Cervicocephalic kinesthetic sensibility in young and middle-aged adults with or without a history of mild neck pain

Previous research has shown that there is no significant relationship between the degree of structural degeneration of the cervical spine and neck pain. We therefore sought to investigate the potential role of sensory dysfunction in chronic neck pain. Cervicocephalic kinesthetic sensibility, expressed by how accurately an individual can reposition the head, was studied in three groups of individuals, a control group of 20 asymptomatic young adults and two groups of middle-aged adults (20 subjects in each group) with or without a history of mild neck pain. An ultrasound-based three-dimensional coordinate measuring system was used to measure the position of the head and to test the accuracy of repositioning. Constant error (indicating that the subject overshot or undershot the intended position) and root mean square errors (representing total errors of accuracy and variability) were measured during repositioning of the head to the neutral head position (Head-to-NHP) and repositioning of the head to the target (Head-to-Target) in three cardinal planes (sagittal, transverse, and frontal). Analysis of covariance (ANCOVA) was used to test the group effect, with age used as a covariate. The constant errors during repositioning from a flexed position and from an extended position to the NHP were significantly greater in the middle-aged subjects than in the control group (beta=0.30 and beta=0.60, respectively; P<0.05 for both). In addition, the root mean square errors during repositioning from a flexed or extended position to the NHP were greater in the middle-aged subjects than in the control group (beta=0.27 and beta=0.49, respectively; P<0.05 for both). The root mean square errors also increased during Head-to-Target in left rotation (beta=0.24;P<0.05), but there was no difference in the constant errors or root mean square errors during Head-to-NHP repositioning from other target positions (P>0.05). The results indicate that, after controlling for age as a covariate, there was no group effect. Thus, age appears to have a profound effect on an individual's ability to accurately reposition the head toward the neutral position in the sagittal plane and repositioning the head toward left rotation. A history of mild chronic neck pain alone had no significant effect on cervicocephalic kinesthetic sensibility.     

Cervicocephalic Relocation Test to the Neutral Head Position: Assessment in Bilateral Labyrinthine-Defective and Chronic, Nontraumatic Neck Pain Patients

Pinsault N, Vuillerme N, Pavan P. Cervicocephalic relocation test to the neutral head position: assessment in bilateral labyrinthine-defective and chronic, nontraumatic neck pain patients.

Objective

To determine whether vestibular or cervical proprioceptive information influence the cervicocephalic relocation test to the neutral head position, by comparing head repositioning errors obtained in asymptomatic, unimpaired control subjects with those obtained in bilateral labyrinthine-defective patients and chronic, nontraumatic neck pain patients.

Design

A group-comparison study.

Setting

University medical bioengineering laboratory.

Participants

Labyrinthine-defective patients (n=7; mean age ± SD, 67±15y), nontraumatic neck pain patients (n=7; 56±9y), and asymptomatic, unimpaired control subjects (n=7; 64±12y).

Interventions

Participants were asked to relocate the head on the trunk, as accurately as possible, after full active cervical rotation to the left and right sides. Ten trials were performed for each rotation side.

Main Outcome Measures

Absolute and variable errors were used to assess accuracy and consistency of the repositioning, respectively.

Results

No significant difference in repositioning errors was observed between labyrinthine-defective patients and control subjects, whereas nontraumatic neck pain patients demonstrated significantly increased absolute errors in horizontal and global components and higher variable errors in horizontal component.

Conclusions

These findings suggest that the vestibular system is not involved in the performance of the cervicocephalic relocation test to neutral head position, and further support this test as a measure of cervical proprioceptive acuity.     

