The assessment of the cervical spine. Part 1: Range of motion and proprioception

Neck pain and headache of cervical origin are complaints affecting an increasing number of the general population. Mechanical factors such as sustained neck postures or movements and long-term "abnormal" physiologic loads on the neck are believed to affect the cervical structures and compromise neck function. A comprehensive assessment of neck function requires evaluation of its physical parameters such as range of motion, proprioception, strength and endurance/fatigue. The complicated structure of the cervical spine however, makes it difficult for any clinician to obtain reliable and valid results. The aim of the first part of this systematic critical review is to identify the factors influencing the assessment of range of motion and proprioception of the cervical spine.     

Do neck kinematics correlate with pain intensity,neck disability or with fear of motion?

PurposeThis study aimed to investigate the relationship between cervical kinematics and subjective measures, including pain intensity, disability, and fear of motion.MethodsTwenty-five patients (19 females, 6 males; mean age 39 ± 12.7 years) with chronic neck pain participated in this cross-sectional study. A customized virtual reality system was employed to evaluate cervical range of motion (ROM) and kinematics, using an interactive game controlled by cervical motion via electromagnetic tracking. Self-reported outcome measures included pain intensity (visual analogue scale); disability (Neck Disability Index); and fear of motion (TAMPA scale of kinesiophobia). Kinematic measures included cervical ROM, mean and peak velocity, and number of velocity peaks (NVP) reflecting smoothness of motion.ResultsResults showed significant correlations of approximately 0.4–0.6 between ROM and fear of motion, pain intensity, and disability. All 12 kinematic measures were correlated with fear of motion, but only a few were correlated with pain intensity, and with disability.ConclusionsThe results emphasise fear of motion as a subjective measure primarily correlated with neck kinematics, including range, velocity, and smoothness of cervical motion. The level of neck disability was found to be partly related to ROM or to other kinematic impairments. However, ROM by itself remains a valid measure related to pain intensity and to fear of motion in patients with chronic neck pain. All correlations demonstrated were moderate, indicating that these measures involve other factors in need of further research.     

Cervical musculoskeletal impairments in cervicogenic headache: a systematic review and a meta-analysis

Abstract

The differential diagnosis of cervicogenic headache (CEH) requires the presence of a pattern of symptoms and cervical musculoskeletal signs that distinguishes it from other types of headaches. The investigation of cervical musculoskeletal impairments (CMI) can help in the diagnosis and treatment of the CEH. In order to assess the evidence concerning CMI in CEH subjects, a systematic review and a meta-analysis was performed. Several electronic databases were searched. A checklist was used to identify suitable articles and a methodological scale was used to analyse their quality. Ten articles met the inclusion criteria. Based on our meta-analysis, patients with CEH have altered range of motion in rotation, flexion-extension, cervical rotation with cervical flexion, altered cervical flexor strength, and altered cervical flexor endurance. More controlled studies investigating the cervical impairments in CEH, with a clear history of patients, and greater sample sizes, are necessary.     

Clinical and radiological assessment of the cervical extensor muscles in people with neck pain. A narrative review

Background: Clinical and radiological investigations of the function and structure of the cervical extensor muscles are increasingly being used in physiotherapy practice.

Objectives: The aim of this review is to investigate the reliability and clinical utility of these tests, to report on normative data and to evaluate the association between the results of these investigations and neck pain.

Major Findings: A range of clinical and radiological tests have been described to assess the function and structure of the cervical extensor muscles. Clinical tests that evaluate cervical muscle strength and endurance can be performed reliably and there is some evidence that performance of these tests is impaired in people with neck pain. There is however, a need for better understanding of what constitutes normal strength and endurance in these muscles and whether abnormal function is a cause or effect of neck pain. Clinical tests of extensor motor control have not been extensively studied. Of the radiological investigations commonly used for evaluation of cervical extensor muscle structure, ultrasound cross-sectional measures have demonstrated acceptable reliability and correlate reasonably well with higher resolution MRI images.

Conclusions: The clinical and radiological tests commonly used to assess cervical extensor muscles generally have acceptable reliability and are mostly well suited within the physiotherapy clinic. Both clinical and radiological tests need further investigation through case-controlled longitudinal studies that explore the relationship between these tests and neck pain.     

