Gender had a significant association with sROM only at C2-C3.

      A non-invasive infrared system Polaris was used to quantify the 3D tROM of the cervical spine
      in 140 asymptomatic volunteers (age 20-93 years, 70 males and 70 females). The standard error
      of measurement for the maximum tROM in 3D space planes was 5%. Gender had no significant
      influence on the 3D cervical tROM. Age had a significant influence on all main movements
      showing 0.55 - 0.79 degrees magnitude decrease per decade per segment.

      Later, an automatic fast and precise method for tracking cervical vertebrae in fluoroscopy
      videos of flexion- extension movement of the cervical spine was developed. The method relies
      only on a rough selection of template areas of each vertebra in a single frame of the video
      sequence, no contours need to be extracted and no vertebra segmentation is required. Tracking
      is done with a normalized gradient field, using only the gradient orientations as features.
      Results show that the algorithm is robust and able to track the vertebrae accurately, even if
      they are partially occluded or if a disc prosthesis is present.

      A clear definition of the normal sequence of segmental contributions in the cervical spine
      using extension cinematographic recordings (ECRs) was defined. They analysed healthy
      participants (n=20) and patients with CDDD (n=10). ECRs were more consistent than flexion
      cinematographic recordings (FCRs) and were therefore used to define "normal" motion. A
      consistent sequence of contribution of sagittal rotation of the three lower cervical motion
      segments C4-C7 was especially identified in the last phase of extension in healthy
      participants. The first peak was found for C4- C5, followed by C5-C6 and finally in C6- C7.
      Sensitivity, specificity, and reliability were calculated. Reliability of scoring as normal
      or abnormal is high (Fleiss kappa of 0.80-0.84, range of 95% CI: 0.66- 0.98). Sensitivity and
      specificity are also high, with an average sensitivity of 90% (range of 95% CI: 78.4 -
      99.8%), nd an average specificity of 85% (range of 95% CI: 72.9 - 96.4%). This is the first
      described method which can reliably differentiate between normal or abnormal movement of the
      cervical spine in an individual subject.5.6 Summary of known and potential risks and benefits
      Flexion- and extension cinematographic recordings are made using the Philips Allura Xper FD20
      X-ray system. Radiation dose per cinematographic recording, determined by radiation experts,
      will be around 0.084 mSv. Participants will perform cinematographic recordings twice,
      resulting in a total radiation dose of 0.168 mSv. Moreover, before definitive inclusion in
      the study a lateral X-ray of the cervical spine will be performed to determine eligibility
      resulting in a radiation dose of 0.0096 mSv. Average radiation dose per participant will
      therefore be 0.1776 mSv. This amount of radiation can be categorized in category IIa using
      the Neurocritical Care Society (NCS) guidelines about risks of radiation dosage (0.1 to 1
      mSv) 11. This category includes moderate risk which can be justified if there is a potential
      health benefit for future patients.

      6. METHODS 6.1 Study parameters/endpoints

      6.1.1 Main study parameter/endpoint To investigate whether the normal sequence of segmental
      contributions in the lower cervical spine during the second half of extension (C4-C5 followed
      by C5-C6, and then C6-C7), which is present in young asymptomatic controls, is similar in
      asymptomatic participants between 55 and 70 years of age by using cinematographic recordings.
      Recordings will be made at two occasions, with an interval of two weeks. These will then be
      analysed within one year.

      6.1.2 Secondary study parameters/endpoints (if applicable) Analysing sROM of C4-C5, C5-C6 and
      C6-C7 by analysing the flexion and extension cinematographic recordings in asymptomatic
      participants between 55 and 70 years of age. Recordings will be made at two occasions, with
      an interval of two weeks. These will then be analysed within one year.

      6.2 Randomisation, blinding and treatment allocation Not applicable.

      6.3 Study procedures This study does not use invasive procedures, but is not regular care.

      Investigations before inclusion in the study:

      Lateral X-ray of the cervical spine to determine Kellgrens' classification. The KS will be
      determined by two neurosurgeons and is a scoring method to determine severity of degenerative
      disc disease, using five gradations :

      Grade 0: absence of degeneration in the disc. Grade 1: minimal anterior osteophytosis. Grade
      2: definite anterior osteophytosis, possible narrowing of the disc space, some sclerosis of
      the vertebral plates.

      Grade 3: moderate narrowing of the disc space, sclerosis of the vertebral plates,
      osteophytosis.