Effect of dorsal neck muscle fatigue on cervicocephalic kinaesthetic sensibility

It has been hypothesized that proprioceptive information plays an important role in cervical spine stabilization and that muscle fatigue may alter proprioceptive ability. Therefore, we investigated the effects of specific dorsal neck muscle fatigue on cervicocephalic kinaesthetic sensibility. Twenty-five asymptomatic young adults (age range 18-30 years) were recruited for the study. The subjects were measured for dorsal neck muscle strength (kg) with a digital dynamo-meter. The repositioning errors (degrees) were measured by two cervicocephalic kinaesthetic sensibility tests: the head-to-neutral head position repositioning and head-to-target repositioning tests. The repositioning tests were performed in the sagittal, transverse and frontal planes. The subjects were then exposed to a dorsal neck muscles fatiguing exercise protocol, after which the dorsal neck muscle strength and repositioning errors were again measured. Dorsal neck muscle strength was significantly reduced and repositioning errors in the sagittal plane were significantly increased after the fatiguing protocol (p < 0.001). However, in terms of frontal and transverse plane movements, no difference in repositioning errors was found following the fatiguing protocol. Dorsal neck muscle fatigue alters cervical position sense in sagittal plane movements. Improving the strength of these muscles might play a vital role in maintaining cervical position sense.     

Association between cervicocephalic kinesthetic sensibility and frequency of subclinical neck pain

Although impaired neck proprioception has been demonstrated in patients with chronic neck pain, previous studies have not consistently shown any association between pain intensity and proprioceptive performance. We therefore investigated whether temporal aspects of pain are associated with cervicocephalic kinesthetic sensibility. One hundred and twenty-seven adults with or without subclinical neck pain undertook two tasks, repositioning their heads to the neutral head position (head-to-NHP) and target position (head-to-target) in sagittal and transverse plane. Absolute error was calculated from position data recorded by an ultrasound-based motion analysis system. Pain frequency, duration, and intensity were evaluated using a questionnaire. A mixed effects model was constructed to test the effect on reposition error by different pain factors, with age, gender and maximal cervical range of motion as covariates. A higher pain frequency was associated with greater reposition errors for all movement directions in the head-to-NHP task. No consistent effect was observed for pain intensity or duration. In the case of the head-to-target task, no consistent effect was observed for any of the three pain factors. The findings reveal that pain frequency, not the intensity or duration of pain, is associated with neck proprioception in individuals with subclinical neck pain.     

Impact of nociceptive stimuli on cervical kinesthesia]

The goal of this study was to evaluate the impact of nociceptive stimuli upon the cervical proprioception ability. METHOD: Thirty healthy young subjects performed a cervicocephalic relocation test (CRT) in two random conditions: the first one was based on a nociceptive electric stimulation called condition "pain", whereas the second one was targeting a painless electric condition called condition "control". The CRT consisted of repositioning the head on the trunk, after an active transversal movement of the head in the transverse field with closed eyes. The pointing was recorded at the beginning and at the end of each rotation using a custom video acquisition system. RESULTS: The average mean of error repositioning was worth 3.98+/-0.99 degrees (average mean, standard deviation) in the condition "pain", and 1.75+/-0.37 degrees in the condition "control" (p<0.01). CONCLUSION: Acute pain provokes a disturbance of the cervical proprioception ability without damaging the anatomic structure. This observation suggests the interest of an early follow-up of the pain to avoid sensory disturbances, as well as the establishment of a cervical proprioceptive rehabilitation program after an algic event.     

Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study

In a single-subject experiment undertaken on 14 consecutive patients, the effects of acupuncture, cervical manipulation, no therapy, and NSAID-percutan application on kinesthetic sensibility, dizziness/vertigo and pain were studied in patients with dizziness/vertigo of suspected cervical origin. The ability to perceive position of the head with respect to the trunk was studied. The effects of different forms of therapy-and none-on dizziness and neck pain were compared, using a 100 mm visual analogue scale (VAS). Active head relocation by subjects with dizziness was significantly less precise than in the control group. Manipulation was the only treatment to diminish the duration of dizziness/vertigo complaints during the past 7 days and increased the cervical range of motion. Both acupuncture and manipulation reduced dizziness/vertigo on the VAS scale and had positive effects on active head repositioning. Ketoprofen percutan application and acupuncture both alleviated pain. The results of this study would suggest that spinal manipulation may impact most efficiently on the complex process of proprioception and dizziness of cervical origin.     