The Swiss Ball: An Overview of Applications in Sports Medicine

Abstract

This paper reviews the historical development of the exercise ball and the theoretical basis and current treatment use of it for sports medicine patients. The more common uses are to increase joint range of motion (ROM) and strength, to enhance joint proprioception, to improve cardiovascular function, and to promote trunk stabilization. The use of the exercise ball has undergone exponential growth over the past decade. Its variability of use, convenience, and low cost make it an ideal tool for the sports medicine setting. Empirical evidence has shown benefits in improving joint ROM, strength, spinal stabilization, and proprioception. However, no peer-reviewed controlled studies have been reported. Clinical research is needed to define the most appropriate exercises and optimal frequency or duration of treatment for a given diagnosis.     

Physical impairments in cervicogenic headache: traumatic vs. nontraumatic onset

In order to quantify the physical impairments associated with different types of headache, 77 subjects belonging to four different groups (postmotor vehicle accident cervicogenic headache subjects, cervicogenic headache subjects nontraumatic, migraine patients and control subjects) were evaluated using the following variables: posture, cervical range of motion, strength of the neck flexors and extensors, endurance of the short neck flexors, manual segmental mobility, proprioception of the neck, and pain (McGill Pain Questionnaire and the skin roll test). The results of this study showed that postmotor vehicle accident cervicogenic patients have significantly limited active cervical range of motion (in flexion/extension and rotations), present decreased strength and endurance of neck flexors and decreased strength of the extensor muscles. Our results suggest that there are enough differences between the postmotor vehicle accident and nontraumatic cervicogenic headache subjects to warrant caution when analysing the data of these two subgroups together, as several studies have done in the past. The onset of headache is therefore an important variable that should be controlled for when attempting to characterize the physical impairments associated with cervicogenic headache.     

Function in Patients With Cervical Radiculopathy or Chronic Whiplash-Associated Disorders Compared With Healthy Volunteers

Objective

The purposes of this study were to examine whether any differences in function and health exist between patients with cervical radiculopathy (CR) due to disk disease scheduled for surgery and patients with chronic whiplash-associated disorders (WADs) and to compare measures of patients' physical function with those obtained from healthy volunteers.

Methods

This is a cross-sectional study of patients with CR (n = 198) and patients with chronic WAD (n = 215). Patient data were compared with raw data previously obtained from healthy people. Physical measures included cervical active range of motion, neck muscle endurance, and hand grip strength. Self-rated measures included pain intensity (visual analog scale), neck disability (Neck Disability Index), self-efficacy (Self-Efficacy Scale), and health-related quality of life (EuroQol 5-dimensional self-classifier).

Results

Patient groups exhibited significantly lower performance than the healthy group in all physical measures (P < .0005) except for neck muscle endurance in flexion for women (P > .09). There was a general trend toward worse results in the CR group than the WAD group, with significant differences in neck active range of motion, left hand strength for women, pain intensity, Neck Disability Index, EuroQol 5-dimensional self-classifier, and Self-Efficacy Scale (P < .0001).

Conclusions

Patients had worse values than healthy individuals in almost all physical measures. There was a trend toward worse results for CR than WAD patients.     

Evaluation of Physical Function in Individuals 11 to 14 Years After Anterior Cervical Decompression and Fusion Surgery—A Comparison Between Patients and Healthy Reference Samples and Between 2 Surgical Techniques

Objective

The purpose of this study was to evaluate neck-related physical function in individuals 11 to 14 years after anterior cervical decompression and fusion (ACDF) surgery for degenerative cervical disk disease and to compare the long-term outcome of 2 surgical techniques, including the Cloward procedure and cervical intervertebral fusion cage.

Methods

In this cross-sectional study, 51 individuals, 11 years or more after ACDF, underwent testing of cervical active range of motion, hand-grip strength, static and dynamic balance, neck muscle endurance, and completed pain ratings. The participants' values were compared with values of age- and sex-matched healthy individuals to evaluate impairments. Correlations between different test scores and pain were performed. Group differences were analyzed between the 2 surgical techniques.

Results

Sixty-five percent and 82% exhibited impairment in ventral and dorsal neck muscle endurance, respectively. Impairment rates of 18% to 39% for cervical active range of motion, 27% to 43% for hand-grip strength, 37% for standing balance, and 35% for dynamic balance were recorded. Twenty-nine percent of the participants had impairment (> 30 mm visual analog scale) in pain. There were no significant differences in physical function between the 2 surgical treatment groups (Cloward procedure or cervical intervertebral fusion cage) (P = .10-.92).

Conclusions

In those studied, a large percentage of patients who had anterior cervical decompression and fusion surgery have impairments in neck-related physical function when compared 11 to 14 years after surgery with age- and sex-matched healthy reference individuals. Neck-specific function, but not balance, was statistically correlated to pain. Neck muscle endurance was most affected, and balance impairments were also present in one-third of the individuals. There were no differences in long-term physical function between the 2 surgical techniques.     

