Predictive and discriminative value of shoulder proprioception tests for patients with whiplash-associated disorders

Assessment of shoulder proprioception in patients with chronic mechanical cervical pain: A comparative study

BACKGROUND

Chronic mechanical cervical pain (CMCP) is a common disabling problem worldwide, interfering with upper extremities function. However studying the impact of CMCP on shoulder proprioception is still lacking.

OBJECTIVE

To investigate the impact of CMCP on shoulder proprioception in young adults compared with normal control (NC) individuals.

METHODS

A comparative study was conducted between two groups; 40 patients with CMCP (mean age 32.28 ± 6.586) and 40 age and sex matched NC (mean age 33.43 ± 9.021). The Biodex isokinetic dynamometer was used to assess shoulder active sense of position at 30∘ external and internal rotations. The absolute angular error was calculated for the dominant and non-dominant shoulders.

RESULTS

The absolute angular error was significantly increased only in the CMCP at both rotation angles for both shoulders, showing a remarkable increase on the dominant shoulder and in the external rotation range compared with NC.

CONCLUSIONS

CMCP can significantly impair shoulder proprioception, particularly on the dominant side and in external rotation range. This could emphasize the careful examination of shoulder proprioception for the early detection of shoulders at risk, to eliminate the possibility of shoulder instability and/or injury in young adults with CMCP.

Influence of Neck Pain, Cervical Extensor Muscle Fatigue, and Manual Therapy on Wrist Proprioception

OBJECTIVE

The purpose of this study was to examine the effects of submaximal isometric neck muscle fatigue and manual therapy on wrist joint position sense (JPS) within healthy individuals and individuals with subclinical neck pain (SCNP).

METHODS

Twelve healthy participants and 12 participants with SCNP were recruited. Each group completed 2 sessions, with 48 hours between sessions. On day 1, both groups performed 2 wrist JPS tests using a robotic device. The tests were separated by a submaximal isometric fatigue protocol for the cervical extensor muscles (CEM). On day 2, both groups performed a wrist JPS test, followed by a cervical treatment consisting of manual therapy (SCNP) or neck rest (20 minutes, control group) and another wrist JPS test. Joint position sense was measured as the participant's ability to recreate a previously presented wrist angle. Each wrist JPS test included 12 targets, 6 into wrist flexion and 6 into wrist extension. Kinematic data from the robot established absolute, variability, and constant error.

RESULTS

Absolute error significantly decreased (P = .01) from baseline to post-fatigue in the SCNP group (baseline = 4.48 ± 1.58°; post-fatigue = 3.90 ± 1.45°) and increased in the control group (baseline = 3.12 ± 0.98°; post-fatigue = 3.81 ± 0.90°). The single session of manual cervical treatment significantly decreased absolute error in participants with SCNP (P = .004).

CONCLUSION

This study demonstrated that neck pain or fatigue can lead to altered afferent input to the central nervous system and can affect wrist JPS. Our findings demonstrate that acute wrist proprioception may be improved in individuals with SCNP by a single cervical manual therapy session.

Does My Neck Make Me Clumsy? A Systematic Review of Clinical and Neurophysiological Studies in Humans

Introduction: Clumsiness has been described as a symptom associated with neck pain and injury. However, the actuality of this symptom in clinical practice is unclear. The aim of this investigation was to collect definitions and frequency of reports of clumsiness in clinical studies of neck pain/injury, identify objective measures of clumsiness and investigate the association between the neck and objective measures of clumsiness.

Methods: Six electronic databases were systematically searched, records identified and assessed including a risk of bias. Heterogeneity in designs of studies prevented pooling of data, so qualitative analysis was undertaken.

Results: Eighteen studies were retrieved and assessed; the overall quality of evidence was moderate to high. Eight were prospective cross-sectional studies comparing upper limb sensorimotor task performance and ten were case series involving a healthy cohort only. Clumsiness was defined as a deficit in coordination or impairment of upper limb kinesthesia. All but one of 18 studies found a deterioration in performing upper limb kinesthetic tasks including a healthy cohort where participants were exposed to a natural neck intervention that required the neck to function toward extreme limits.

