Standing balance: A comparison between idiopathic and whiplash-induced neck pain

Validity and reliability of the Balance Error Score System (BESS) Thai version in patients with chronic non-specific neck pain

BACKGROUND

Neck pain has been found to affect the somatosensory system, which can lead to impaired balance control. To assess the balance of patients with neck pain and other conditions, the balance error scoring system (BESS) is commonly used as a static balance measurement tool. However, this tool is seldom used in Thailand due to its English language format.

OBJECTIVE

To translate and determine the content, convergent validity, and reliability of a Thai version of the BESS tool.

MATERIAL AND METHODS

A process of cross-cultural adaptation was utilized to translate BESS into a Thai version, called BESS-TH. To assess content validity, five physical therapy lecturers specializing in the musculoskeletal field used BESS to measure balance in participants with neck pain. For the convergent validity process, 130 patients diagnosed with chronic non-specific neck pain (CNSNP) were randomly assessed using four static balance tests (BESS, Single-leg balance test (SLBT), Romberg test, and Tandem stance test). For reliability, two assessors with varying years of work experience independently assessed videos of the participants twice using the BESS-TH, with a minimum 7-day interval between assessments.

RESULTS

The BESS-TH used to assess balance of patients with neck pain demonstrated acceptable content validity (index of item objective congruence (IOC) = 0.87). The Spearman's Rank Correlation Coefficient was calculated between the BESS-TH and three other measures: the SLBT with eyes open and eyes closed, the Romberg test with eyes open and eyes closed, and the Tandem stance test with eyes open and Tandem stance test with eyes closed. The values obtained were as follows: -0.672, -0.712, -0.367, -0.529, -0.570, and -0.738, respectively. The inter-rater and intra-rater reliability were 0.922 (95% CI = 0.864-0.956) and 0.971 (95% CI = 0.950-0.983), respectively. Minimum detectable change (MDC) for the total BESS score of inter-rater and intra-rater reliability were 7.16 and 4.34 points, respectively.

CONCLUSION

The BESS-Thai version was acceptable, reliable, and valid for evaluating balance performance in patients with CNSNP. This tool can be used and applied to clinically evaluate postural control in Thailand.

Stimulated cervical afferent input increases postural instability in older people with chronic neck pain: a cross-sectional study

BACKGROUND

Several potential causes can impair balance in older people. The neck torsion maneuver may be useful in demonstrating impaired balance caused by the stimulation of cervical proprioceptive input. Whereas evidence suggests impaired standing balance in older people with chronic neck pain, balance impairment during the neck torsion position and its relationship with clinical characteristics have not yet been investigated in this population. The aims of this study were to investigate whether the neck torsion position could significantly influence balance responses in older people with chronic non-specific neck pain and to determine the relationships between the balance responses and characteristics of neck pain.

METHODS

Sixty-eight older people (34 with chronic non-specific neck pain and 34 controls) participated in the study. Balance was tested using a force plate during comfortable stance with eyes open under four conditions: neutral head on a firm surface, neutral head on a soft surface, neck torsion to left and right on a firm surface and neck torsion to left and right on a soft surface. Balance outcomes were anterior-posterior (AP) and medial-lateral (ML) displacements, sway area and velocity. Characteristics of neck pain were intensity, duration and disability.

RESULTS

Overall, the neck pain group exhibited greater AP and ML displacements, sway area and velocity in the neck torsion position on firm and soft surfaces compared to controls (partial eta squared (η²p) = 0.06-0.15, p < 0.05). The neck pain group also had greater AP displacement, sway area and velocity in the neutral position on a soft surface compared to controls (η²p = 0.09-0.16, p < 0.05). For both groups, the neck torsion position displayed overall greater postural sway compared to the neutral position (η²p = 0.16-0.69, p < 0.05). There were no relationships between the postural sway outcomes and characteristics of neck pain (p > 0.05).

CONCLUSION

The neck torsion maneuver, stimulating the receptors resulted in increased postural sway in older people, with a more pronounced effect in those with neck pain. The study provides evidence supporting the use of neck torsion for assessing impaired balance related to abnormal cervical input in older people with chronic non-specific neck pain.

The relationship between cervical spine range of motion and postural sway in mechanical neck pain: A cross-sectional study

Background

Impairments in postural sway have been identified in people with mechanical neck pain. The influence of cervical spine range of motion (ROM) on postural sway is unclear in mechanical neck pain (MNP).

Objective

This study investigated the relationship between cervical spine range of motion (ROM) and postural sway in MNP.

Methods

The cervical ROM was measured using the Cervical Range of Motion (CROM) device. Standing postural sway characterised by mean centre of pressure (COP) measurements in the anterior posterior (AP) and medio-lateral direction with eyes closed and feet together condition was recorded on a posturography platform. Pearson product moment correlation coefficient was used to identify the relationship between cervical ROM and postural sway.

Results

Seventy-two MNP individuals (Mean age: 29 . 9 ± 11 . 7 ) of either sex (Male: Female = 23 : 49 ) were recruited. Overall, no statistically significant correlations were identified between cervical spine ROM in sagittal and frontal plane and postural sway (r values ranging from 0.00 to - 0 . 38 ; p-values > 0 . 05 ). However, a weak negative correlation was present between the cervical rotation and AP (r-value =- 0 . 23 ; p-value = 0 . 04 ) and mediolateral (r-value =- 0 . 38 ; p-value = 0 . 01 ) COP excursion.

Conclusion

The cervical spine ROM was found to have a weak relationship with postural sway in individuals with MNP. This suggests the investigation of other mechanisms especially muscle tension which might be responsible for altered postural sway in MNP.

Positive Outcomes Following Cervical Acceleration-Deceleration (CAD) Injury Using Chiropractic BioPhysics® Methods: A Pre-Auto Injury and Post-Auto Injury Case Series

This series illustrates how rear-end impact motor vehicle collisions (MVCs) alter the cervical spine's alignment and demonstrates therapeutic use of cervical extension traction to improve lordotic alignment and other outcomes. This is a retrospective reporting of 7 adult patients (4 males and 3 females, 28-42 years) treated for cervical hypolordosis. These subjects received Chiropractic BioPhysics® (CBP®) rehabilitation and then were involved in a rear-end MVC. All cases had radiographic assessment that quantified the buckling of the cervical spine, presumably resulting directly from the CAD trauma. After an average of 3 years and 9 months (range: 1-7.6 years) following their initial program of care, the 7 patients sought care for a second time after the MVC. At this time, compared with their previously recorded post-treatment spine radiographs, there was an average 18.7° (range: 7.6-35.4°) reduction in cervical lordosis, a 9.2 mm (range: 3.6-19.8 mm) increase in anterior head translation (AHT), an 11.3° (range: 0.2-19.9°) decrease in the atlas plane line (APL), as well as a 35.7% (range: 22-52%) average neck disability index score (NDI) measured after the MVC. After the crash, a second round of CBP rehabilitation was administered, resulting in an average 15.1° improvement in cervical lordosis, 10.9 mm reduction in AHT, 10.4° increase in APL, and a 23.7% drop in NDI after an average of 35 treatments over 9 weeks. Treatment was universally successful, as an average 80% re-establishment of the lordosis toward its pre-injury state was found. There were no adverse events reported. This case series demonstrates that motor vehicle collisions may alter the alignment of the cervical spine. Rehabilitation of the cervical curve using extension traction improved the patients' initial pre-crash alignments toward their pre-injury alignments and was likely responsible for improvement in the patients' conditions. Clinical trials are needed to confirm these findings.

Balance alterations are associated with neck pain and neck muscle endurance in migraine

BACKGROUND

Migraine patients may present with both cervical and balance dysfunctions. The neck plays an important role in balance by providing substantial proprioceptive input, which is integrated in the central nervous system and influences the balance control systems. Whether balance and neck dysfunctions are associated in patients with migraine is still to be explored.

OBJECTIVES

This study aimed to assess the association between the sensory organization test of balance with neck pain features, cervical strength, endurance, and range of motion in patients with migraine.

METHODS

Sixty-five patients with migraine underwent the sensory organization test assessed with the Equitest-Neurocom® device. Maximum voluntary isometric contraction, cervical flexion and extension range of motion, and cervical flexor and extensor endurance were assessed. In addition, the features of migraine and neck pain were collected. Patients were dichotomized according to cut-off scores of balance performance and the association between outcomes were explored.