The Influence of the Cervical Spine on Chronic Headache in Women: A Pilot Study

Abstract

This study compares selected posture, mobility, strength and endurance variables in subjects with chronic headaches to the same features in asymptomatic subjects. Two convenience samples of 10 female subjects were obtained: 1) those who experience chronic headache, mean age of 34.2 years (SD=11, range=23-57), and 2) a group not experiencing headache mean age of 30 years (SD=9.6, range=21-50). Measurements compared: 1) cervical range of motion in flexion, extension, rotation, and lateral flexion, 2) cervical strength in flexion and extension, 3) forward head posture (FHP), 4) forward shoulder posture (FSP), and 5) endurance testing of the anterior cervical musculature between the two groups.

Statistical analysis was completed using the Kruskal-Wallis test. The headache group was found to have significantly less cervical extension ROM (p<0.05) and lower strength for both the cervical flexor (p=0.001) and cervical extensor (p<0.01) muscle groups; in addition the endurance of the anterior cervical musculature was significantly decreased (p=0.001) as compared to the controls. Forward head and forward shoulder posture measurements did not differ between the two groups.     

Effect of adding stretching to standardized procedures on cervical range of motion,pain, and disability in patients with non-specific mechanical neck pain: A randomized clinical trial

Objectiveto investigate the benefit of adding stretching exercises to cervical joint mobilization and active rotation exercises for patients with non-specific mechanical neck pain.MethodsThirty-eight subjects with non-specific mechanical neck pain were randomly assigned to a standard procedure group (passive cervical mobilization and active cervical rotation range of motion exercise) or a combined procedure (passive cervical mobilization, active cervical rotation range of motion exercises, and stretching procedures). Mixed factorial analysis of variance was used to compare changes between groups over time in active cervical range of motion, Numeric Pain Rating Scale, Neck Disability Index, Global Rating of Change, and Pressure Pain Threshold.ResultsThere was a significant change in mean active range of motion in all directions, Pressure Pain Threshold, perceived pain, disability levels, and global rating of change over time (p < 0.001). There was a significant group by time interaction in mean active range of motion during extension (p = 0.01), right rotation (p = 0.004), right and left lateral flexion (p = 0.05, and p = 0.02 respectively). However, there was no significant group by time interaction in mean active range of motion during flexion, left rotation, pain intensity (p = 0.09), right and left pressure pain threshold (p = 0.30, 0.47, respectively), and disability (p = 0.07).ConclusionsBoth study groups improved significantly in all subjective and objective outcome measures. However, data from this study suggest that adding stretching to the standard procedures may be more effective than the standard procedure alone at improving cervical extension, right rotation, and lateral flexion active range of motion, but not pain and disability.     

A preliminary study comparing the use of cervical/upper thoracic mobilization and manipulation for individuals with mechanical neck pain

Objectives:Neck pain is routinely managed using manual therapy (MT) to the cervical and thoracic spines. While both mobilizations and manipulations to these areas have been shown to reduce neck pain, increase cervical range of motion, and reduce disability, the most effective option remains elusive. The purpose of this preliminary trial was to compare the pragmatic use of cervical and thoracic mobilizations vs. manipulation for mechanical neck pain.Methods:This trial included 20 patients with mechanical neck pain. Each patient was randomized to receive either mobilization or manipulation to both the cervical and thoracic spines during their plan of care. Within-group analyses were made with Wilcoxon signed-rank tests and between-group analyses were made with Mann–Whitney U.Results:There were no between-group differences for any of the dependent variables including cervical active range of motion (CAROM) (P = 0.18), deep cervical flexion (DCF) endurance (P = 0.06), numerical pain rating scale (NPRS) (P = 0.26), the neck disability index (NDI, P = 0.33), patient-specific functional scale (PSFS, P = 0.20), or the global rating of change (GROC) scale (P = 0.94). Within-group results were significant for all outcome variables (P<0.001) from initial evaluation to discharge for both groups.Discussion:These findings were consistent with other trials previously conducted that applied the MT techniques in a pragmatic fashion, but varied from previous trials where the treatment was standardized. A larger experimental study is necessary to further examine the differences between mobilization and manipulation for neck pain.     

Do cervical degenerative changes in women with chronic neck pain affect function?