Conclusion: Alterations in neck sensory input occurring as a result of requiring the neck to operate near the end of its functional range in healthy people and in patients with neck pain/injury are associated with reductions in acuity of upper limb kinesthetic sense and deterioration in sensorimotor performance. Understanding the association between the neck and decreased accuracy of upper limb kinesthetic tasks provide pathways for treatment and rehabilitation strategies in managing clumsiness.

Slower reaction and response times and impaired hand-eye coordination in individuals with neck pain

BACKGROUND

Neck pain is associated with sensorimotor dysfunction. Research is sparse of the effect of neck pain on reaction and response times and hand-eye coordination.

OBJECTIVES

To investigate hand and foot reaction and response times and hand-eye coordination in individuals with neck pain and to determine any relationships with clinical features of neck pain.

METHODS

Sixty individuals with neck pain and 60 controls of similar age and gender were recruited. Tests of simple reaction and response time were measured on the dominant hand and foot. Hand-eye coordination was measured by tracing a variety of coordination patterns with different levels of difficulty. Clinical features measured were intensity and duration of pain, and neck disability.

RESULTS

Hand and foot reaction and response times were significantly slower in the neck pain group compared to controls (all p < 0.001). The neck pain group took longer to trace the hand-eye coordination task at the hardest level (p = 0.03). Neck disability scores correlated with hand reaction time (r = 0.4, p = 0.005) and time taken in hand-eye coordination tasks (r = 0.2 for all levels, p < 0.05). Reaction and response times were correlated with time taken in the hand-eye coordination test (r = 0.2-0.4, p < 0.01).

CONCLUSIONS

Individuals with neck pain had slower hand and foot reaction and response times and impaired hand-eye coordination, suggesting deficits in sensorimotor function. Training speed, as a function of acuity, and hand-eye coordination might be considered in clinical assessment. Further research is needed to identify potential underlying mechanisms of the slower and less well coordinated movement.

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.

Identifying upper limb disability in patients with persistent whiplash

BACKGROUND

Patients with persistent whiplash associated disorders (WAD) report upper limb (UL) symptoms and functional difficulties but there is limited information regarding the nature of these complaints. Impairments in motor performance may relate to functional deficits.

OBJECTIVE

To identify symptoms and the degree and nature of UL functional difficulties.

DESIGN

Cross sectional study.

METHODS

Twenty-four age matched subjects with persistent WAD and healthy controls were surveyed using the Disabilities of the Arm, Shoulder and Hand (DASH), Neck Disability Index (NDI) and Patient Specific Functional Scale (PSFS). A series of case studies on six subjects with persistent WAD and thirteen age and gender matched controls also had their motor performance assessed using a specialised UL testing battery, including reaction time, movement speed, accuracy, co-ordination and tapping speed.

RESULTS

The results suggest that UL symptoms and functional deficits are prevalent in persistent WAD. All individual item scores on the DASH, except one, were significantly higher in the WAD group and the DASH moderately correlated to pain, NDI and PSFS. Four-choice reaction time was the only motor performance measure that was significantly impaired in the WAD compared to control group and this correlated to pain levels.

CONCLUSIONS

The findings suggest the DASH is a suitable measure for subjects with persistent WAD and could be administered when high NDI scores are present or the patient specifically reports difficulty with UL activities. Further investigation regarding UL motor performance in subjects with persistent WAD is warranted to determine relationships between symptoms and reported functional deficits.

Altered activity of the serratus anterior during unilateral arm elevation in patients with cervical disorders

Altered activity in the axioscapular muscles is considered to be an important feature in patients with neck pain. The activity of the serratus anterior (SA) and trapezius muscles during arm elevation has not been investigated in these patients. The objectives of this study was to investigate whether there is a pattern of altered activity in the SA and trapezius in patients with insidious onset neck pain (IONP) (n=22) and whiplash associated disorders (WAD) (n=27). An asymptomatic group was selected for baseline measurements (n=23). Surface electromyography was used to measure the onset of muscle activation and duration of muscle activity of the SA as well as the upper, middle, and lower trapezius during unilateral arm elevation in the three subject groups. Both arms were tested. With no interaction, the main effect for the onset of muscle activation and duration of muscle activity for serratus anterior was statistically significant among the groups. Post hoc comparison revealed a significantly delayed onset of muscle activation and less duration of muscle activity in the IONP group, and in the WAD group compared to the asymptomatic group. There were no group main effects or interaction effects for upper, middle and lower trapezius. This finding may have implications for scapular stability in these patients because the altered activity in the SA may reflect inconsistent or poorly coordinated muscle activation that may reduce the quality of neuromuscular performance and induce an increased load on the cervical and the thoracic spine.