      Grade 4: severe narrowing of the disc space, severe sclerosis of the vertebral plates,
      multiple large osteophytes.

      Questionnaire the NDI:

      The NDI is a modification of the Oswestry Low Back Pain Disability Index. It is a patient-
      completed, condition-specific functional status questionnaire with 10 items including pain,
      personal care, lifting, reading, headaches, concentration, work, driving, sleeping and
      recreation. Each section is scored on a 0 to 5 rating scale, in which zero means 'No pain'
      and 5 means 'Worst imaginable pain'. Al the points can be summed to a total score. The test
      can be interpreted as a raw score, with a maximum score of 50, or as a percentage. 0 points
      or 0% means: no activity limitations, 50 points or 100% means complete activity limitation.

      Investigations during the study:

      - Cinematographic recordings: participants are seated on a crutch, adjustable in height, with
      their neck, shoulders and head free. Before recordings are made, participants will be taught
      to perform the prescribed flexion and extension movement on about 16 seconds using a
      metronome. Participants are placed on the crutch with their shoulder's perpendicular to the
      image intensifier to obtain sagittal images from the occiput till C7. As soon as the
      recording is started, the participant is instructed to move his head in the sagittal plane
      from maximal ex- tension to maximal flexion, without moving the upper part of the body. It is
      important that the participants shoulders are kept as low as possible while making the
      recordings to ensure that all the cervical vertebrae are visible. The movement of the
      cervical spine should be as fluent as possible to prevent for sudden large rotations and
      translations between consecutive frames. The cinematographic recordings will be made twice
      with an interval of two weeks using the Philips Alura Xper FD20 X- ray system. To stay below
      the limit of 1 mSv per participant, the 0.9 mm Cu + 1 mm Al filter will be used for the
      entire study. The Alura Xper automatically selects correct tube voltage, with an expected
      maximum around 70-80 kV for cervical cinematographic recordings.

      6.4 Withdrawal of individual subjects Participants can cease study participation at any time
      for any reason if they wish to do so, without any consequences. If participants leave the
      study before the second recording, only the first recording will be included and analysed.

      Researchers cannot decide to withdraw participants from the study, unless participants do not
      respond to calls before the first cinematographic recording is made.

      6.5 Replacement of individual subjects after withdrawal If a participant withdraws before the
      first cinematographic recording is made, researchers are allowed to replace this
      participant.cal cinematographic recordings.

      6.6 Follow-up of subjects withdrawn from treatment Participants who withdraw from the study
      will not be actively recalled.

      6.7 Premature termination of the study Interim analysis will not be performed, so there will
      be no reason to terminate the study prematurely.

      7. SAFETY REPORTING 7.1 Temporary halt for reasons of subject safety In accordance to section
      10, subsection 4, of the WMO, the investigator will suspend the study if there is sufficient
      ground that continuation of the study will jeopardise subject health or safety. The sponsor
      will notify the accredited METC without undue delay of a temporary halt including the reason
      for such an action. The study will be suspended pending a further positive decision by the
      accredited METC. The investigator will take care that all subjects are kept informed.

      7.2 AEs, SAEs and SUSARs 7.2.1 Adverse events (AEs) Adverse events are defined as any
      undesirable experience occurring to a participant during the study, whether or not considered
      related to experimental intervention. All adverse events reported spontaneously by the
      participant or observed by the investigator or his staff will be recorded.

      7.2.2 Serious adverse events (SAEs) A serious adverse event is any untoward medical
      occurrence or effect that results in: Death.

      Is life threatening (at the time of event). Requires hospitalization or prolongation of
      existing inpatients' hospitalization. Results in persistent or significant disability or
      incapacity.

      Is a congenital anomaly or birth defect. Any other important medical event that did not
      result in any of the outcomes listed above due to medical or surgical intervention but could
      have been based upon appropriate judgement by the investigator. An elective hospital
      admission will not be considered as a serious adverse event. The investigator will report all
      SAEs to the sponsor without undue delay of obtaining knowledge of the events. Sponsor will
      report these SAEs through the web portal ToetsingOnline to the accredited METC that approved
      the protocol, within 7 days for SAEs that result in death or life- threatening event,
      followed by a period of maximum of 8 days to complete the initial preliminary report. All
      other SAEs will be reported within a period of maximum 15 days after sponsor has first
      knowledge of the serious adverse events.