OBJECTIVE: Previous investigations suggest little association between clinical findings and radiographic degenerative findings. However, the association between degenerative changes and neck function has not been investigated. DESIGN: A cross-sectional study. SUBJECTS: Data were collected from 179 female office workers aged 25-53 years with chronic neck pain who were referred for institutional rehabilitation. METHODS: Radiographs of the cervical spine, and neck function including isometric muscle strength and passive range of motion were evaluated. All subjects completed self-report questionnaires including questions about neck pain and disability. RESULTS: Fifty-nine percent of the women presented degenerative changes and they were older than women without the changes (p=0.001). Neck pain and disability were comparable when the patients were put into subgroups according to the radiological cervical changes. Neck mobility and muscle strength were comparable in women with or without degenerative changes, except for a lower rotational range of motion in women with degenerative changes (p=0.009). CONCLUSION: The results suggest that the degenerative changes in cervical plain films are poorly related to the severity of symptoms or neck function in women with chronic neck pain working in sedentary occupations.     

Predicting Ankle Sprain

Abstract

The purpose of this study was to assess predictors of ankle sprain from a measure of balance ability, ankle evertor strength, ankle dorsiflexion range of motion and ankle proprioception. Twenty five male athletes who had sustained an ankle sprain were compared with a matched group of subjects. Ankle evertor strength was measured with a strain gauge, ankle dorsiflexion range of motion was measured with an inclinometer, balance ability was measured with a force plate and proprioception was measured by having the subject duplicate ankle positions on a platform which measured inversion and eversion. Both the previously sprained ankle and the unaffected ankle of the injured group had less ankle evertor muscle strength than the control group. A regression equation which used ankle evertor strength could correctly identify injured and uninjured subjects in 72% of the cases.     

The assessment of the cervical spine. Part 2: strength and endurance/fatigue

Quantitative documentation of physical deficits such as muscle strength and endurance/fatigue in the cervical spine may provide objective information, not only helping the diagnostic procedures, but also monitoring rehabilitation progress and documenting permanent impairments. The reliable and valid evaluation of muscle strength and endurance both in clinical and research environments are a difficult task since there are many factors that could affect the assessment procedure and the obtained values. The aim of the second part of this critical review is to identify the factors influencing the assessment of strength and endurance/fatigue of the muscles in the cervical spine.     

Association of thoraco-lumbar fascia length in individuals with non-specific low back pain - an observational study

ObjectiveThe purpose of the study was to assess the length of TLF and to evaluate the strength of muscles attached to it in subjects with and without nonspecific low back pain (NSLBP).Methods31 patients with NSLBP and 31 healthy individuals were included in the study. In each subject the TLF length was assessed by quantifying lumbar rotation using Back range of motion (BROM-II) instrument. The endurance of transverses abdominis was assessed using the pressure biofeedback unit while the strength of Latissimus dorsi, internal and external oblique's were assessed using MMT. Outcome measure such as Range of Motion (ROM) was compared across the group using independent sample T-test. While the muscle strength of Latissimus dorsi and oblique's were compared across the group using Man-whitney U- test. Transverse abdominis endurance was tested using chi-square test.ResultsThere was statistically significant difference in the length of TLF of subjects with NSLBP when compared with subjects without NSLBP. When the strength of Latissimus dorsi muscle, transverses abdominis muscle and internal and external oblique's muscle was assessed no significant (p value > 0.05) difference was found in either group.ConclusionsThere was statistically significant reduction in length of TLF but there was no difference in the strength of Latissimus dorsi, internal and external oblique's or endurance of transverses abdominus attached to the TLF in individuals with NSLBP and without low back pain. This study will help in determining the inclusion of TLF and the associated structures in evaluation and management of subjects with NSLBP.     

Deep cervical flexor training with a pressure biofeedback unit is an effective method for maintaining neck mobility and muscular endurance in college students with forward head posture

[Purpose] This study investigated the effects of deep cervical flexor training on maintaining forward head posture, muscular endurance, and cervical mobility. It also examined the effectiveness of deep cervical flexor training with a pressure biofeedback unit. [Subjects and Methods] Twenty college students were recruited and randomly assigned to groups that underwent either deep cervical flexor training with a pressure biofeedback unit (experimental group, n=10) or conventional deep cervical flexor training (control group, n=10). The craniovertebral angle of each subject was measured with a lateral-view picture. Neck mobility was assessed using a cervical range of motion device and muscular endurance was measured using a pressure biofeedback unit. Both groups performed conventional deep cervical flexor exercises three times a week for six weeks. The experimental group underwent a pressure biofeedback unit training was 5 to10 minutes/day, thrice a week. [Results] Cervical range of motion in the experimental group increased significantly between the end of training and the end of the four week detraining period, compared to that in control group. [Conclusion] Deep cervical flexor training with a pressure biofeedback unit is a useful method for maintaining neck mobility and muscular endurance in people with forward head posture.Key words: Forward head posture, Deep cervical flexor, Pressure biofeedback unit     

