Submitted by
Hajrah Mohammad Hafeez

In the partial Fulfillment for the Degree of
Doctor of Physical Therapy

Dr Umair Ahmed
Assistant Professor

University Institute of Physical Therapy
Faculty of Allied Health Sciences
(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

Supervisor Dr Umair Ahmed
Assistant Professor



HOD, University Institute of Physical Therapy

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

External Examiner Internal Examiner

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)


I Hajrah Mohammad Hafeez (DPT01133113) declare that the contents of my thesis
entitled ”
(Thesis topic)”
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.

Student’s Name


The University of Lahore
Faculty of Allied Health Sciences
University Institute of Physical Therapy (UIPT)

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Sr.No. Contents Page No.


Background and Introduction




Key Words:



Wearing 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(1). Females in Islamic
cultures wear the headscarf when they are in public and usually begin wearing it at the onset of
puberty (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(3).
According to the Pew Research Center (2014), there are approximately 1.7 billion Muslims in the
world(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(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(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(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)(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(9). Additionally soft neck collars significantly reduced
cervical spine rotation(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(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.



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(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(9).

Cervical ROM can be a predictive outcome measure for neck-pain related conditions. Kasch et
al(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(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(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 (p5
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.


The objective is to assess the effect of wearing hijab on cervical mobility.



Study Design: Cross-sectional survey

Setting: Data was collected from University of Lahore, Main campus

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



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.



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.



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

The mean age was 26.60±5.81


Table II BMI
Mean 23.1456
Std. Deviation 3.33547
Minimum 18.15
Maximum 30.20

The mean BMI was 23.14±3.33


Table III Height
Mean 5.4071
Std. Deviation .12663
Minimum 5.20
Maximum 5.80

The mean height was 5.4±0.12


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

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


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

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

It was observed that 57.1% of hijabis 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


Right Rotation

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

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

The mean for left rotation was 81.07±3.66



Table XI Flexion
Mean 57.8571
Std. Deviation 2.6772
Minimum 53.00
Maximum 62.00

The mean cervical flexion was 57.85±2.67



Table XII Extension
Mean 67.500
Std. Deviation 2.7333
Minimum 62.00
Maximum 73.00

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


Table XV
Do you wear scarf
on regular basis?
N Mean Std. Deviation t test p-valu
yes 35 80.89 4.13 -6.00