RESULTS

Patients with reduced balance performance presented a higher frequency of migraine (p = 0.035), a higher frequency of aura (p = 0.002), greater neck pain intensity (p = 0.013), and decreased endurance of cervical flexors (p = 0.010) and extensors (p < 0.0001). The total balance score was correlated with age (r = -0.33; p = 0.007), migraine frequency (r = -0.29; p = 0.021), neck pain intensity (r = -0.26; p = 0.038), and endurance of the cervical flexors (r = 0.39; p = 0.001) and extensors (r = 0.36; p = 0.001). Migraine frequency, neck pain intensity, and endurance of the cervical flexors can predict 21% of the sensory organization test variability.

CONCLUSION

Neck pain features and endurance of the cervical muscles are related to reduced balance performance in patients with migraine. These results shed light to a better understanding of balance alterations in migraine patients.

A gait-based paradigm to investigate central body representation in cervical dystonia patients

BACKGROUND

Cervical dystonia (CD) is a common adult-onset idiopathic form of dystonia characterized by an abnormal head posture caused by an excessive activity of the neck muscles. The position of the head is important to direct viewpoint in the rounding environment, and the body orientation, during gait, must be coherent with the subjective straight ahead (SSA). An alteration of the SSA, as in the case of CD patients, could affect gait when visual input is not available. The aim of this study was to probe the behavior of patients with CD during blindfolded walking, investigating the ability to walk straight ahead based only on somatosensory and vestibular information.

METHODS

In this observational cross-sectional study, patients with CD and healthy control subjects (HC) were compared. All participants were evaluated through a gait analysis during blindfolded walking on a GAITRite carpet, relying on their own sense of straightness.

RESULTS

Patients with CD showed lower values of path length (p < 0.001), a lower number of steps on the carpet (p < 0.001). A higher number of CD patients deviated during the task, walking out of the carpet, (p < 0.005) compared to HS. No relation was found between the dystonic side and the gait trajectory deviation. A significant correlation was found between pain symptom and gait performance.

CONCLUSIONS

CD patients showed dysfunctions in controlling dynamic body location during walking without visual afferences, while the dystonic side does not seem to be related to the lateral deviation of the trajectory. Our results would assume that a general proprioceptive impairment could lead to an improper body position awareness in patients with CD.

A randomized controlled trial on the effects of "Global Postural Re-education" versus neck specific exercise on pain, disability, postural control, and neuromuscular features in women with chronic non-specific neck pain

BACKGROUND

Neck pain is associated with decreased health-related quality of life, decreased work productivity, and increased visits to health care providers.

AIM

The aim of this study was to assess the effectiveness of "Global Postural Re-education" (GPR) versus a neck specific exercise (SE) program on neck pain, disability, cervical range of movement, postural stability, and activity of the superficial cervical flexor muscles.

DESIGN

A parallel-group and single-blinded clinical trial.

SETTING

Community interventions.

POPULATION

Fifty women with non-specific chronic neck pain (NSCNP).

METHODS

Participants were randomly assigned to one of the two intervention groups (GPR [N.=25] or SE [N.=25]). Both interventions consisted of eight sessions of ~40 minutes duration, performed twice a week, for four weeks. Outcomes included neck pain intensity and disability, cervical range of motion (CROM), postural sway, and activity of the superficial neck flexor muscles during a cranio-cervical flexion test (CCFT). All outcomes were assessed twice before the intervention and immediately following eight treatment sessions over four weeks.

RESULTS

Both interventions were equally effective in reducing neck pain (P<0.001, ŋp²=0.770) and disability (P<0.001, ŋp²=0.306), improving neck mobility (P<0.001, 0.385≤ŋp²≤0.623, for all measurements) and decreasing the activity of the superficial cervical flexor muscles (P>0.001). Neither intervention altered postural sway.

CONCLUSIONS

Our results revealed that GPR and SE induced significant positive results in all measures apart from postural stability but with no difference between the interventions.

CLINICAL REHABILITATION IMPACT

"Global Postural Re-education" (GPR) and neck SE interventions are equally effective in reducing neck pain and disability, and improving neck mobility in women with NSCNP. Overall, this study indicates that GPR and SE interventions can be used to effectively manage patients with NSCNP.

Changing the horizontal position of a fixed backpack load: The effect on postural stability in young adults

BACKGROUND

Modifying the horizontal position of the load in a backpack will change the size of the external torque it creates on the wearer but the effect on postural stability is unclear.

OBJECTIVE

To determine if changing the horizontal position of a fixed backpack load affects postural stability in young adults.

METHODS

A backpack was attached to a steel frame with a bar protruding posteriorly. A fixed load (5% body mass) was placed at three distances along the bar - 0 m, 0.20 m, and 0.40 m. Centre of pressure (CoP) derived measurements were recorded from a force platform sampling at 100 Hz. For each condition participants performed three 90s narrow stance trials with their eyes closed whilst standing on a firm surface. A comparison was made across unloaded (no backpack) and loaded conditions.

RESULTS

There was an immediate decrease in postural stability when a loaded backpack was worn. Only two of the CoP derived measures (Total Excursion - TEx, and Mean Velocity Total Excursion - MVel TEx) differed between the loaded at 0.20 m and loaded at 0 m conditions. All CoP derived measures differed between the loaded at 0.40 m and loaded at 0 m conditions. Furthermore, three of the CoP derived measures (Anterior/Posterior Root Mean Square - A/P RMSq, TEx, and MVel TEx) differed between the loaded at 0.40 m and loaded at 0.20 m conditions.

CONCLUSION

The distribution of a load within a backpack must be carefully considered. The findings for the 0.40 m condition are important for the use and design of large backpacks used by multi-day hikers, travellers, and the military.

SPATIOTEMPORAL GAIT PARAMETERS, PELVIC MOVEMENTS AND PELVIC SYMMETRY DURING SINGLE AND DUAL TASK IN INDIVIDUALS WITH CHRONIC IDIOPATHIC NECK PAIN

Purpose: Neck pain is associated with gait disturbances. The first aim of this study was to examine spatiotemporal gait parameters, pelvic movements and pelvic symmetry during single and dual task conditions in persons with CINP compared to healthy subjects (HS). The second aim was to investigate the relationship between disability and gait in persons with CINP.Methods: Thirty-one individuals with CINP (mean age 22.06±1.38 years, range 18-56 years) and 24 HS (mean age 22.60±1.51 years, range 18-43 years) participated in the study. CINP group completed Neck Disability Index. All participants performed 10-meter walking test in two conditions: (1) walking with head straight at usual speed, (2) walking with head straight at usual speed while carrying a tray. The BTS G-Walk wearable sensor was used to assess spatiotemporal parameters (speed, cadence, step length), pelvic movements (tilt, obliquity, rotation), and pelvic symmetry. Results: During single task gait, the CINP group had significantly lower walking speed, shorter stride length and worse pelvic tilt symmetry (p&lt;0.05), but pelvic movements did not differ significantly according to the HS (p&lt;0.05). During dual task condition, the CINP group had significantly lower cadence, gait speed and stride length, significantly increased pelvic movements and significantly worse pelvic rotation symmetry compared to HS (p&lt;0.05). Conclusion: Patients with CINP had a slower gait, lower stride length, decreased pelvic symmetry and increased pelvic movements compared to HS. Differences in gait and pelvic movements between the two groups were more pronounced during the dual task gait than single task gait. 

Sensory Interaction Balance and Limits of Stability in Neck Pain: Comparison of Traumatic and Non-traumatic Patients

Background and Purpose: A variety of sensory-motor changes are reported in both the traumatic and non-traumatic neck pain. However, it is still unclear whether there is a significant difference between individuals with traumatic neck pain and those with non-traumatic in terms of postural control. The aim of this cross-sectional study was to investigate whether there was a difference between individuals with traumatic pain and non-traumatic neck pain in terms of postural control and disability. Methods: Ninety-two patients with chronic neck pain were grouped according to the onset of pain. Clinical test of sensory interaction balance (CTSIB) and limits of stability (LOS) test were used for postural control assessment. The Numeric Rating Scale and Neck Pain Disability Index (NPDI) were used to measure pain intensity and disability, respectively. Mann-Whitney U test was used to compare groups. Results: There were no significant differences between groups in terms of LOS, CTSIB and NPDI scores (p > 0.05). Conclusion: The results of this study suggest that postural control and disability do not differ between patients with traumatic and non-traumatic neck pain. Therefore, from a clinical perspective, postural control and disability should be evaluated without considering trauma history in patients with neck pain.

