1,2, 3
Cervical Spine
- Afferent signal can be altered by:
- Chemical changes- ischemic or inflammation
- Reflex joint inhibition of m. spindles
- Pain- change m. spindle sensitivity & altered presentation and modulation of input
- Psychosocial distress
- Functional impairment of m. ie fatiguability, degenerative changes, fatty infiltrate, atrophy
- Changes can be associated with afferent changes in Cx spine:
- Altered postural stability
- Cervical proprioception
- Head-eye movement control
1,2,3
Postural Control
1,2
Symptoms
Cx spine is more vulnerable to trauma with a variety of symptoms including:
- Dizziness
- Unsteadiness
- Visual disturbances
- Vertigo
- Nasea
- Fatigue
- Headaches
- Changes in concentration
- Requires musculoskeletal and sensorimotor function
- Postural Orientation: " relative positioning of body segments with respect to each other and to the environment"
- Postural Equilibrium: "all forces acting on the body tend to keep the body in a desired position and orientation (static equilibrium) or to move in a controlled way (dynamic equilibrium)"
- Receives inputs from somatosensory, vestibular and visual systems
1, 3
Cervical Spine Anatomy
1,2,3
- Upper Cx spine is the most mobile levels of the vertebral column
- Increased mobility is at the expense of limited mechanical stability.
- Cx spine has a well developed proprioception system to provide N-M control to the mobile Cx spine.
Vestibular System
1,2,3
Somatosensory System
Visual System
- Goal: maintain adequate postural tone in trunk & extremities to provide balance during posture and locomotion.
- Semicircular canals: receptors receive input in changes in angular velocity.
- Otolithic membrane: (utricules and saccular macculae) position and velocity relative of gravity forces. The info is sent to vestibular n. and cerebellum
- Mechanoreceptors in muscle spindles interpret perception of:
- pain
- temperature
- touch
- proprioception
- CNS input of head orientation via neurophysiological connections to vestibular and visual systems.
- Secondary proprioceptive input: joint receptors and golgi tendon organs refine input.
- Upper cervical muscle: numerous mechanorecptors in gamma motor neurons to provide feedback
- Upper Cx spine: more likely to have disturbances compared to lower Cx spine due to abundance of mechanoreceptors.
- Primary sensory system used when discrepancy between visual and somatosensory systems.
- Eye movements:
- Smooth pursuit- stabilizes images of smoothly moving targets
- Saccadic - rapid small movements of both eyes simultaneously in changing a point of fixation
- Optokinetic- stabilizes images on entire retina when the entire visual field is moving or while walking
1,2
Cervical Pain and Whiplash
- Second most common diagnosis attend physical therapy and chiropractors, following LBP
- 1/3 of pts with cervical diagnoses have whiplash associated disorder (WAD)
- PT has been found to provide short term relief by treating musculoskeletal interventions.
1,3,4
Clinical Findings
- Increased muscle tone
- Impaired joint mobility
- Pain- possible hypersensitivity
- Decreased functional stability
- Decreased proprioception
- Decreased motor control
Cervical Proprioception and Sensorimotor Control
Joint Position Error (JPE) Test
3,4
tan-1(error distance/90cm)?!?!
Cervicocephalic kinesthetic sensibility in patients with cervical pain
Revel et al.
The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash
Treleaven et al.
- Pts with chronic cervicalgia n = 32, mean age = 45 years
- Healthy controls: n = 30, mean age = 44 years
- < 4.5 degrees (horizontal) denotes “normal” cervical
proprioception. (Sn 86%, Sp 93%)
- > 4.5 degrees (horizontal) indicates abnormal cervical
proprioception.
- n = 100 with WAD, n = 40 healthy controls
- JPE, standing balance, smooth pursuit neck torsion test
- Results to determine if pt has balance or smooth pursuit neck torsion deficits
- Positive Predictive Value: 88%
- Sensitivity: 60%
- Specificity: 54%
- The results suggest that in patients with persistent WAD, it is not sufficient to measure JPE alone. All three measures are required to identify disturbances in the postural control system
- 7.1 cm error distance = meaningful error of 4.5 degrees called joint position error.
- Errors > 4.5 degrees = impairment of relocation accuracy of head-neck
- Include quality of motion assessment:
- Jerky or altered movement patterns
- Overshoot for increased feedback
- "Searching" for position
- Occasional reproduction of dizziness
3,4
How to Perform the Test?
11,12
3,4
Other Reliability Studies
Test Specifics
1. Pt is asked to find resting position for a few sec sitting 90 cm away from a wall.
2. Close eyes- actively move head and then try to come back to the resting position as accurately as possible.
3. The difference in positions is measured in cm then converted to degrees:
angle (in degrees) = tan-1(error distance/90cm)
By: Alyssa Baletti, SPT
Test Re-test Reliability for pts with Chronic Cervical Pain:
Adequate to Excellent: relocation to neutral head position: ICC = 0.45 - 0.80;
Poor relocation from Extension to NHP: ICC = 0.29
Adequate to Excellent: head to target: ICC = 0.42 - 0.90
Inter/Intratester Reliability s/p Whiplash Injury:
- Total n = 22
- Whiplash injury n = 11, mean age = 42, time from injury > 3 months < 2 years
- Control group n = 11, mean age = 43
Interrater reliability ICC = 0.972
Intrarater reliability ICC = 0.975 (therapist 1), ICC = 0.985 (therapist 2)
"Test-retest reliability of cervicocephalic relocation test to neutral head position"
Pinsault et al.