Effects of scapular stabilization and upper limb proprioception as an adjunct to cervical stabilization in chronic neck pain patients: A randomized controlled trial

BackgroundChronic neck pain is a prevalent health condition and a leading cause of disability worldwide. Prompt therapeutic measures are required to overcome this condition.ObjectivesTo evaluate the efficacy of incorporation of scapular stabilization and upper limb proprioceptive exercises to cervical stabilization exercises in patients with chronic neck pain (CNP).DesignA single-blinded randomized controlled design.MethodsA sample of convenience was deployed to recruit twenty-eight patients having CNP (18–45 years) and was randomized into two groups: group A (cervical stabilization exercises group) and group B (scapular stabilization and upper limb proprioceptive exercises group + cervical stabilization exercises). Pain intensity, disability, sleep quality, quality of life, scapular muscles strength and proprioception were assessed at 4 weeks follow up to determine the efficacy of the intervention.ResultsA mixed model ANOVA was used. A statistically significant (p < 0.05) group by time interaction for pain intensity (p = 0.000), scapular muscles strength of all muscles (p = 0.000) was observed. Significant group interaction for absolute error (p = 0.00), for pain (p = 0.001), disability (p = 0.04) and scapular muscle's strength (p = 0.000) was also demonstrated.ConclusionThe results indicated that scapular stabilization and upper limb proprioceptive exercises when combined with cervical stabilization exercises are more beneficial in alleviating pain and disability and improving scapular muscle strength and proprioception in patients with CNP.     

Elderly Drivers' Perceptions of Their Driving Abilities Compared to Their Functional Motor Skills and Their Actual Driving Performance

Occupational therapy is based on helping individuals to develop and function indpendently within their environment. The ability to drive allows a person to remain independent by providing the mobility and freedom to accomplish other activities of daily living. This study examined the elderly drivers' perceptions of their driving abilities, compared to their clinically tested functional skills in the area of motor abilities, and their actual in-car driving performance. The specific motor abilities include: range of motion, muscle strength, grip strength, head and trunk control, reaction time, proprioception, and light touch and localization. A population sample of 115 individuals 65 years and older was chosen from the Veteran's Administration Hospital. The results, although nonsignificant, indicated that the elderly individuals are indeed aware of their abilities for range of motion, muscle strength, head and trunk control, grip strength, reaction time, proprioception, and light touch and localization. The study also indicated that clinically tested motor skills and actual in-care driver performance can be predictive based on reaction time. Limitations of this study and ideas for future research are provided.     

Does the postoperative cervical lordosis angle affect the cervical rotational range of motion after cervicothoracic multilevel fusion?

BackgroundLaminectomy and multilevel fusion in patients with degenerative cervical myelopathy lead to severe restriction in cervical spine mobility. Since fusions from C₂ to the thoracic spine result in a permanently stiff subaxial cervical spine, it seems obvious to restore physiological cervical lordosis, especially with regard to sagittal balance. However, there are reports that a fusion in a more lordotic position leads to a reduction of rotational cervical range of motion in the still mobile segments C₀-C₂. This study investigates the relationship between postoperative cervical lordosis and the objective rotational range of motion and subjective restriction.MethodsIn this single-center, retrospective cohort study, patients with degenerative cervical myelopathy operated via laminectomy and fusion from C₂ to the thoracic spine were included. X-ray imaging was evaluated for common lordosis parameters. The patient-reported rotational restriction of cervical spine mobility was acquired by a five-step score. Objective rotational range of motion was measured. The radiological parameters for cervical lordosis (C₂-C₇ lordotic angle, C₂-C₇ Cobb angle) were correlated with the measurements and the patient-reported subjective scores.FindingsWe found a significant, medium negative correlation between the measurements for rotation and the C₂-C₇ lordotic angle and a significant, large negative correlation to the C₂-C₇ Cobb angle. For subjective restriction, no or only small correlation was observed.InterpretationWe found significant negative correlations between radiological cervical lordosis and objective measurements for rotation. These results indicate that for this particular patient population, a stronger postoperative cervical lordosis does not seem favorable under the aspect of rotational range of motion.