Test de repositionnement céphalique : étude de la stabilité de performance

OBJECTIVE: The purpose of the present experiment was to determine the reliability of the cervicocephalic relocation test (CRT). METHODOLOGY: Thirteen young healthy adults were recruited to undergo a CRT test-retest. The test-retest reliability was determined by repeatedly measuring CR to a neutral position after active movement, with trials approximately 1 hour apart. Each CRT involved 20 CRs to a natural head position, 10 repositioning after right head rotation, and 10 repositioning after left head rotation (with the order of rotation sides randomized). The performance score for each subject for each CRT was the mean of the errors made during the 20 relocations (in degrees). STUDY RESULTS: The mean rate of error of the first and second trials was 3.2+/-1.1 degrees and 2.9+/-0.9 degrees, respectively. The intra class correlation coefficient was 0.81, and the standard error of measurement 0.90 degrees. CONCLUSION: CRT testing supports evidence of reliable cervicocephalic performance stability in healthy young adults. CRT shows promise as a relevant tool of assessment in head and neck proprioception.     

Generalised muscular hyperalgesia in chronic whiplash syndrome.

The whiplash syndrome has immense socio-economic impact. Despite extensive studies over the past years, the mechanisms involved in maintaining the pain in chronic whiplash patients are poorly understood. The aim of the present experimental study was to examine the muscular sensibility in areas within and outside the region involved in the whiplash trauma. Eleven chronic whiplash patients and 11 sex and age matched control subjects were included in the study. Before the experiment, the whiplash patients had pain in the neck and shoulder region with radiating pain to the arm. Five patients reported pain that was more widespread. The somatosensory sensibility in the areas over the infraspinatus, brachioradial, and anterior tibial muscles was assessed by pressure stimulation, pin-prick stimulation, and cotton swap stimulation. Infusion of hypertonic saline (5.85%, 0.5 ml) into the infraspinatus and anterior tibial muscles was performed to assess the muscular sensibility and referred pain pattern. The saline-induced muscle pain intensity was assessed on a continuous visual analogue scale (VAS). The distribution of pain was drawn on an anatomical map. The pressure pain thresholds were significantly lower in patients (P<0. 01) compared with controls: infraspinatus (mean 152.2 vs. 172.7 kPa), brachioradial (mean 70.0 vs. 363.8 kPa), and anterior tibial muscle (mean 172.7 vs. 497.8 kPa). The skin sensibility to pin-prick stimulation and cotton swap stimulation was not different between patients and controls. Infusion of hypertonic saline caused significantly higher VAS scores with longer duration in patients compared to control subjects (P<0.01). The area under the VAS-time curve was significantly (P<0.01) increased in patients compared to control subjects after injection into the infraspinatus muscle (mean 4138.1 vs. 780.0 cm s) and anterior tibial muscle (mean 4370.8 vs. 978.7 cm s). The saline infusion caused local pain defined as pain located around the injection site and referred pain areas not included in the local pain area. The area of local and referred pain were significantly larger in patients compared to control subjects (P<0.01). In the control group, the referred pain areas to infusion of hypertonic saline into the anterior tibial muscle were found at the dorsal aspect of the ankle. In contrast, the areas of referred pain were quite widespread in the patient group with both distal and proximal referred pain areas. In the present study, muscular hyperalgesia and large referred pain areas were found in patients with chronic whiplash syndrome compared to control subjects both within and outside the traumatised area. The findings suggest a generalised central hyperexcitability in patients suffering from chronic whiplash syndrome. This indicates that the pain might be considered as a neurogenic type of pain, and new pharmacological treatments should be investigated accordingly.     

Cervical outcome measures: testing for postural stability and balance

BACKGROUND: Clinical tests assessing a correlation between structural pathology and cervical pain have been unsuccessful, leading the way for the development of functionally based tests. The purpose of this narrative is to review 4 promising functional tests for the assessment of sensorimotor dysfunction in patients with neck pain. The Joint Position Error/Head Repositioning Accuracy tests, and the Rod and Frame Test were reviewed. SPECIAL FEATURES: The SPNTT was developed to test proprioceptive mechanisms in the neck by applying torsion to mainly mechanoreceptors in the cervical spine. The Joint Position Error and Head Repositioning Accuracy test cervicocephalic kinesthesia or the ability to perceive both movement and position of the head in space related to the trunk. The Rod and Frame Test assesses patients' perception of the vertical orientation of their head in 3-dimensional space. All of these tests evaluate important mechanisms responsible for maintaining postural stability and balance and are thought to be applicable for use in mechanical neck pain patients. SUMMARY: All of the reviewed tests show clinical promise because they are able to distinguish patients with neck pain, particularly those with whiplash trauma and dizziness from asymptomatic controls. All of the tests assess cervical sensorimotor dysfunction, although considerably more research is needed to more clearly establish the psychometric properties for each test including minimal clinical important difference. Although these tests can be used in routine clinical practice, they should be used in combination with other related tests.     