- 40 subjects performed test with rotation from B sides to neutral head position
- 10 trials were preformed
- ICC ranging from fair to excellent (0.52 to 0.81)
- > 0.75 indicates ‘‘excellent’’ reliability
- 0.40 and 0.75 indicated "fair to good" reliability
- < 0.40 indicates ‘‘poor’’ reliability
- Absolute and variable errors: 0.49-0.77
- Excellent in global and horizontal
- Fair in vertical
- Increase # of trials: ICC reliability increased; error decreased
- Article recommends 8 times to have fair to excellent reliability.
References
1. Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther. 2009;39(5):364-77.
2. Armstrong B, Mcnair P, Taylor D. Head and neck position sense. Sports Med. 2008;38(2):101-17.
3. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. J Orthop Res. 2007;25(3):404-12.
4. Pinsault N, Fleury A, Virone G, Bouvier B, Vaillant J, Vuillerme N. Test-retest reliability of cervicocephalic relocation test to neutral head position. Physiother Theory Pract. 2008;24(5):380-91.
5. Treleaven J, Jull G, Lowchoy N. The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash. Man Ther. 2006;11(2):99-106.
6. Swait G, Rushton AB, Miall RC, Newell D. Evaluation of cervical proprioceptive function: optimizing protocols and comparison between tests in normal subjects. Spine. 2007;32(24):E692-701.
7. Jorgensen R, Ris I, Falla D, Juul-kristensen B. Reliability, construct and discriminative validity of clinical testing in subjects with and without chronic neck pain. BMC Musculoskelet Disord. 2014;15:408.
8. Gross A, Kay TM, Paquin JP, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015;1:CD004250.
9. Revel, M., Andre-Deshays, C., et al. . "Cervicocephalic kinesthetic sensibility in patients with cervical pain." Arch Phys Med Rehabil 1991;72(5): 288-291.
10. Treleaven, J., Jull, G., et al. (2006). "The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash." Man Ther. 2006;11(2): 99-106.
11. Lee, H. Y., Teng, C. C., et al. (2006). "Test-retest reliability of cervicocephalic kinesthetic sensibility in three cardinal planes." Man Ther. 2006; 11(1): 61-68.
12. Loudon, J. K., Ruhl, M., et al. "Ability to reproduce head position after whiplash injury." Spine (Phila Pa 1976) 1997; 22(8): 865-868.
5
" Evaluation of Cervical Proprioceptive Function: Optimizing Protocols and Comparison Between Tests in Normal Subjects"
Swait et al.
- Number of trials of cervical JPE test and cervicocephalic kinesthesia test to obtain reliable and stable objective measurements.
- ICC used to assess reliability of multiple data trials
- JPE test: 5 or more trials had the greatest reliability
- ICC= 0.73 - 0.84
- Cervicocephalic kinesthesia test: 5 or more trial
- ICC= .90-.97
- There is no correlation to the performances between the two tests
- r = -0.476- 0.228 p>0.0.5
- Recommend 6 trials to improve reliability
Another Tool for your Toolbox
Lets try it!
Stay Tuned!
Never Underestimate Cx Proprioception of a Shark
Companies are creating more accurate clinical system to improve accuracy than just using a laser beam ie. The Fly
http://www.jospt.org/doi/suppl/10.2519/jospt.2009.2834/suppl_file/May2009-Kristjansson-Video.mp4
8
Exercises for mechanical neck disorders (Cochrane Review)
Gross et al.
Chronic neck pain
Moderate quality evidence supports:
1) Cervico-scapulothoracic/upper extremity strength training to improve pain post treatment & short-term follow-up
2) Scapulothoracic/upper extremity endurance training for mild beneficial effect on pain at immediate post treatment and short-term follow-up
3) Combined cervical, shoulder and scapulothoracic strengthening/stretching exercises with small to large improvement of pain & medium magnitude of improved function
4) Cervico-scapulothoracic strengthening/stabilization exercises to improve pain
and function at intermediate term
5) Mindfulness exercises (Qigong) minimally improved function after treatment
Low evidence suggests :
1) Breathing exercises
2) General fitness training
3) Stretching alone
Very low evidence suggests:
1. Neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.
1, 3,5
Treatments
- If JPE test is positive:
- Start training in neutral
- Progress to other ranges
- Maze tracing/ Figure 8s
- Challenging positions- standing, balancing on one leg
- Exercises should NOT increase pain or headache
- Some exacerbation of dizziness, nausea, unsteadiness &/or visual disturbances is acceptable.
- If increased pain:
- Try a more stable position- lying
- Decrease reps
- Gradually introduce exercise training
- Goal: 1-2 times per day, 3-5 progressing to 10 reps.
1,2,6,7
Treatments for Cx Afferent Input
- Neuromuscular control training- Cx positional sense
- Manipulative therapy- improve joint position sense and dizziness
- Cervical muscular endurance training -improve balance and postural control
- Acupuncture- Cx position sense, vertigo and standing balance
"Retraining cervical joint position sense: the effect of two exercise regimes "
Jull et al.
- 64 subjects with persistent neck pain
- Comparing effectiveness on JPE test, pain and disability level after proprioceptive training or craniocervical flexion training.
- Head relocation practice- back to neutral and various ranges. Progressed to eyes closed.
- Gaze stability
- Eye-follow and eye/head coordination
- Oculomotor exercises: eye movement with the head stationary, movements of the head with visual fixation on a target.
- leading with the eyes first to a target, followed by the head, ensuring the eyes are focused
- All subjects in both groups improved after training at 6 weeks of trianing- JPE, NDI, NPRS
- Subjects with proprioceptive training demonstrated improved JPE test with R rotation compared craniocervical flexion training
- Long term??
Treatment Ideas