      7.3 Follow-up of adverse events All AEs will be followed until they have abated, or until a
      stable situation has been reached. Depending on event, follow up may require additional tests
      or medical procedures as indicated, and/or referral to general physician or medical
      specialist. SAEs need to be reported till end of study (last follow up moment for last
      subject), as defined in the protocol.

      8. STATISTICAL ANALYSIS 8.1 Primary study parameter(s) The primary study parameter is to
      define if the normal sequence of segmental contributions in the lower cervical spine during
      the second half of extension (C4-C5 followed by C5-C6, and then C6-C7) is present in
      asymptomatic participants between 55 and 70 years of age by using cinematographic recordings.
      Participants are seated on a crutch, adjustable in height, with their neck, shoulders and
      head free. As soon as the recording is started, the participant is instructed to move his
      head in the sagittal plane from maximal extension to maximal flexion, without moving the
      upper part of the body, in about 16 seconds. Participants perform this procedure twice with
      an interval of two weeks. Images will be analysed using computer software that uses an
      algorithm to follow motion of the vertebrae during complete flexion and extension. This will
      be done by two researchers for 4 cinematographic recordings to determine reproducibility
      using two way mixed, absolute agreement, intra-class correlation coefficient. Graphs will be
      made for flexion and extension in which segmental rotation between each pair of successive
      frames of each individual segment within C4 to C7 will be plotted against the cumulative
      rotation in segments C4 to C7 together (block C4-C7) to describe the sequence of segmental
      contributions during flexion and extension. These graphs will be made and analysed for each
      individual participant to determine if the normal sequence of segmental contributions is
      present or absent. T1 will be tested against T2 using coefficient of variation and
      intra-individual standard deviation to determine if the defined sequence is consistent
      between two recordings in the intra-individual variability.

      8.2 Secondary study parameter(s) The secondary study parameter is defining the sROM of C4-C5,
      C5-C6 and C6- C7 by analysing the flexion and extension cinematographic recordings in
      asymptomatic participants between 55 and 70 years of age. Rotation within a segment is
      calculated between each pair of successive frames to be able to determine the sequence of
      segmental contributions. All these small rotations from extension to flexion (or vice versa)
      can be summated to calculate sROM for that motion segment.

      9. ETHICAL CONSIDERATIONS 9.1 Regulation statement This research is conducted according to
      principles enshrined in the Declaration of Helsinki (3th edition 2013) and in accordance with
      the Medical Research Involving Human Subjects Act (WMO, version 1 July 2012).

      9.2 Recruitment and consent Participants will be recruited from Zuyd Hogeschool
      Sittard/Heerlen and Zuyderland Medical Center Sittard-Geleen/Heerlen using posters. Possible
      participants have to contact the researcher by email if they are interested in participation.
      Further information will be given verbally and in writing, followed by a thinking time of
      seven days. When people are willing to participate and meet the inclusion criteria, informed
      consent will be signed during the first meeting between researcher and participant.
      Participants can terminate their participation at all times, without giving a reason. For any
      questions regarding the study, an independent physician is available throughout the duration
      of the study.

      9.3 Objection by minors or incapacitated subjects (if applicable) Not applicable.

      9.4 Benefits and risks assessment, group relatedness Participants do not directly benefit
      from participating in this study. They make a contribution to knowledge in the field of
      motion of the cervical spine in the elderly population. Increased knowledge of physiological
      motion enables us to recognize abnormal motion in future. Phantom measurements of the Alura
      Xper in Zuyderland Sittard were used to determine radiation dosage. According to radiation
      experts, radiation dosage per cinematographic recording will be 0.084 mSv. Participants will
      perform cinematographic recordings twice, resulting in a total radiation dose of 0.168 mSv.
      Moreover, before definitive inclusion in the study a lateral X-ray of the cervical spine will
      be performed to determine eligibility resulting in a radiation dose of 0.0096 mSv. Total
      radiation dose per participant will therefore be 0.1776 mSv. This amount of radiation can be
      categorized in category IIa using the NCS guidelines about risks of radiation dosage (0.1 to
      1 mSv). This category includes moderate risk which can be justified if there is a potential
      health benefit for future patients.

      9.5 Compensation for injury The sponsor/investigator has a liability insurance which is in
      accordance with article 7 of the WMO. The sponsor (also) has an insurance which is in
      accordance with the legal requirements in the Netherlands (Article 7 WMO). This insurance
      provides cover for damage to re- search subjects through injury or death caused by the study.
      The insurance applies to the damage that becomes apparent during the study or within 4 years
      after the end of the study.