Pain-side related difference in cross-sectional area of the longus colli muscle and its relationship with standing balance in persons with non-specific neck pain

BACKGROUND

Longus colli muscle has a significant role in postural control. A reduction of longus colli cross-sectional area (CSA) has been demonstrated in neck pain patients. However, pain-side related difference and its relationship with clinical features and standing balance remain unclear.

OBJECTIVE

To investigate side-to-side difference in the longus colli CSA and to determine the relationships of the CSA with clinical characteristics and standing balance in neck pain patients.

STUDY DESIGN

Cross-sectional study.

MATERIALS AND METHODS

Fifty participants with chronic non-specific neck pain (20 unilateral and 30 bilateral) were recruited. CSA of the longus colli muscle was measured using ultrasound imaging. Balance was measured using a force platform during a narrow stance with eyes open, eyes closed, and neck torsion (left and right). Balance outcomes were sway area and displacement in anterior-posterior (AP) and medial-lateral (ML) directions. Clinical characteristics were neck pain intensity, disability, and duration.

RESULTS

The longus colli CSA was reduced on the painful side in patients with unilateral neck pain (p < 0.01). There was a trend towards reduced CSA on the more painful side in those with bilateral neck pain (p = 0.08). The reduced CSA was mostly correlated with the greater AP sway displacement and sway area (r ranged from -0.27 to -0.54, p < 0.05). The longus colli CSA was not correlated with pain intensity, disability, and duration (p > 0.05).

CONCLUSION

The longus colli CSA was reduced on the painful side of neck pain. The reduced CSA was correlated with impaired standing balance, but not with clinical characteristics of neck pain.

Prevalence of Static Balance Impairment and Associated Factors of University Student Smartphone Users with Subclinical Neck Pain: Cross-Sectional Study

The aim of this study was to assess the prevalence of static balance impairment in university student smartphone users with subclinical neck pain and identify the associated risk factors. Because of rapid and widespread smartphones use, and the subsequent effect on neck pain in university students, it is essential to determine the prevalence of balance impairment and associated factors in this population. Simple random sampling was completed among eighty-one participants in this cross-sectional study. A self-reported questionnaire, fitted precisely for smartphone users, was used prior to clinical assessment by the Balance Error Scoring System. Both simple and multiple logistic regressions were used to analyze the prevalence of static balance impairment and associated factors. The prevalence of static balance impairment in university student smartphone users with subclinical neck pain was 74.07% (95% CI: 64.32 to 83.82). The significant risk factors were "daily smartphone use ≥ 4 h'' (AOR: 19.24 (95% CI 4.72 to 78.48) p = 0.000), "≥4 years of smartphone use" (AOR: 5.01 (95% CI 1.12 to 22.38) p = 0.035), and "≥7 neck disability index score'' (AOR: 12.91 (95% CI 2.24 to 74.45) p = 0.004). There was a high prevalence of static balance impairment in university smartphone users with subclinical neck pain. University student smartphone users with subclinical neck pain who met at least one of the risk factors should realize their static balance impairment.

Investigation of Joint Position Sense and Balance in Individuals With Chronic Idiopathic Neck Pain: A Cross-Sectional Study

OBJECTIVE

The aim of this study was to determine the relationship between joint position sense and static and dynamic balance in female patients with chronic neck pain compared with healthy controls.

METHODS

The study sample comprised 25 female patients with chronic neck pain and 25 healthy (asymptomatic) female controls. Pain severity with the visual analog scale, joint position sense with the laser pointer method, static balance with the Single-Leg Balance Test, and dynamic balance with the Y Balance Test were assessed.

RESULTS

The deviation in cervical joint position sense was greater in extension (P < .001), right rotation (P < .001), and left lateral rotation (P < .05) in the patients with chronic neck pain compared with the healthy controls. The results of the patients with chronic neck pain were worse than the healthy controls in the Single-Leg Balance Test with both eyes open (P < .05) and eyes closed (P < .05). The patients with chronic neck pain had worse dynamic balance only in the anterior direction reach of the left leg (P < .05).

CONCLUSION

Cervical joint position sense and static balance were worse in female patients with chronic idiopathic neck pain when compared with asymptomatic controls. Dynamic balance in all other directions except for the anterior direction was not negatively affected in individuals with chronic idiopathic neck pain.

Proprioceptive Disturbance in Chronic Neck Pain: Discriminate Validity and Reliability of Performance of the Clinical Cervical Movement Sense Test

Chronic neck pain is associated with sensorimotor dysfunctions, which may develop symptoms, affect daily activities, and prevent recovery. Feasible, reliable, and valid objective methods for the assessment of sensorimotor functions are important to identify movement impairments and guide interventions. The aim of this study was to investigate the discriminative validity of a clinical cervical movement sense test, using a laser pointer and an automatic video-based scoring system. Individuals with chronic neck pain of idiopathic onset (INP), traumatic onset (TNP), and healthy controls (CON) were tested. Associations between movement sense and neck disability were examined and the repeatability of the test was investigated. A total of 106 participants (26 INP, 28 TNP, and 52 CON) were included in a cross-sectional study. Acuity, Speed, Time, and NormAcuity (i.e., normalized acuity by dividing acuity with movement time) were used as outcome measures. ANOVAs were used for group comparisons and Pearson correlations for associations between movement sense variables and neck disability index (NDI). Notably, 60 of the participants (30 CON, 17 INP, and 13 TNP) performed the test on a second occasion to explore test-retest reliability. Results revealed a reduced NormAcuity for both INP and TNP compared with CON (p < 0.05). The neck pain groups had similar Acuity but longer Time compared with CON. Among TNP, there was a fair positive correlation between Acuity and NDI, while there was a negative correlation between Acuity and NDI among INP. Reliability measures showed good to excellent ICC values between tests, but standard error of measurements (SEM) and minimal detectable change (MDC) scores were high. The results showed that NormAcuity is a valuable measure to identify disturbed cervical movement sense among INP and TNP. While Acuity was similar between the groups, different strategies, such as longer Time, to perform the task among neck patient groups were used. Few differences were identified between the neck pain groups, but altered strategies may exist. Reliability was acceptable, and the test is feasible to perform in the clinic. However, the technical complexity of the automated image analysis is a concern. Future developments will provide more feasible solutions.

Cervical musculoskeletal and sensorimotor impairments 4 weeks to 6 months following mild traumatic brain injury: An observational cohort study

BACKGROUND

Clinically relevant scores of neck disability have been observed in adults post mild traumatic brain injury (mTBI), even in those who initially report to be recovered. Potentially cervical musculoskeletal and/or cervical sensorimotor impairments may underlie these persistent symptoms post mTBI.

OBJECTIVE

To determine whether cervical impairments exist beyond expected recovery times following concussion compared to healthy controls (HC).

STUDY DESIGN

Observational cohort study.

METHODS

Participants aged 18-60 years consisting of 39 HC, and 72 individuals, 4 weeks to 6 months post mTBI of which 35 considered themselves asymptomatic (Asymp), and 37 symptomatic (Symp). Cervical outcome measures included range and velocity of motion, flexor muscle endurance, presence of at least one dysfunctional cervical joint, joint position error -neutral and torsion, movement accuracy, smooth pursuit neck torsion test (SPNT) and balance.

RESULTS

Individuals in the Symp mTBI group demonstrated significantly reduced: flexion and rotation range, rotation velocity, flexor endurance and movement accuracy as well as increased postural sway and a higher percentage had positive cervical joint dysfunction (p < 0.01]. The mTBI group who considered themselves recovered (Asymp)demonstrated significantly lower rotation range, flexor endurance, and a higher percentage had positive cervical joint dysfunction and positive SPNT (p < 0.05) compared to HCs.

CONCLUSION

Individuals reporting symptoms post mTBI demonstrated cervical spine musculoskeletal and sensorimotor impairments beyond expected recovery times. Those not reporting symptoms had fewer but some cervical impairments. The need for a comprehensive neck assessment should be considered, perhaps even in those not reporting symptoms.