Is the sagittal configuration of the cervical spine changed in women with chronic whiplash syndrome? A comparative computer-assisted radiographic assessment

OBJECTIVE: To reveal whether women with chronic whiplash-associated disorder (WAD) symptoms, grade I-II, demonstrate regional and/or segmental radiographic signs of altered cervical lordosis. DESIGN: Case-control study. SETTING: Radiography department at a university hospital. PARTICIPANTS: Three age-balanced groups comprising 120 women. The case group included women with chronic whiplash syndrome (n = 41), and the control group included women with chronic insidious onset neck pain (n = 39) and an asymptomatic group (n = 40), who were given baseline data. The sample was referred from informed doctors and physiotherapists. INTERVENTION: The women sat in a standardized sitting position and radiographs were taken in a lateral position with fluoroscopic control for alignment. Outcome Measures: Two distinct measurements were taken; 1 of the angles of the upper and lower cervical curvatures, respectively, and 1 of the angles between the inferior borders of each pair of vertebrae in the lower cervical spine. The 3 groups were compared on the ratio of the lower to upper cervical spine angles and on the mean angular values for each segment in the cervical spine. RESULTS: The whiplash group showed a decreased ratio between the lower versus upper cervical spine but comparisons between groups were not statistically significant. The whiplash group was in a significantly more flexed position at the C4-C5 level compared with the asymptomatic group (P =.007). The reliability measures have to be strengthened to render these results definitely conclusive. CONCLUSION: The whiplash group exhibited a different configuration of cervical lordosis. This is clinically important and needs to be studied more closely.     

Cervical muscles weakness in chronic whiplash patients

BACKGROUND: Isometric cervical strength has been used for assessing the severity of cervical spine pathologies. However there is a conspicuous dearth of information relating to cervical strength data in patients suffering from chronic whiplash. Therefore the objective of this study was to compare absolute and ratio-based isometric cervical strength scores in chronic whiplash patients with reported corresponding scores in healthy subjects. METHODS: Isometric cervical strength was measured in the directions of flexion, extension, right and left lateral flexion in 97 patients, 51 women and 46 men, using a wall-mounted dynamometer. FINDINGS: Compared to published values of normal subjects, whiplash patients suffered sharp reductions of about 90% in both genders and in all directions. The consistency of the isometric cervical strength scores as indicated by the mean coefficient of variation was relatively low, 17% and 20% in men and women respectively. The flexion/extension strength ratio ranged 0.8--0.9, slightly higher than the reported range for normal subjects. This ratio was highly correlated (r=0.91, P=0.01) with the mean coefficient of variation in a subgroup of 9 patients. INTERPRETATION: In the absence of an obvious reason such as sever atrophy or grossly dysfunctional neurological control the indicated weakness of the cervical muscles may be associated with learned pain avoidance behavior which is typical among this group of patients.     

Diagnosis and Management of Cervicogenic Headache

Abstract:   Upper cervical pain and/or headaches originating from the C0 to C3 segments are pain-states that are commonly encountered in the clinic. The upper cervical spine anatomically and biomechanically differs from the lower cervical spine. Patients with upper cervical disorders fall into two clinical groups: (1) local cervical syndrome; and (2) cervicocephalic syndrome. Symptoms associated with various forms of both disorders often overlap, making diagnosis a great challenge. The recognition and categorization of specific provocation and limitation patterns lend to effective and accurate diagnosis of local cervical and cervicocephalic conditions.     