      9.6 Incentives (if applicable) Participants will be reimbursed for extra time that is needed
      to fill out the questionnaires and undergo cinematographic recordings. They will receive €50
      for participating in T1 and T2. Participants that live outside of Sittard will receive
      mission expenses of €0.20 per kilometre.

      10. ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION 10.1 Handling and storage of data and
      documents Data will be stored in two ways; cinematographic recordings on CDs and
      questionnaires on paper. Both of them will be coded with participant-number (e.g. participant
      5). Cinematographic recordings will also be coded with recording-number (e.g. recording 5).
      CDs and questionnaires will be locked up in a secured room in the Maastricht University
      Medical Centre (MUMC+). Data analysis will also take place in the MUMC+. Data will be kept
      for 15 years after ending the study. Handling of personal data will comply with the Dutch
      Personal Data Protection Act (Wbp).

      10.2 Monitoring and Quality Assurance Monitoring will be performed by trained and qualified
      monitors. According to Good Clinical Practice (GCP) guidelines main task of the monitor is
      ensuring that: Rights and well-being of human participants are protected.

      Reported trial data are accurate, complete and verifiable from source documents.

      Conduct of trial is in compliance with currently approved protocol, GCP and applicable
      regulatory requirements.

      Prior to the study start a monitoring plan will be assembled, specifying Source Document
      Verification Plan, frequency of monitoring visits and frequency of checking Trial Master
      Files/Investigator Site Files.

      Monitoring will be performed remotely and on site.

      There are several kinds of monitoring visits:

      Site initiation visit (SIV): SIV will be performed after all approvals have been obtained and
      prior to enrolling the first subject in that centre.

      Interim monitoring visit (IMV): Several IMV's will be performed during the trial.

      Frequency of visits is determined in monitoring plan.

      - Close out visit (COV): COV will be performed at the end of the trial, after collection of
      all data. Monitoring visits will be planned in agreement with study site personnel. According
      to GCP guidelines, the investigators must provide the monitor with all necessary information
      and documents. Furthermore, the investigators are obliged to answer all queries raised by
      monitor in eCRF in timely manner. After each monitoring visit, a follow-up email with all
      action points will be sent to the study site. These action points will be addressed at
      beginning of the next monitoring visit.

      10.3 Amendments Amendments are changes made to the research after a favourable opinion by the
      accredited METC has been given. All amendments will be notified to the METC that gave a
      favourable opinion.

      10.4 Annual progress report The researcher will submit a summary of progress of the trial to
      the accredited METC once a year. Information will be provided on date of inclusion of the
      first subject, numbers of subjects included and numbers of subjects that have completed the
      trial, serious adverse events, other problems, and amendments.

      10.5 Temporary halt and (prematurely) end of study report The researcher will notify the
      accredited METC of the end of the study within a period of 8 weeks. The end of the study is
      defined as the last participants' last visit. The researcher will notify METC immediately of
      a temporary halt of the study, including reason of such an action. In case of ending the
      study prematurely, the researcher will notify the accredited METC within 10 days, including
      reasons for premature termination. Within one year after the end of the study, the researcher
      will submit a final study report with results, including any publications/abstracts, to the
      accredited METC.

      10.6 Public disclosure and publication policy This trial will be registered in a public trial
      register before recruitment of the first participant. Results will preferable be published in
      open access, peer-reviewed journals. Data of participants will be anonymous for publication
      and cannot be traced to an individual. In case of negative results, data will also be
      published. Possible funding has through contractual agreement no effect on publication. There
      is no veto over whether or not to publish data by one of the parties.
    

Intervention name(s): Cinematographic Recording
Intervention type(s): Diagnostic Test
Intervention description(s): A cinematographic recording during the second half of extension of the cervical spine will be made during 16 seconds at two timepoints with an interval of two weeks.
Intervention model: Single Group Assignment
Intervention model description: Fundamental research. Cinemathographic recordings will be made in healthy volunteers to determine physiological range of motion in the cervical spine. No health outcome of the intervention will be assessed.
Masking: None (Open Label)
Primary purpose: Basic Science
Keywords: Cervical Motion; Physiological movement; Cervical spine; Segmental Rage of Motion; Elderly; Lower Cervical Spine; Fundamental Research; Cinematographic recordings