Contribution of Cervical Proprioception, Vision, and Vestibular Feedback on Reducing Dynamic Head–Trunk Orientation Error in the Yaw Direction

The contribution of cervical proprioception, vision, and vestibular feedback to the dynamic head–trunk orientation error in the yaw direction was investigated to further the understanding over the mechanism of coordination among different sensory modalities for dynamic head–trunk orientation. To test the contribution of each sensory modality, individually and together, to dynamic head–trunk orientation, 10 healthy human subjects participated in the extended cervical joint position error test, measuring the ability of repositioning the head back to the reference orientation after 45° yaw rotation of head or trunk. The error between initial and returned angles was measured. The test was repeated under eight different conditions of sensory feedback, with or without each of three sensory modalities. Each subject completed 64 trials (8 per condition) in a random order for fair comparison. No change was found in bias when one of the three modalities was missing, while variance was largest at the lack of dynamic cervical proprioception. When two of the three modalities were missing (i.e., one of the three modalities was present), both bias and variance were minimum at the presence of cervical proprioception. Additionally, both visual and vestibular feedback was redundant (i.e., no further improvement in both bias and variance), if the other one (visual or vestibular feedback) was present with dynamic cervical proprioception. In sum, the experimental results suggest that dynamic cervical proprioception is the most significant sensory modality for reducing the dynamic head–trunk orientation error in the yaw direction.

Effect of Combined Manual Therapy and Therapeutic Exercise Protocols on the Postural Stability of Patients with Non-Specific Chronic Neck Pain. A Secondary Analysis of Randomized Controlled Trial

Postural stability is a little-studied factor in non-specific chronic neck pain; the causes that can alter it are unknown. The relationship with chronic pain could be a determining factor for its deficit. The aim of this study was to investigate the relationship between sustained pain and a postural stability deficit. A randomized and blinded clinical trial (double-blind; placebo control; 12 weeks follow-up) was conducted with a total of 69 subjects divided into three groups, two experimental (manual therapy and specific exercise) and a control treatment, and carried out over a treatment period of three weeks with a follow-up after 12 weeks. Their postural stability was assessed through the overall balance index (OBI). The postural stability of subjects with non-specific chronic neck pain improved in the experimental treatments. There were no statistically significant differences between the experimental groups. This trial found that manual therapy and therapeutic exercise significantly improved OBI compared to the control group. Trial registration: Brazilian Clinical Trial Registry, RBR-2vj7sw.

Altered neuromuscular activity and postural stability during standing balance tasks in persons with non-specific neck pain

OBJECTIVES

To compare neck, trunk, and lower extremity muscle activity in standing in persons with neck pain (NP) to healthy controls and determine associations with postural sway.

METHODS

Participants included 25 persons with NP and 25 controls. Surface electromyography was recorded bilaterally from neck (sternocleidomastoid, SCM; splenius capitis, SC; upper trapezius, UT), trunk (erector spinae, ES), and lower extremity (rectus femoris, RF; biceps femoris, BF; tibialis anterior, TA; medial gastrocnemius, GN) muscles. Postural sway was measured using a force platform in narrow stance with eyes open/closed, on firm/soft surfaces.

RESULTS

Compared to controls, the NP group demonstrated higher activity in all muscles, except UT and had higher amplitude ratios for neck muscles (SCM, SC) for all tasks (p < .05). No between-group difference was found in amplitude ratios for lower extremity muscles, except for GN. Lower extremity activity was moderately correlated with larger postural sway for both groups (r = 0.41-0.66, p < .05). There were no correlations between sway and neck and trunk muscle activity (p > .05).

CONCLUSION

Increased muscle activity with NP is associated with increased postural sway. Both groups used similar postural control strategies, but the increased neck activity in the NP group is likely related to the NP disorder rather than postural instability.

Effects of Global Postural Reeducation versus Specific Therapeutic Neck Exercises on Pain, Disability, Postural Control, and Neuromuscular Efficiency in Women with Chronic Nonspecific Neck Pain: Study Protocol for a Randomized, Parallel, Clinical Trial

Background: Chronic nonspecific neck pain is the most frequent form of neck pain. It is more prevalent in women, and a costly public health issue. It is commonly associated with biomechanical, functional, proprioceptive, and postural impairments. The aim of this trial is to compare the effects of global postural exercises versus specific therapeutic exercises on neck pain, disability, mobility, pressure pain threshold, kinesiophobia, pain catastrophizing, postural control, and neuromuscular efficiency in women with chronic nonspecific neck pain. Methods and analysis: This study is a randomized, parallel-group and single blinded clinical trial. Sixty-two women with nonspecific chronic neck pain were recruited from the community of Guarda, Portugal, and randomly assigned to one of two intervention groups: (1) global postural reeducation (GPR group), (2) specific therapeutic exercises (STE group). The intervention was carried out over 4 weeks, with two sessions per week (eight sessions), and applied by a physiotherapist and paired with a daily individual at-home-exercise program. Primary outcomes are neck pain intensity and disability (Numerical Pain Rating Scale, Neck Disability Index). Secondary outcomes are cervical mobility and pressure pain threshold (CROM, algometry), attitude to pain (kinesiophobia, pain catastrophizing), standing postural control (Center of Pressure (COP) displacements), and neuromuscular efficiency (electromyography). There are four points of evaluation where the outcomes were assessed twice before the intervention, 1 week apart, and the two post-intervention assessments will be carried out after four and eight sessions. The objective was to increase scientific knowledge of different exercise modalities, such as global postural reeducation, in musculoskeletal disorders. Trial registration: ClínicalTrials.gov (NCT04402463), prospectively registered (data 22 May 2020).

A meta-analysis and systematic review of changes in joint position sense and static standing balance in patients with whiplash-associated disorder

OBJECTIVE

To synthesise and analyse the current evidence regarding changes in joint position sense (JPS) and standing balance in people with whiplash-associated disorder (WAD) taking the presence or absence of dizziness into account.

DATA SOURCES

PubMed, CINAHL Plus, Web of Science, Embase, MEDLINE and APA PsycINFO were searched by two independent reviewers from inception until August 2020 and reference lists of all included studies were also reviewed.

STUDY SELECTION

Only cross-sectional studies that measured JPS and/or standing balance between people with WAD vs. healthy controls (HC) or people with WAD complaining of dizziness (WADD) vs. those not complaining of dizziness (WADND) were selected.

DATA EXTRACTION

Relevant data were extracted using specific checklists and quality assessment was performed using Downs and Black Scale (modified version).

DATA SYNTHESIS

Twenty-six studies were included. For JPS, data were synthesized for absolute error in the primary plane of movement for separate movement directions. For standing balance, data were synthesized for traditional time- and frequency domain sway parameters considering the conditions of eyes open (EO) and eyes closed (EC) separately. For meta-analysis, reduced JPS was observed in people with WAD compared to HC when the head was repositioned to a neutral head position (NHP) from rotation (standardised mean difference [SMD] = 0.43 [95%: 0.24-0.62]) and extension (0.33 [95%CI: 0.08-0.58]) or when the head was moved toward 50° rotation from a NHP (0.50 [0.05-0.96]). Similarly, people with WADD had reduced JPS compared to people with WADND when the head was repositioned to a NHP from rotation (0.52 [0.22-0.82]). Larger sway velocity and amplitude was found in people with WAD compared to HC for both EO (0.62 [0.37-0.88] and 0.78 [0.56-0.99], respectively) and EC (0.69 [0.46-0.91] and 0.80 [0.58-1.02]) conditions.

CONCLUSION

The observed changes of JPS and standing balance confirms deficits in sensorimotor control in people with WAD and especially in those with dizziness.

The effect of cognitive task on postural stability in cervical dystonia

BACKGROUND

Cervical dystonia (CD) is the most common form of focal dystonia. It is not known exactly whether abnormal head postures in cervical dystonia cause balance problems. Dual-tasking is a common every-day life situation.

OBJECTIVE

We aimed to evaluate postural stability (PS) in patients with CD and the effect of cognitive task on PS. As a secondary aim, we evaluated the effect of onabotulinum toxin A (BoNT) injection on PS.

METHODS

A total of 24 patients with CD who were on BoNT treatment for at least one year and 23 healthy controls were included. Posturographic analyses were carried out in all the subjects on static posturography platform under four different conditions: eyes open, eyes closed, tandem stance and cognitive task. In patients, posturographic analysis was carried out just before the BoNT injections and was repeated four weeks later.

RESULTS

Before treatment, the anterior-posterior sway was significantly higher in CD patients with the eyes open condition compared to the controls (p=0.03). Cognitive task significantly affected several sway velocities. Tandem stance significantly affected many sway parameters, whereas the eyes closed condition did not. After treatment, only two parameters in tandem stance and one in cognitive task improved within the patient group, in a pairwise comparison.

CONCLUSIONS

Postural control is impaired in CD patients probably due to the impaired proprioceptive and sensorimotor integration. In reference to dual task theories possibly due to divided attention and task prioritization, cognitive dual-task and harder postural task disturbes the PS in these patients.

Can a simple clinical test demonstrate head-trunk coordination impairment in neck pain?