Quantitative posturography in altered sensory conditions: a way to assess balance instability in patients with chronic whiplash injury

OBJECTIVES: To quantify neck mobility and posture with and without various postural perturbations. DESIGN: A multivariable 2-group study with repeated measures and treatments. SETTING: A human performance laboratory. PARTICIPANTS: Eleven patients with chronic whiplash injury (mean age, 33.3+/-6.7 y; weight, 73.4+/-11.4 kg; height, 173.3+/-7.2 cm) with a sex- and age-matched control group (mean age, 33.1+/-6.8 y; weight, 68+/-12.5 kg; height, 171.5+/-6.3 cm). INTERVENTIONS: Neck mobility and the effects of postural perturbations affecting the visual, vestibular, cutaneous, proprioceptive, and nociceptive systems were measured. MAIN OUTCOME MEASURES: Active range of motion, neck position sense, and postural activity. RESULTS: We found significantly reduced neck mobility and increased postural activity in the patient group compared with the control group. In patients, there was significantly greater postural activity with eyes closed, eyes open and speaking, and eyes closed with Achilles' tendons vibrations compared with eyes open with no vibrations. In the controls, there was no significant effect of experimental muscle pain on postural activity. CONCLUSIONS: Patients with chronic whiplash injury had a protective response to neck movement and different tuning, sequencing, and execution of the postural synergies probably because of excessive reliance on visual input despite a possible deficit and altered vestibular and/or proprioceptive activity. In healthy volunteers, the pain induced by a single bolus injection of hypertonic saline was probably too limited in intensity and spreading to decrease postural stability.     

Biomechanics of the cervical spine Part 3: minor injuries

Minor injuries of the cervical spine are essentially defined as injuries that do not involve a fracture. Archetypical of minor cervical injury is the whiplash injury. Among other reasons, neck pain after whiplash has been controversial because critics do not credit that an injury to the neck can occur in a whiplash accident. In pursuit of the injury mechanism, bioengineers have used mathematical modelling, cadaver studies, and human volunteers to study the kinematics of the neck under the conditions of whiplash. Particularly illuminating have been cinephotographic and cineradiographic studies of cadavers and of normal volunteers. They demonstrate that externally, the head and neck do not exceed normal physiological limits. However, the cervical spine undergoes a sigmoid deformation very early after impact. During this deformation, lower cervical segments undergo posterior rotation around an abnormally high axis of rotation, resulting in abnormal separation of the anterior elements of the cervical spine, and impaction of the zygapophysial joints. The demonstration of a mechanism for injury of the zygapophysial joints complements postmortem studies that reveal lesions in these joints, and clinical studies that have demonstrated that zygapophysial joint pain is the single most common basis for chronic neck pain after injury.     

Gait information flow indicates complex motor dysfunction

Gait-related back movements require coordination of multiple extremities including the flexible trunk. Ageing and chronic back pain influence these adjustments. These complex coordinations can advantageously be quantified by information theoretically based communication measures such as the gait information flow (GIF). Nine back pain patients (aged 61+/-10 yr) and 12 controls (aged 38+/-10 yr) were investigated during normal walking across a distance of 300 m. The back movements were measured as distances between characteristic points (cervical spine CS, thoracic spine TS, lumbar spine LS) by the sonoSens Monitor, a system for mobile motion analysis. Gait information flow and regularity indices (RI1: short prediction horizon of 100 ms, RI2: longer prediction horizon of walking period) were assessed as communication characteristics. All indices were non-parametrically tested for group differences. Sensitivity and specificity were assessed by bivariate logistic regression models. We found regularity indices systematically dependent on measurement points, information flow horizon and groups. In the patients RI1 was increased, but RI2 was decreased in comparison to the control group. These results quantitatively characterize the altered complex communication in the patients. We conclude that ageing and/or chronic back pain related dysfunctions of gait can advantageously be monitored by gait information flow characteristics of back movements measured as distances between characteristics points at the back surface.     

Lack of impairment of kinaesthetic sensibility in cervicogenic headache patients

To compare the cervical kinaesthetic sensibility of cervicogenic headache (CEH) patients and asymptomatic controls, the head repositioning accuracy of 10 CEH patients and 23 asymptomatic controls was measured. Should an impaired kinaesthetic sensibility be demonstrated, its assessment could be of diagnostic value in the evaluation of patients with suspected CEH. Additionally, specific exercises to improve cervical kinaesthesia could be prescribed. Kinaesthetic sensibility was assessed using a head repositioning task: subjects were asked to relocate their heads as accurately as possible to a previously memorized head position following an active movement (flexion, extension and left and right rotations). The repositioning error was registered using a validated magnetic tracking device (Flock of Birds). No significant differences were found between the asymptomatic controls and the CEH patients (independent-samples T -test, P  < 0.05). We conclude that cervical kinaesthetic sensibility is not impaired in non-traumatic CEH. The use of kinaesthetic assessment and treatment in this patient group seems to be limited.     

