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Cervical Proprioception and Sensorimotor Control

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on 26 February 2015

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Transcript of Cervical Proprioception and Sensorimotor Control

Another Tool for your Toolbox

Lets try it!
Cervical Proprioception and Sensorimotor Control
By: Alyssa Baletti, SPT
Joint Position Error (JPE) Test
Cx spine is more vulnerable to trauma with a variety of symptoms including:
Visual disturbances
Changes in concentration
Clinical Findings
Increased muscle tone
Impaired joint mobility
Pain- possible hypersensitivity
Decreased functional stability
Decreased proprioception
Decreased motor control
Never Underestimate Cx Proprioception of a Shark
Treatment Ideas
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.
Cervical Spine Anatomy
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.
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
Postural Control

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
Somatosensory System
Mechanoreceptors in muscle spindles interpret perception of:
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.

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
Vestibular System
Primary sensory system used when discrepancy between visual and somatosensory systems.

Eye movements:
Smooth pursuit
- stabilizes images of smoothly moving targets
- rapid small movements of both eyes simultaneously in changing a point of fixation
- stabilizes images on entire retina when the entire visual field is moving or while walking
Visual System
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)

How to Perform the Test?
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

tan-1(error distance/90cm)?!?!

Companies are creating more accurate clinical system to improve accuracy than just using a laser beam ie. The Fly
Stay Tuned!
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
Treatments for Cx Afferent Input
Test Specifics
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

: 1-2 times per day, 3-5 progressing to 10 reps.

" 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
"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.
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.
. 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.
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.

"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??

1, 3
1,2, 3
1, 3,5
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.
Exercises for mechanical neck disorders (Cochrane Review)
Gross et al.

Cervicocephalic kinesthetic sensibility in patients with cervical pain
Revel 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

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

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)
The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash
Treleaven et al.
Other Reliability Studies
Treatment Ideas
Full transcript