BACKGROUND

Sensorimotor impairment in neck pain sufferers is well established. Recent research has identified impairment in head and trunk co-ordination in this population. Presently, no clinically appropriate testing exists to quantify such impairment.

OBJECTIVE

To determine if a simple and clinically relevant test of head-trunk co-ordination can identify dysfunction in neck pain subjects when compared to healthy controls.

STUDY DESIGN

Cross-sectional observational study.

METHODS

Thirty-one neck pain and 29 healthy control subjects were assessed using head- and chest-mounted lasers with a target positioned 90 cm away. Subjects were required to rotate the trunk at least 45° with the head laser to be kept as accurately as possible in the centre of the target while sitting and standing. Maximal deviation of the head to the left and right of the target's centre with each trunk movement was measured.

RESULTS

The neck pain group demonstrated significantly greater head deviation from the centre in all but one test direction (p= <0.03). Head deviation to the same side as trunk rotation was larger in the neck pain group for both sitting and standing (p= <0.01). No significant differences existed between testing in sitting and standing.

CONCLUSION

Differences in trunk-head control exist in persons suffering from neck pain compared to healthy individuals, which can be demonstrated using simple equipment suggesting clinical utility of the measure. Performing the task in standing would seem most suitable as it can avoid influence by reduced thoracic mobility. Further research is required to establish the clinical suitability of this test.

[Posturographic and oculomotor findings in the first 24 hours after whiplash]

INTRODUCTION AND OBJECTIVES

Instability is a frequent symptom after whiplash (WL) with alterations in postural control in chronic phases. The main objective of our study was to evaluate if there were objective alterations in postural control in the acute phases after a WL, as well as to determine the presence or absence of oculomotor alterations in early phases.

MATERIAL AND METHODS

A posturographic study was carried out using the NedSVE/IBV system, as well as an oculomotor assessment, in a sample of 44 patients with WL in the first 24h after the accident.

RESULTS

More than half of the patients had a global assessment below normal. The predominant sensory pattern was vestibular. The main parameters of the Romberg test (total displacement, swept area, average speed, anteroposterior and mediolateral displacement and anteroposterior force) increased following the sequence Romberg open eyes, Romberg foam rubber open eyes, Romberg closed eyes, and Romberg foam rubber closed eyes. Concerning the comparison with normality and using the reference values of the Institute of Biomechanics of Valencia, the data from the WL patients showed significant differences in all the parameters analysed, except for gait assessment and the mediolateral directional rhythmic control.

CONCLUSIONS

Our data confirm that patients in the acute phase of WL have worse postural control than non-injured persons. The results suggest that patients with WL have greater visual dependence. Only a minority of patients had oculomotor abnormalities during early examination.

Cervical Sensorimotor Control Does Not Change Over Time and Is Not Related to Chronic Idiopathic Neck Pain Characteristics: A 6-Month Longitudinal Observational Study

BACKGROUND

Cervical sensorimotor control (CSMC) outcomes have been suggested to be important in the assessment of individuals with neck pain, despite the lack of consistent supporting evidence that CSMC skills are related to neck pain.

OBJECTIVE

The aim of this study was to investigate whether CSMC changes over time in individuals with chronic idiopathic neck pain and whether neck pain characteristics are associated with CSMC.

DESIGN

A longitudinal observational study was performed.

METHODS

A total 50 participants with chronic idiopathic neck pain and 50 matched participants who were healthy (controls) completed 7 CSMC tests (including 14 test conditions): joint position error, postural balance, subjective visual vertical, head tilt response, The Fly, smooth pursuit neck torsion, and head steadiness. Neck pain characteristics included pain intensity (visual analog scale), pain duration, and neck disability (Neck Disability Index). Linear mixed models were used to investigate whether any factors were associated with changes in CSMC.

RESULTS

Neck pain intensity was associated with 1 of 14 CSMC test conditions (balance with torsion and eyes open), and neck disability was associated with balance with eyes open and high-load head steadiness. Other factors, including sex, age, body mass index, physical activity levels, and neck pain duration, showed no association with CSMC.

LIMITATIONS

Although all other tests involved computerized data collection, the joint position error test was administered manually, introducing the risk of researcher bias.

CONCLUSIONS

The few associations between test conditions and neck pain characteristics were at best weak; hence, these are likely to be chance findings. These results suggest that CSMC may not be associated with improvement/worsening of chronic idiopathic neck pain, spawning debate on the clinical usefulness of CSMC tests.

No Differences Between Individuals With Chronic Idiopathic Neck Pain and Asymptomatic Individuals on 7 Cervical Sensorimotor Control Tests: A Cross-sectional Study

OBJECTIVE

Cervical sensorimotor outcomes have been suggested to be important in the assessment of individuals with neck pain. However, the large variety of sensorimotor control tests used in varying populations makes it difficult to draw conclusions about their clinical value. We aimed to compare cervical sensorimotor control outcomes between individuals with chronic idiopathic neck pain and asymptomatic individuals using a battery of recommended tests, and to investigate the correlation between cervical sensorimotor control outcomes and pain intensity and neck disability.

DESIGN

Case-control study.

METHODS

Fifty participants with chronic idiopathic neck pain and 50 age- and sex-matched asymptomatic controls completed 7 cervical sensorimotor control tests: joint position error (including joint position error torsion), postural balance, subjective visual vertical, head-tilt response, "the Fly," smooth pursuit neck torsion, and head steadiness. Between-group differences were investigated with the Mann-Whitney U test. Correlations between tests and levels of neck pain and disability were investigated using the Spearman rho.

RESULTS

There were no differences in cervical sensorimotor outcomes between participants with chronic idiopathic neck pain and asymptomatic controls for any test (P = .203-.981). For each test, "poor performers" consisted of both individuals with and without neck pain. Correlations were weak between tests and levels of neck pain (r = 0.010-0.294) and neck disability (r = 0.007-0.316).

CONCLUSION

These findings suggest that sensorimotor control disturbances in individuals with chronic idiopathic neck pain may not be present, spawning debate on the clinical usefulness of these tests. J Orthop Sports Phys Ther 2020;50(1):33-43. Epub 23 Aug 2019. doi:10.2519/jospt.2020.8846.

Effects of tandem walk and cognitive and motor dual- tasks on gait speed in individuals with chronic idiopathic neck pain: a preliminary study

Introduction: Gait impairment has been associated with neck pain. It is relevant to understand the possible influence of narrow-based walk and an attention-demanding secondary task on gait performance in neck pain.Purpose: To investigate the effects of tandem walk and cognitive and motor dual-tasks on gait speed in persons with chronic idiopathic neck pain (CINP) compared with controls.Methods: A cross-sectional study. Thirty participants with CINP and 30 asymptomatic controls participated in the study. Gait speed was assessed using a timed 10-m walk test at a comfortable pace under four conditions: (1) comfortable walk (as reference); (2) tandem walk (single task); (3) cognitive dual-task walking; and (4) motor dual-task walking. Dual-task interference was calculated.Results: There was no difference in comfortable gait speed between groups (p= 0.40). The CINP group had slower gait speed during the tandem walk than controls (p= 0.02). The dual-task interference on gait speed was not different between groups (p = 0.67 for cognitive, p = 0.93 for motor).Conclusion: Participants with CINP had impaired gait stability during tandem walk. An attention-demanding secondary task did not influence gait speed in individuals with CINP compared to controls. The study suggests that tandem walk could be considered as an assessment tool and part of rehabilitation for neck pain.

Clinical assessment of cervical movement sense in those with neck pain compared to asymptomatic individuals

BACKGROUND

A simple clinical test involving subject tracing zigzag (ZZ) and figure of eight (F8) patterns with a head mounted laser device in determining cervical movement sense has proven reliability and feasibility. However, its validity in comparing individuals with and without neck pain (NP) has not been examined.

METHODS

Seventy-six subjects (38 NP and 38 asymptomatic subjects) performed both patterns while motion of their laser point was videoed. Independent examiners subsequently rated the videos (real-time) to record the time needed and the number of errors when completing each task. Sensitivity, specificity, and positive and negative likelihood ratios (LR+ and LR-) for various cut-offs to optimise clinical interpretation were determined. Comparisons between 25 subjects with idiopathic neck pain versus 13 with whiplash-associated disorders were also undertaken.

RESULTS

All outcome variables except ZZ time were significantly different between individuals with NP and controls. Optimal cut-offs of 9 and 10 errors yielded LR+/LR- of 3.67/0.17 (F8) and 3.00/0.38 (ZZ). Whiplash patients performed the ZZ task faster with similar errors to those with idiopathic neck pain.