Altered Alignment of the Shoulder Girdle and Cervical Spine in Patients With Insidious Onset Neck Pain and Whiplash-Associated Disorder

Clinical theory suggests that altered alignment of the shoulder girdle has the potential to create or sustain symptomatic mechanical dysfunction in the cervical and thoracic spine. The alignment of the shoulder girdle is described by two clavicle rotations, i.e, elevation and retraction, and by three scapular rotations, i.e., upward rotation, internal rotation, and anterior tilt. Elevation and retraction have until now been assessed only in patients with neck pain. The aim of the study was to determine whether there is a pattern of altered alignment of the shoulder girdle and the cervical and thoracic spine in patients with neck pain. A three-dimensional device measured clavicle and scapular orientation, and cervical and thoracic alignment in patients with insidious onset neck pain (IONP) and whiplash-associated disorder (WAD). An asymptomatic control group was selected for baseline measurements. The symptomatic groups revealed a significantly reduced clavicle retraction and scapular upward rotation as well as decreased cranial angle. A difference was found between the symptomatic groups on the left side, whereas the WAD group revealed an increased scapular anterior tilt and the IONP group a decreased clavicle elevation. These changes may be an important mechanism for maintenance and recurrence or exacerbation of symptoms in patients with neck pain.

Objective assessment of mandibular motor control using a 'reach-and-hold' task

Mandibular motor function is well known to be impaired in the presence of temporomandibular disorders. However, while a vast literature is available concerning accuracy of motor control in limbs, quantitative and objective assessment of mandibular motor control has been seldom performed, also because of the lack of adequate investigative tools. Aim of this work is to present a technique for reliable evaluation of the motor performance of the mandible based on a kinesiography-monitored reach-and-hold task. Nineteen healthy subjects were engaged in a task in which they had to drive a cursor on a screen by corresponding movements of the mandible in the frontal plane and reach 30 random targets sequentially displayed on the screen. The whole task was repeated three times per session in two different days. The individual performance was assessed by different indices evaluating precision and steadiness of target matching. The performance progressively improved in the three trials of the first session, further improved and stabilised in the second session, with an average positioning error of 0·59 ± 038 mm and was slightly correlated with the horizontal dimension of the mandible border movement (r = 0·55). Intraclass correlation coefficient ranged between 0·76 and 0·94 for the different indices indicating good repeatability. The kinesiographic technique allowed for objective and reliable assessment of the voluntary control of the mandible position. Its potential applications include support to the characterisation of temporomandibular disorders and to motor training and progress monitoring in rehabilitation treatments.

Altered scapular orientation during arm elevation in patients with insidious onset neck pain and whiplash-associated disorder

STUDY DESIGN

Controlled laboratory study using a cross-sectional design.

OBJECTIVES

To investigate whether there is a pattern of altered scapular orientation during arm elevation in patients with insidious onset neck pain (IONP) and whiplash-associated disorder (WAD) compared to asymptomatic people.

BACKGROUND

Altered activity in the axioscapular muscles and impairments in scapular orientation are considered to be important features in patients with cervical disorders. Scapular orientation has until now not been investigated in these patients.

METHODS

A 3-dimensional tracking device measured scapular orientation during arm elevation in patients with IONP (n = 21) and WAD (n = 23). An asymptomatic group was selected for comparison (n = 20).

RESULTS

The groups demonstrated a significantly reduced clavicle retraction on the dominant side compared to the nondominant side. The WAD group demonstrated an increased elevation of the clavicle compared to the asymptomatic group and the IONP group, and reduced scapular posterior tilt on the nondominant side compared to the IONP group.

CONCLUSION

Altered dynamic stability of the scapula may be present in patients with cervical disorders, which may be an important mechanism for maintenance of recurrence or exacerbation of symptoms in these patients. Patients with cervical disorders may demonstrate a difference in impairments, based on their diagnosis of IONP or WAD.