Discrimination between pain-induced head movement disturbances after whiplash injuries and their simulation

Neck pain after whiplash injury of the cervical spine often induces typical changes in head motion patterns (amplitude, velocity). These changes of kinematics may help to recognize malingerers. We investigated the hypothesis that malingerers are not able to reproduce their simulated head movement disturbances three times. The kinematics of head movements of 23 patients with neck pain after whiplash injury and of 22 healthy subjects trying to act as malingerers were compared. The healthy subjects were informed about the symptomatology of whiplash injury and were asked to simulate painful head movements. Two different kinds of head movements were registered and analyzed by Cervicomotography: (1) the slow free axial head rotation (yaw) and (2) the axial head rotation (yaw) tracking a moving visual target. Each experimental condition was presented three times, expecting the malingerers not to be able to produce as well as to reproduce the same head movement disturbances again and again. In patients, as a consequence of their distinct pain patterns, we expected less variance between the test repetitions. The statistical analysis showed significant differences of the calculated kinematic parameters between both groups and the inability of healthy subjects to simulate and to reproduce convincingly distinct pain patterns.     

Effects of Cervical Spine Manual Therapy on Range of Motion,Head Repositioning,and Balance in Participants With Cervicogenic Dizziness: A Randomized Controlled Trial

Objective

To evaluate and compare the effects of 2 manual therapy interventions on cervical spine range of motion (ROM), head repositioning accuracy, and balance in patients with chronic cervicogenic dizziness.

Design

Randomized controlled trial with 12-week follow-up using blinded outcome assessment.

Setting

University School of Health Sciences.

Participants

Participants (N=86; mean age ± SD, 62.0±12.7y; 50% women) with chronic cervicogenic dizziness.

Interventions

Participants were randomly assigned to 1 of 3 groups: sustained natural apophyseal glides (SNAGs) with self-SNAG exercises, passive joint mobilization (PJM) with ROM exercises, or a placebo. Participants each received 2 to 6 treatments over 6 weeks.

Main Outcome Measures

Cervical ROM, head repositioning accuracy, and balance.

Results

SNAG therapy resulted in improved (P≤.05) cervical spine ROM in all 6 physiological cervical spine movement directions immediately posttreatment and at 12 weeks. Treatment with PJM resulted in improvement in 1 of the 6 cervical movement directions posttreatment and 1 movement direction at 12 weeks. There was a greater improvement (P<.01) after SNAGs than PJM in extension (mean difference, −7.5°; 95% confidence interval [CI], −13° to −2.0°) and right rotation (mean difference, −6.8°; 95% CI, −11.5° to −2.1°) posttreatment. Manual therapy had no effect on balance or head repositioning accuracy.

Conclusions

SNAG treatment improved cervical ROM, and the effects were maintained for 12 weeks after treatment. PJM had very limited impact on cervical ROM. There was no conclusive effect of SNAGs or PJMs on joint repositioning accuracy or balance in people with cervicogenic dizziness.     

Does cervical kyphosis relate to symptoms following whiplash injury?

The mechanisms for developing long-lasting neck pain after whiplash injuries are still largely unrevealed. In the present study it was investigated whether a kyphotic deformity of the cervical spine, as opposed to a straight or a lordotic spine, was associated with the symptoms at baseline, and with the prognosis one year following a whiplash injury. MRI was performed in 171 subjects about 10 d after the accident, and 104 participated in the pain recording at 1-year follow-up. It was demonstrated that postures as seen on MRI can be reliably categorized and that a straight spine is the most frequent appearance of the cervical spine in supine MRI. In relation to symptoms it was seen that a kyphotic deformity was associated with reporting the highest intensities of headache at baseline, but not with an increased risk of long-lasting neck pain or headache. In conclusion, a kyphotic deformity is not significantly associated with chronic whiplash associated pain. Moreover, it is a clear clinical implication that pain should not be ascribed to a straight spine on MRI. We suggest that future trials on cervical posture focus upon the presence of kyphotic deformity rather than just on the absence of lordosis.