CONCLUSION

The clinical utility of this inexpensive measure to assess cervical movement sense in people with NP is supported. Moderate LRs+ were demonstrated for number of errors for both patterns. Individuals with NP generated significantly more errors while tracing each pattern. Optimal cut offs of 9 errors for ZZ and 10 errors for F8 were established. Overall, these tests appear to be clinically suitable to determine altered cervical movement sense in those with NP.

No Differences Between Individuals With Chronic Idiopathic Neck Pain and Asymptomatic Individuals on Seven Cervical Sensorimotor Control Tests: A Cross-Sectional Study

STUDY DESIGN

Case-control study.

BACKGROUND

Cervical sensorimotor outcomes have been suggested to be important in the assessment of individuals with neck pain. However, the large variety of sensorimotor control tests used in varying populations makes it difficult to draw conclusions about their clinical value.

OBJECTIVES

To compare cervical sensorimotor control outcomes between individuals with chronic idiopathic neck pain and asymptomatic individuals using a battery of recommended tests, and to investigate the correlation between cervical sensorimotor control outcomes and pain intensity and neck disability.

METHODS

Fifty participants with chronic idiopathic neck pain and 50 age and sex-matched asymptomatic controls completed seven cervical sensorimotor control tests: joint position error, joint position error torsion, postural balance, subjective visual vertical, head tilt response, The Fly, smooth pursuit neck torsion, and head steadiness. Between-group differences were investigated with Mann-Whitney U tests. Correlations between tests and levels of neck pain and disability were investigated using Spearman's rho.

RESULTS

There were no differences in cervical sensorimotor outcomes between participants with chronic idiopathic neck pain and asymptomatic controls for any test (p-values ranged from p=0.203 to p=0.981). For each test, 'poor performers' consisted of both individuals with and without neck pain. Correlations were weak between tests and levels of neck pain (r values ranged from 0.010 to 0.294) and neck disability (0.007 to 0.316).

DISCUSSION

These findings suggest sensorimotor control disturbances in individuals with chronic idiopathic neck pain may not be present, spawning debate on the clinical usefulness of these tests. J Orthop Sports Phys Ther, Epub 23 Aug 2019. doi:10.2519/jospt.2019.8846.

Manual therapy versus therapeutic exercise in non-specific chronic neck pain: study protocol for a randomized controlled trial

Background

The underlying mechanisms of non-specific chronic neck pain relapses are not clear, but they could be associated with a deficit and alteration of neck muscles propioception that play a decisive role in cervical joint position, motor control of the head, and postural stability. Numerous treatments for non-specific chronic neck pain have been described in the scientific literature. However, few studies analyze its influence on postural stability, since these alterations are not fully described, and various theories emerge about the reasons that cause it. Our primary aim is to analyze the differences in postural stability, pain, cervical disability, and the relation between them produced by a treatment based on manual therapy and another based on therapeutic exercise.

Methods

The short-term and mid-term changes produced by different therapies on subjects with non-specific chronic neck pain will be studied. The sample will be randomly divided into three groups: manual therapy, therapeutic exercise, and placebo. As dependent variables of the study, we will take (1) Overall Balance Index, measured through a dynamic stabilometric platform; (2) pain, based on the visual analog scale and the Pressure Pain Threshold; (3) cervical disability, through the neck disability index. The findings will be analyzed statistically considering a 5% significance level (p ≤ 0.05).

Discussion

Our study aims to provide knowledge about postural stability and its relationship with pain in subjects with non-specific chronic neck pain. Analyzing the results produced by different types of therapy will allow us to draw conclusions about the mechanisms, structural or central, that may elicit these alterations.

Trial registration

Brazilian Clinical Trials Registry, RBR-2vj7sw. Registered on 28 November 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3598-7) contains supplementary material, which is available to authorized users.

Associations between brain morphology and motor performance in chronic neck pain: A whole-brain surface-based morphometry approach

Changes in brain morphology are hypothesized to be an underlying process that drive the widespread pain and motor impairment in patients with chronic neck pain. However, no earlier research assessed whole-brain cortical morphology in these patients. This case-control study assesses group-differences in whole-brain morphology between female healthy controls (HC; n = 34), and female patients with chronic idiopathic neck pain (CINP; n = 37) and whiplash-associated disorders (CWAD; n = 39). Additionally, the associations between whole-brain morphology and motor performance including balance, strength, and neuromuscular control were assessed. Cortical volume, thickness, and surface area were derived from high resolution T1-weighted images. T2*-weighted images were obtained to exclude traumatic brain injury. Vertex-wise general-linear-model-analysis revealed cortical thickening in the left precuneus and increased volume in the left superior parietal gyrus of patients with CINP compared to HC, and cortical thickening of the left superior parietal gyrus compared to HC and CWAD. Patients with CWAD showed a smaller cortical volume in the right precentral and superior temporal gyrus compared to HC. ANCOVA-analysis revealed worse neuromuscular control in CWAD compared to HC and CINP, and in CINP compared to HC. Patients with CWAD showed decreased levels of strength and sway area compared to CINP and HC. Partial correlation analysis revealed significant associations between the volume of the precentral gyrus, and neuromuscular control and strength together with an association between the volume of the superior temporal gyrus and strength. Our results emphasize the role of altered gray matter alterations in women with chronic neck pain, and its association with pain and motor impairment.

Gait speed and gait asymmetry in individuals with chronic idiopathic neck pain

BACKGROUND

Recent studies have shown that individuals with chronic idiopathic neck pain (CINP) exhibit altered spatiotemporal gait parameters. Problems arising from the neck joints and related soft tissues, and most mechanical neck pain appear asymmetric. However, whether individuals with CINP have an asymmetric gait has not been clarified.

OBJECTIVES

The aim was to investigate if there was a significant difference in gait speed (GS) and gait asymmetry (GA) between individuals with CINP and healthy controls.

DESIGN

Case-Control Study.

METHOD

Twenty individuals with CINP and 20 healthy controls were included. All participants performed the 10-m walking test in three walking conditions: preferred walking (PW), preferred walking with head rotation and walking at maximum speed (MAXW). The timing gate system and pressure sensitive insoles were used to calculate GS and GA, respectively. GA was calculated using the difference between right and left swing durations.

RESULTS/FINDINGS

Individuals with CINP had slower GS in all walking conditions compared to controls (p < 0.05). In PW and MAXW conditions, gait was found to be asymmetric in individuals with CINP compared to controls (p < 0.05). There was no difference in GA between the walking conditions in either group (p > 0.05).

CONCLUSIONS

Individuals with CINP had a slower and more asymmetrical gait. GA should be evaluated as a part of the routine gait analysis since it has potential to cause asymmetric loading on joints which could cause other musculoskeletal problems in the long-term. Also, future research is needed to clarify the reasons why gait is more asymmetric in individuals with CINP.

Postural control in subclinical neck pain: a comparative study on the effect of pain and measurement procedures

BACKGROUND AND AIMS

This study investigated whether young university students with neck pain (NP) have postural control deficits when compared to sex and age-matched asymptomatic subjects.

METHODS

Centre of pressure (COP) sway area, velocity, anterior-posterior and mediolateral distances were measured in participants with (n=27) and without (n=27) neck pain for different combinations of static standing (narrow stance, tandem stance and single leg stance) and measurement time (90, 60, 30 and 15 s) with eyes closed using a force plate. Additionally, static and dynamic clinical tests of postural control were used.

RESULTS

No significant between group differences were found for the COP measurements (p>0.05). However, individuals with subclinical NP were more likely to fail the 90 s tandem test (p<0.05) in the force plate and univariate comparisons revealed significant between group differences in the tandem and single leg stance clinical test measurements.

CONCLUSIONS

Taken together, the inconsistent results might suggest an emerging postural control deficit in university students with low disability and low intensity chronic idiopathic NP.

Is There Support for the Paradigm 'Spinal Posture as a Trigger for Episodic Headache'? A Comprehensive Review

PURPOSE OF REVIEW

The International Classification of Headache Disorders provides an extensive framework to classify headaches. Physiotherapy is indicated if neuromusculoskeletal dysfunctions are involved in the pathophysiology. Maladaptive postures seem a dominant trigger in tension-type and cervicogenic headache. Yet, outcomes following physiotherapy vary. The absence of protocol studies to identify determinants concerning the role of spinal posture in headache might explain such variability. Hence, multi-dimensional profiling of patients with headache based on interactions between spinal posture, psychosocial and lifestyle factors might be essential. Therefore, the aim of this paper was to perform a comprehensive review to find support for the paradigm of spinal posture triggering episodic headache based on a multi-dimensional view on tension-type and cervicogenic headache including modern pain neuroscience.