Long-Term Adaptation to Neck/Shoulder Pain and Perceptual Performance in a Hand Laterality Motor Imagery Test

The effect of neck/shoulder pain on the performance in a hand laterality motor imagery test was studied. Responses to the Cooper and Shepard (1975, Journal of Experimental Psychology: Human Perception and Performance104 48–56) hand laterality test were explored in twenty-four individuals with chronic non-specific neck pain and twenty-one subjects with chronic neck pain of traumatic origin (whiplash-associated disorder). Twenty-two controls were also included in the study. Digitalised right- or left-hand stimuli were presented at five different stimulus angles (0°, 45° laterally, 90° laterally, 135° laterally, and 180°). The experimental task was to decide the laterality as fast and accurately as possible. The performance, both reaction time (RT) and accuracy, of the two experimental groups was contrasted with that of the control group. The main results revealed that the subjects afflicted with whiplash injury on the average exhibited a faster response pattern than symptom-free healthy controls. Despite their musculoskeletal deficits and experience of pain these volunteers also exhibited a preserved speed–accuracy tradeoff. Longer duration of time with symptoms of neck pain was, moreover, associated with progressively faster RTs. These results point to perceptual learning and may reflect different stages of adaptation to neck pain.

A novel method for neck coordination exercise--a pilot study on persons with chronic non-specific neck pain

BACKGROUND

Chronic neck pain is a common problem and is often associated with changes in sensorimotor functions, such as reduced proprioceptive acuity of the neck, altered coordination of the cervical muscles, and increased postural sway. In line with these findings there are studies supporting the efficacy of exercises targeting different aspects of sensorimotor function, for example training aimed at improving proprioception and muscle coordination. To further develop this type of exercises we have designed a novel device and method for neck coordination training. The aim of the study was to investigate the clinical applicability of the method and to obtain indications of preliminary effects on sensorimotor functions, symptoms and self-rated characteristics in non-specific chronic neck pain

METHODS

The study was designed as an uncontrolled clinical trial including fourteen subjects with chronic non-specific neck pain. A new device was designed to allow for an open skills task with adjustable difficulty. With visual feedback, subjects had to control the movement of a metal ball on a flat surface with a rim strapped on the subjects' head. Eight training sessions were performed over a four week period. Skill acquisition was measured throughout the intervention period. After intervention subjects were interviewed about their experience of the exercise and pain and sensorimotor functions, including the fast and slow components of postural sway and jerkiness-, range-, position sense-, movement time- and velocity of cervical rotation, were measured. At six-month follow up, self-rated pain, health and functioning was collected.

RESULTS

The subjects improved their skill to perform the exercise and were overall positive to the method. No residual negative side-effects due to the exercise were reported. After intervention the fast component of postural sway (p = 0.019) and jerkiness of cervical rotation (p = 0.032) were reduced. The follow up showed decreased disability (one out of three indices) and fear of movement, and increased general health (three out of eight dimensions).

CONCLUSION

The results support the clinical applicability of the method. The improvements in sensorimotor functions may suggest transfer from the exercise to other, non-task specific motor functions and justifies a future randomized controlled trial.

Changes in Head and Neck Position Have a Greater Effect on Elbow Joint Position Sense in People With Whiplash-associated Disorders

BACKGROUND

It has been shown that perception of elbow joint position is affected by changes in head and neck position. Further, people with whiplash-associated disorders (WAD) present with deficits in upper limb coordination and movement.

OBJECTIVES

This study is aimed to determine whether the effect of changes in head position on elbow joint position error (JPE) is more pronounced in people with WAD, and to determine whether this is related to the participant's pain and anxiety levels.

METHODS

Nine people with chronic and disabling WAD and 11 healthy people participated in this experiment. The ability to reproduce a position at the elbow joint was assessed after changes in the position of the head and neck to 30 degrees , and with the head in the midline. Pain was monitored in WAD participants.

RESULTS

Absolute elbow JPE with the head in neutral was not different between WAD and control participants (P=0.5). Changes in the head and neck position increased absolute elbow JPE in the WAD group (P<0.05), but did not affect elbow JPE in the control group (P=0.4). There was a connection between pain during testing and the effect of changes in head position on elbow JPE (P<0.05).

DISCUSSION

Elbow JPE is affected by movement of the head and neck, with smaller angles of neck rotation in people with WAD than in healthy individuals. This observation may explain deficits in upper limb coordination in people with WAD, which may be due to the presence of pain or reduced range of motion in this population.