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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

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Postural Control

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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

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Cervical Spine Anatomy

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  • 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

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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

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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.

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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

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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

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How to Perform the Test?

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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.

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" 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

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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.

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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.

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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

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"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

Treatment Ideas

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