RECENT FINDINGS

A review was conducted to support spinal posture-induced episodic headache. Pubmed, Web of Science, Pedro and the Cochrane database were explored based on the following 'Mesh' or 'Topics': 'Headache', 'Posture', 'Spine', 'Psychosocial', 'Lifestyle'. The contemporary review of neuroanatomical, biomechanical and non-nociceptive pathways, with integration of modern pain neuroscience in tension-type and cervicogenic headache, supports spinal posture as a trigger for episodic headache. Maladaptive postures can activate C1-C3 nociceptors. Convergence with trigeminal afferents at the trigeminocervical nucleus could explain spinal headache. Interactions with psychosocial and lifestyle factors might contribute to peripheral and central sensitisation. Neuroanatomical, biomechanical and non-nociceptive pathways seem to justify profiling patients based on a postural trigger. Further research is needed to determine the contribution of postural dysfunctions in headache and the effect of specific interventions.

The effect of cervical spine subtypes on center of pressure parameters in a large asymptomatic young adult population

BACKGROUND

Recent research highlighted that non-lordotic subtypes are common within an asymptomatic population of young adults. The potential mechanisms responsible for the decreased postural control witnessed in healthy participants exhibiting non-lordotic cervical alignment are unclear.

RESEARCH QUESTION

Therefore, the aim of this study is to compare and contrast asymptomatic radiographically derived sagittal cervical alignment subtypes with Center of Pressure (CoP) parameters.

METHODS

In this cross-sectional study strict asymptomatic inclusion criteria were met by 150 of the original 182 volunteers. All radiographs were assessed using a multi-method subtype system with participants classified into lordotic and non-lordotic groups. Participants performed 90s narrow stance trials with their eyes closed whilst standing on both a firm surface (FS) and compliant surface (CS) (3 trials per surface). CoP parameters were recorded from a force platform sampling at 100 Hz. Nonparametric statistical tests were conducted to assess differences between groups for each surface type and to determine differences in CoP parameters between FS and CS types.

RESULTS

Significant differences were found between groups on both surfaces for the anterior to posterior range (FS: p = 0.013; CS: p = 0.023), total excursion (FS: p = 0.029; CS: p = 0.005) and mean velocity of total excursion (FS: p = 0.032; CS: p = 0.004).

SIGNIFICANCE

Our data suggest that sagittal plane cervical alignment is a measure capable of distinguishing between the postural control of asymptomatic lordotic and non-lordotic young adult participants on both surfaces types. Furthermore, decreased postural control is present in asymptomatic participants across all non-lordotic subtypes and is not isolated exclusively to those with forward head posture. Consequently, future research endeavours should investigate the clinical significance of these non-lordotic findings in relation to both the potential for early cervical osseous degeneration and the transitional stages of non-specific pain sufferers from previously asymptomatic young adults.

Evaluation of Postural Balance and Articular Mobility of the Lower Limbs in Chronic Neck Pain Patients by Means of Low-Cost Clinical Tests

OBJECTIVE

The purpose of this study was to correlate measurements of chronic neck pain with the balance and mobility of the lower limbs and to compare these variables between individuals with chronic neck pain and asymptomatic participants.

METHODS

This was a blinded cross-sectional study. Participants with chronic neck pain (n = 30) and asymptomatic participants (n = 30) were included in the study. To measure pain in the neck region, the Numeric Rating Scale, Neck Disability Index, and Pain-Related Catastrophizing Thoughts Scale were applied. The assessment of postural balance and mobility of the lower limbs was made using the Timed Up and Go Test, Functional Reach Test (FRT), Lateral Reach Test, and 30-second Chair Stand Test.

RESULTS

No statistically (P > .05) and clinically (d < 0.50) significant differences were identified for the variables tested here. However, regarding the correlations, a significant association was identified only between the intensity of pain during cervical movements and FRT (r = -0.312).

CONCLUSION

Young adults with chronic neck pain present changes in static balance measured by means of the FRT; that is, the higher the intensity of pain, the lower the anteroposterior excursion of the body during the execution of the test.

Instant reduction in postural sway during quiet standing by intraoral dental appliance in patients with Whiplash associated Disorders and non-trauma neck pain

OBJECTIVES

This study tested the hypothesis that modulation of jaw sensorimotor control by intraoral dental appliance can reduce postural sway during quiet standing and hence improve standing balance, in patients with whiplash associated disorders (WAD) and non-trauma neck pain.

DESIGN

Postural sway during quiet standing with feet together was examined in 54 WAD patients (40 females) and 10 non-trauma patients (8 females) using wireless 3D movement recording technique. Recordings were performed alternating without and with intraoral dental appliance, and with closed eyes and open eyes, respectively. In this protocol the participants served as their own controls. A reference group of 30 healthy subjects (17 females) was also recorded. Each recording lasted 120 s, followed by 3-5 min of rest. Speed, acceleration and perimeter of postural sway area were documented.

RESULTS

In the patients, but not in the healthy group, the intraoral dental appliance instantly and significantly reduced standing postural sway in recordings with closed and open eyes.

CONCLUSIONS

The prompt reduction in standing postural sway from intervention by intraoral dental appliance i.e. improved standing balance, suggests a potent effect on the postural control system by modulation of the jaw sensorimotor system, probably involving reflex transmission. The result opens for new insight into mechanisms behind postural control and the pathophysiology of balance disorders, and adds to the knowledge on plasticity of the nervous system. It may help developing new procedures for assessment and management of impaired balance in WAD and non-trauma neck pain patients.

Neck muscle vibration produces diverse responses in balance and gait speed between individuals with and without neck pain

BACKGROUND

Neck muscle vibration can influence cervical proprioception and sensorimotor function. It is hypothesized to affect motor performance differently in persons with and without neck pain.

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To clarify the extent to which vibration-induced motor responses of neck muscles affect static standing balance and gait speed in persons with and without neck pain.

METHODS

Thirty participants with chronic neck pain and 30 healthy controls were recruited. Balance and gait were measured before and after 30 s of suboccipital neck muscle vibration. Balance was measured in a confortable stance with eyes closed using a swaymeter and gait using the timed 10 m walk test.

RESULTS

At baseline, neck pain participants had greater postural sway, particularly in the anterior-posterior direction and slower gait speed than healthy controls (p < 0.001). Immediately after vibration, neck pain participants displayed decreased postural sway, and increased gait speed (p < 0.001). Healthy controls had increased postural sway and decreased gait speed (p < 0.001).

CONCLUSION

Neck muscle vibration improved standing balance and gait speed in participants with neck pain but reduced performance in healthy controls. The study supports the importance of cervical proprioceptive information in postural control. Use of vibration could be considered neck pain patients' rehabilitation.

Postural stability in patients with non-specific chronic neck pain: A comparative study with healthy people

Background: Impairment of cervical sensory input in patients with neck pain may disturb postural stability. The purpose of present study was to assess the dynamic postural stability of subjects with chronic neck pain compared to a matched control group. Methods: In this case-control study, 22 chronic non-specific neck pain and 22 healthy individuals participated. Postural stability was measured with Techno-body Prokin tilting platform. Subjects performed balance tests under two conditions: eyes open and closed. The parameters for assessment of postural stability were total stability index (TSI), anteroposterior stability index (APSI), mediolateral stability index (MLSI), and trunk deviation which demonstrated total trunk sway in medio-lateral and antero-posterior. We used a separate 2 (group) by 2 (postural difficulty) mixed-design analysis of variance (ANOVA) for analysis of postural performance. Results: There were significant differences between the chronic neck pain and matched control groups in APSI, MLSI, and TSI, p<0.001 in both eyes opened and closed conditions. The trunk deviation was greater for non-specific neck pain in comparison to healthy subjects, p<0.05 in both conditions of eyes open and closed. Conclusion: The results of this study showed that patients with chronic neck pain have poorer postural control than healthy subjects. The findings suggest that clinicians take into account the importance of dynamic postural stability assessment in patients with chronic non-specific neck pain and consider the application of intervention programs for improvement of the dynamic balance.

