{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T03:44:24Z","timestamp":1792554264400,"version":"4.5.0"},"reference-count":15,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T00:00:00Z","timestamp":1792454400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract\u2003<\/jats:title>\n                  <jats:p>Improvements in cervical endurance hold (CEH) time have been used as evidence that training interventions reduce neck pain risk in Air Force fighter pilots. This assumes that a longer hold time reflects a meaningfully lower risk of neck pain in this population, an assumption that remains unvalidated. We examine the reliability and validity evidence for the CEH and argue that its use as a surrogate for training success should be reconsidered. The CEH, known as Grimmer\u2019s test, shows strong intra-rater reliability but considerably weaker inter-rater reliability, particularly where test cessation depends on subjective examiner judgment rather than pain or exhaustion. No reliability data exist for this test in fighter pilots specifically. Validity evidence in this population was absent until a 2026 study of Royal Air Force Typhoon pilots found no significant correlation between neck flexor endurance and flight-related neck pain, despite high pain prevalence in the cohort. This is the first direct test of the assumption underlying the test\u2019s current use as an outcome measure, and it does not support that assumption. Prior evidence further suggests that neck pain in military pilots is more associated with coronal plane strength than the sagittal plane flexion this test assesses, and evidence that training cervical endurance reduces neck pain incidence remains mixed. An improvement in hold time is weak evidence that an intervention reduced neck pain risk. We recommend that the CEH be reported as a measure of endurance, not a proxy for pain outcomes, with future work evaluating coronal plane and extension-based alternatives.<\/jats:p>","DOI":"10.1093\/milmed\/usag486","type":"journal-article","created":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T23:47:36Z","timestamp":1792540056000},"source":"Crossref","is-referenced-by-count":0,"title":["Improved Hold Time, Unproven Benefit: Reassessing the Cervical Endurance Hold as an Outcome Measure in Fighter Pilots"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-8290-5769","authenticated-orcid":false,"given":"Anthony","family":"Acevedo","sequence":"first","affiliation":[{"name":"Exercise and Nutritional Sciences, College of Natural Science, Grand Canyon University , Phoenix, AZ 85017,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7690-8221","authenticated-orcid":false,"given":"Zachary","family":"Zeigler","sequence":"additional","affiliation":[{"name":"Exercise and Nutritional Sciences, College of Natural Science, Grand Canyon University , Phoenix, AZ 85017,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,10,20]]},"reference":[{"key":"2026102023364641300_usag486-B1","doi-asserted-by":"publisher","first-page":"465","DOI":"10.1093\/milmed\/usae153","article-title":"Performance optimization and injury mitigation for Air Force student fighter pilots","volume":"189","author":"Chayrez","year":"2024","journal-title":"Mil Med"},{"key":"2026102023364641300_usag486-B2","doi-asserted-by":"publisher","first-page":"605","DOI":"10.1093\/milmed\/usaf284","article-title":"Evaluating the impact of a spine training program on Air Force student fighter pilots","volume":"190","author":"Chayrez","year":"2025","journal-title":"Mil Med"},{"key":"2026102023364641300_usag486-B3","doi-asserted-by":"publisher","first-page":"559","DOI":"10.3357\/asem.2935.2011","article-title":"Neck pain among fighter pilots after the introduction of the JHMCS helmet and NVG in their environment","volume":"82","author":"Lange","year":"2011","journal-title":"Aviat Space Environ Med"},{"key":"2026102023364641300_usag486-B4","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1136\/oemed-2014-102268","article-title":"Cervical and lumbar pain and radiological degeneration among fighter pilots: a systematic review and meta-analysis","volume":"72","author":"Shiri","year":"2015","journal-title":"Occup Environ Med"},{"key":"2026102023364641300_usag486-B5","doi-asserted-by":"publisher","first-page":"1092","DOI":"10.3357\/ASEM.3146.2012","article-title":"Gz-induced spinal symptoms in fighter pilots: operational and individual associated factors","volume":"83","author":"Wagstaff","year":"2012","journal-title":"Aviat Space Environ Med"},{"key":"2026102023364641300_usag486-B6","doi-asserted-by":"publisher","first-page":"e245","DOI":"10.1097\/JOM.0000000000002519","article-title":"Healthcare avoidance in aircraft pilots due to concern for aeromedical certificate loss: a survey of 3765 pilots","volume":"64","author":"Hoffman","year":"2022","journal-title":"J Occup Environ Med"},{"key":"2026102023364641300_usag486-B7","author":"Mattock","year":"2019"},{"key":"2026102023364641300_usag486-B8","doi-asserted-by":"publisher","first-page":"251","DOI":"10.1016\/S0004-9514(14)60461-X","article-title":"Measuring the endurance capacity of the cervical short flexor muscle group","volume":"40","author":"Grimmer","year":"1994","journal-title":"Aust J Physiother"},{"key":"2026102023364641300_usag486-B9","doi-asserted-by":"publisher","first-page":"134","DOI":"10.1016\/j.jmpt.2005.12.009","article-title":"Reliability of a clinical test for deep cervical flexor endurance","volume":"29","author":"Olson","year":"2006","journal-title":"J Manipulative Physiol Ther"},{"key":"2026102023364641300_usag486-B10","doi-asserted-by":"publisher","first-page":"1349","DOI":"10.1093\/ptj\/85.12.1349","article-title":"Reliability of a measurement of neck flexor muscle endurance","volume":"85","author":"Harris","year":"2005","journal-title":"Phys Ther"},{"key":"2026102023364641300_usag486-B11","doi-asserted-by":"publisher","first-page":"332","DOI":"10.1080\/21679169.2019.1626906","article-title":"Reliability and validity of clinical tests to assess the function of the cervical spine in adults with neck pain and its associated disorders: part 5. A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) collaboration","volume":"22","author":"Lemeunier","year":"2020","journal-title":"Eur J Physiother"},{"key":"2026102023364641300_usag486-B12","doi-asserted-by":"publisher","first-page":"478","DOI":"10.3357\/AMHP.6564.2026","article-title":"Relationship between neck flexor endurance and flight-related neck pain in Typhoon pilots","volume":"97","author":"Magill","year":"2026","journal-title":"Aerosp Med Hum Perform"},{"key":"2026102023364641300_usag486-B13","doi-asserted-by":"publisher","first-page":"448","DOI":"10.1016\/j.jmpt.2022.09.006","article-title":"Neck strength in coronal and sagittal head movement in military pilots and aircrew with chronic neck pain: a systematic review with meta-analysis","volume":"45","author":"Miranda","year":"2022","journal-title":"J Manipulative Physiol Ther"},{"key":"2026102023364641300_usag486-B14","doi-asserted-by":"publisher","first-page":"425","DOI":"10.3357\/AMHP.6597.2025","article-title":"Exercise training and neck pain in fighter pilots","volume":"96","author":"Acevedo","year":"2025","journal-title":"Aerosp Med Hum Perform"},{"key":"2026102023364641300_usag486-B15","doi-asserted-by":"publisher","first-page":"611","DOI":"10.1177\/17479541251388819","article-title":"Neck training in military pilots: a scoping review","volume":"21","author":"Bruno","year":"2026","journal-title":"Int J Sports Sci Coach"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article-pdf\/doi\/10.1093\/milmed\/usag486\/72141491\/usag486.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article-pdf\/doi\/10.1093\/milmed\/usag486\/72141491\/usag486.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T03:36:51Z","timestamp":1792553811000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article\/doi\/10.1093\/milmed\/usag486\/8944173"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,20]]},"references-count":15,"URL":"https:\/\/doi.org\/10.1093\/milmed\/usag486","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,20]]},"article-number":"usag486"}}