Effects of local treatment with and without sensorimotor and balance exercise in individuals with neck pain: protocol for a randomized controlled trial

Background

Impaired cervical joint position sense and balance are associated with neck pain. Specific therapeutic exercise and manual therapy are effective for improving neck pain and functional ability but their effects on joint position sense and balance impairments remain uncertain. Changes in the joint position sense and balance may need to be addressed specifically. The primary objective is to investigate the most effective interventions to improve impaired cervical joint position sense and balance in individuals with neck pain. The secondary objective is to assess the effectiveness of the interventions on pain intensity and disability, pain location, dizziness symptoms, cervical range of motion, gait speed, functional ability, treatment satisfaction and quality of life.

Methods

A 2 × 2 factorial, single blind RCT with immediate, short- and long-term follow-ups. One hundred and sixty eight participants with neck pain with impaired joint position sense and balance will be recruited into the trial. Participants will be randomly allocated to one of four intervention groups: i) local neck treatment, ii) local treatment plus tailored sensorimotor exercises, iii) local treatment plus balance exercises, and iv) local treatment plus sensorimotor and balance exercises. Participants receive two treatments for 6 weeks. Primary outcomes are postural sway and cervical joint position error. Secondary outcomes include gait speed, dizziness intensity, neck pain intensity, neck disability, pain extent and location, cervical range of motion, functional ability, perceived benefit, and quality of life. Assessment will be measured at baseline, immediately after treatment and at 3, 6, 12 month-follow ups.

Discussion

Neck pain is one of the major causes of disability. Effective treatment must address not only the symptoms but the dysfunctions associated with neck pain. This trial will evaluate the effectiveness of interventions for individuals with neck pain with impaired cervical joint position sense and balance. This trial will impact on clinical practice by providing evidence towards optimal and efficient management.

Trial registration

ClinicalTrials.gov (NCT03149302). May 10, 2017.

Postural control and the relation with cervical sensorimotor control in patients with idiopathic adult-onset cervical dystonia

Cervical dystonia (CD) is a movement disorder characterized by involuntary muscle contractions leading to an abnormal head posture or movements of the neck. Dysfunctions in somatosensory integration are present and previous data showed enlarged postural sway in stance. Postural control during quiet sitting and the correlation with cervical sensorimotor control were investigated. Postural control during quiet sitting was measured via body sway parameters in 23 patients with CD, regularly receiving botulinum toxin treatment and compared with 36 healthy controls. Amplitude and velocity of displacements of the center of pressure (CoP) were measured by two embedded force plates at 1000 Hz. Three samples of 30 s were recorded with the eyes open and closed. Disease-specific characteristics were obtained in all patients by the Tsui scale, Cervical Dystonia Impact Profile (CDIP-58) and Toronto Western Spasmodic Rating Scale (TWSTRS). Cervical sensorimotor control was assessed with an infrared Vicon system during a head repositioning task. Body sway amplitude and velocity were increased in patients with CD compared to healthy controls. CoP displacements were doubled in patients without head tremor and tripled in patients with a dystonic head tremor. Impairments in cervical sensorimotor control were correlated with larger CoP displacements (r_s ranged from 0.608 to 0.748). Postural control is impaired and correlates with dysfunction in cervical sensorimotor control in patients with CD. Treatment is currently focused on the cervical area. Further research towards the potential value of postural control exercises is recommended.

Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain

Synopsis There is considerable evidence to support the importance of cervical afferent dysfunction in the development of dizziness, unsteadiness, visual disturbances, altered balance, and altered eye and head movement control following neck trauma, especially in those with persistent symptoms. However, there are other possible causes for these symptoms, and secondary adaptive changes should also be considered in differential diagnosis. Understanding the nature of these symptoms and differential diagnosis of their potential origin is important for rehabilitation. In addition to symptoms, the evaluation of potential impairments (altered cervical joint position and movement sense, static and dynamic balance, and ocular mobility and coordination) should become an essential part of the routine assessment of those with traumatic neck pain, including those with concomitant injuries such as concussion and vestibular or visual pathology or deficits. Once adequately assessed, appropriate tailored management should be implemented. Research to further assist differential diagnosis and to understand the most important contributing factors associated with abnormal cervical afferent input and subsequent disturbances to the sensorimotor control system, as well as the most efficacious management of such symptoms and impairments, is important for the future. J Orthop Sports Phys Ther 2017;47(7):492-502. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7052.

Use of neck torsion as a specific test of neck related postural instability

BACKGROUND

Disturbed postural stability in neck pain (NP) is likely due to abnormal cervical afferent function. Several potential causes requires specific diagnostic tests. The neck torsion (head still body rotated) manoeuvre stimulates cervical but not vestibular receptors and identified abnormal cervical afferent input as the cause in patients with NP compared to healthy controls. Comparison between vestibular and NP subjects is now needed.

AIMS

To compare individuals with unilateral vestibular loss (UVL), persistent NP and asymptomatic controls. It was hypothesized that neck torsion will increase postural stability in NP compared to both the asymptomatic and UVL groups.

METHODS

Twenty UVL, 20 persistent NP and 20 asymptomatic control subjects underwent measurement of postural stability on a computerised force plate with eyes closed in comfortable stance under 5 conditions: neutral head, head rotated 45° (left and right) and neck torsion (left and right). Root mean square (rms) amplitude of sway was measured in the anterior posterior (AP) and medial lateral (ML) directions. Average torsion and torsion difference (average torsion - neutral neck) were calculated.

RESULTS

NP subjects had significantly greater (p < 0.05) AP sway with average torsion and torsion difference compared to both control and UVL. There were no significant differences between control and UVL and no between group differences for neutral neck, rotation or rotation difference.

CONCLUSION

The results of the study suggest that the torsion manouever may identify cervical afferent causes of disturbed postural stability. This is important for guiding assessment and management of balance disturbances in patients.

A prospective investigation of changes in the sensorimotor system following sports concussion. An exploratory study

BACKGROUND

Sports concussion is a risk for players involved in high impact, collision sports. Post-concussion, the majority of symptoms subside within 7-10 days, but can persist in 10-20% of athletes. Understanding the effects of sports concussion on sensorimotor systems could inform physiotherapy treatment.

OBJECTIVE

To explore changes in sensorimotor function in the acute phase following sports concussion.

DESIGN

Prospective cohort study.

METHODS

Fifty-four players from elite rugby union and league teams were assessed at the start of the playing season. Players who sustained a concussion were assessed three to five days later. Measures included assessments of balance (sway velocity), vestibular system function (vestibular ocular reflex gain; right-left asymmetry), cervical proprioception (joint position error) and trunk muscle size and function.

RESULTS

During the playing season, 14 post-concussion assessments were performed within 3-5 days of injury. Significantly decreased sway velocity and increased size/contraction of trunk muscles, were identified. Whilst not significant overall, large inter-individual variation of test results for cervical proprioception and the vestibular system was observed.

LIMITATIONS

The number of players who sustained a concussion was not large, but numbers were comparable with other studies in this field. There was missing baseline data for vestibular and cervical proprioception testing for some players.

CONCLUSIONS

Preliminary findings post-concussion suggest an altered balance strategy and trunk muscle control with splinting/over-holding requiring consideration as part of the development of appropriate physiotherapy management strategies.

Efficacy of Carbon Microcoils in Relieving Cervicogenic Dizziness

Introduction Cervical pain contributes to postural deviations and imbalance. Nanotechnology may be used for the treatment of neck pain by fixing to the skin small rounds silicone patches containing double spiral carbon nanotubes arranged in the form of a coil (Helical), which would then relieve dizziness caused by muscular contraction.

Objective The objective of this study is to Evaluate pain and dizziness scores before and after Helical patches effect on cervicogenic dizziness treatment.

Methods The selected patients should have neck pain arising from muscle contraction with loss of balance or instability lasting more than 90 days and normal electrooculography. Treatment consisted of placing 10 Helical patches distributed as follows: two in the upper cervical area, two in the lower cervical area (near the 5^th and 6^th vertebrae), two in the upper trapezius muscle area (between neck and shoulder), and four in the tender point area (as reported by the patient). Using a Visual Analogue Scale (VAS), we matched pain and dizziness scores from Day 1 to those from Day 15 and Day 30 using Mann-Whitney test.

Results There was a significant difference between pain score reported on Day 1 and Day 15 (Z = 2.43, U = 5, p = 0.01). We also found significant differences between dizziness scores reported on days 1 and 15 (Z = 2.62, U = 3.5, p = 0.01) and days 1 and 30 (Z = 2.36, U = 5.5, p = 0.01).

Conclusion The Helical patches seem to be an effective treatment for cervicogenic dizziness.