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

Usability of a visual feedback system to assess and improve movement disorders related to neck pain: Perceptions of physical therapists and patients

A prototype visual feedback system has been developed to assess and improve movement disorders related to neck pain. The aim of this study was to assess the usability of the prototype in a rehabilitation setting. Twelve physical therapists integrated the device into their regular therapy programs for 24 neck pain patients with movement disorders. Each patient performed three individual therapy sessions with the device under physical therapist supervision. Usability was assessed by the physical therapists and patients using therapy diaries, the System Usability Scale, and focus group or personal interviews. Based on an overall usability rating of marginally acceptable, the visual feedback system was generally found to be a device with the potential to assess and train neck pain patients but needs improvement. To become a useful adjunct to regular physical therapy, improvements in the hardware and software, and further system developments are required.

Measurement properties of cervical joint position error in people with and without neck pain: a systematic review and narrative synthesis

INTRODUCTION

Proprioception can be impaired in people with neck pain. The cervical joint position sense test, which measures joint position error (JPE), is the most common test used to assess neck proprioception. The aim of this systematic review was to assess the measurement properties of this test for the assessment of people with and without neck pain.

METHODS

This systematic review was registered prospectively on Prospero (CRD42020188715). It was designed using the COSMIN guidelines and reported in line with the PRISMA checklist. Two reviewers independently searched Medline, Embase, SportDiscus, and CINAHL Plus databases from inception to the 24th July 2022 with an update of the search conducted until 14th of October 2023. The COSMIN risk of bias checklist was used to assess the risk of bias in each study. The updated criteria for good measurement properties were used to rate individual studies and then the overall pooled results. The level of evidence was rated by two reviewers independently using a modified GRADE approach.

RESULTS

Fifteen studies were included in this review, 13 reporting absolute JPE and 2 reporting constant JPE. The measurement properties assessed were reliability, measurement error, and validity. The measurement of JPE showed sufficient reliability and validity, however, the level of evidence was low/very low for both measurement properties, apart from convergent validity of the constant JPE, which was high.

CONCLUSION

The measure of cervical JPE showed sufficient reliability and validity but with low/very low levels of evidence. Further studies are required to investigate the reliability and validity of this test as well as the responsiveness of the measure.

Neck muscle activation in response to eye movement depends on sitting posture and is modified in whiplash associated disorders: Cross-sectional study

BACKGROUND

Activity of specific neck muscles is modulated by eye movement. This activity modulation is exaggerated in people with whiplash associated disorders (WAD), but it is unknown whether it is impacted by sitting posture.

OBJECTIVE

This study investigated; (i) whether activity of cervical muscles differs with spinal posture; (ii) whether the effect of eye gaze direction (horizontal/vertical) on neck muscle activity differs between postures, and (iii) whether these effects differ between individuals with and without WAD.

METHODS

In three seated postures (normal relaxed, head forward, sit tall) electromyography (EMG) was recorded right obliquus capitis inferior (OI), multifidus (MF), splenius capitis (SP) and left sternocleidomastoid (SCM) with fine-wire and surface electrodes in ten healthy controls and nine with WAD. Electro-oculography recorded eye movements.

RESULTS

In controls, EMG was less for extensor muscles in Sit Tall than Head Forward, but higher in SCM. Only SC EMG modulated with eye movement. When WAD participants adopted similar sitting postures several responses were different; compared to Normal Relaxed posture OI EMG was less in Head Forward; MF EMG was less in Sit Tall; and SC was less in Head Forward and Sit Tall. Neck muscles in WAD were generally more sensitive to eye movement, except SC which did not modulate.

CONCLUSIONS

These finding support the hypothesis that neck muscle activity is influenced by spinal posture and eye movement. In WAD, this relationship is distorted and the response to eye movement is increased.

SIGNIFICANCE

These observations have potential implications for clinical management of individuals with WAD.

Neural processing of pain-related distress to neck-specific movements in people with chronic whiplash-associated disorders

ABSTRACT

Pain-related distress contributes to long-term disability in chronic whiplash-associated disorders. Recently, neuroimaging studies have revealed altered neural responses to viewing pictures of movements associated with back pain in key regions for threat and affective processing. In this study, we examined neural correlates of imagining neck-specific movements designed to elicit pain-related distress in individuals with whiplash-associated disorders (n = 63) when compared with that in sex-matched pain-free controls (n = 32). In the scanner, participants were presented with neck-specific movement-related pictures divided into 3 categories (high fear, moderate-fear, and neutral control pictures) and asked to imagine how they would feel if they were performing the movement. Whole-brain analyses revealed greater differential activation (high-fear vs neutral) in individuals with whiplash-associated disorders when compared with that in pain-free controls in 6 clusters including right and left postcentral gyri, left parietal operculum, dorsal precuneus, left superior frontal gyrus/anterior cingulate cortex, and posterior cingulate cortex/ventral precuneus. For the contrast moderate-fear vs neutral, patients showed greater differential activation than controls in the right and left posterolateral cerebellum. Activation patterns in the precuneus and posterior cingulate cortex were negatively associated with pain-related fear, but no other correlations were observed. Together, the findings suggest that when conceptualizing neck-specific movements associated with pain, people with chronic whiplash-associated disorders may predict-and potentially amplify-their sensory and affective consequences and therewith trigger dysfunctional affective and/or behavioral responses. Herewith, we provide new insights into the neural mechanisms underlying chronic pain in people with whiplash-associated disorders, pointing towards a complex interplay between cognitive/affective and sensorimotor circuitry.

Manual cervical therapy and vestibular migraine: A case series

Background

Vestibular migraine (VM) is a relatively new diagnostic entity with incomplete knowledge regarding pathophysiological mechanisms and therapeutic guidelines. By reporting the effect of manual cervical therapy (MCT) on people with VM, we suggest a possible role for upper cervical afferents in VM treatment and/or pathogenesis. The objective was to describe the change in clinical presentation and self-reported symptoms of VM corresponding to MCT and followed up to six months.

Methods

A nonrandomised *ABA design was utilised to consecutively and prospectively evaluate selected patients with diagnosed VM. Symptom characteristics (frequency and intensity) were recorded along with standardised patient-reported outcomes (PROs) to document the response to MCT.

Results

Three patients were recruited who met the diagnostic criteria for VM. All three patients demonstrated improvement in both migraine attack and interictal symptom frequency. These improvements mirrored changes in PROs and were sustained over a six-month follow-up period.

Conclusions

The improvement that coincided with the intervention including MCT was rapid, observable and sustained. This suggests that the upper cervical spine could be a therapeutic target in VM and may have implications for future research into the pathogenesis of VM.

Cervicogenic headache

INTRODUCTION

Cervicogenic headache, first proposed as a distinct headache in 1983, is a secondary headache to a primary cervical musculoskeletal disorder. Research into physical impairments was integral to clinical diagnosis and to develop and test research informed conservative management as the first line approach.

PURPOSE

This narrative presents an overview of the body of cervicogenic headache research from our laboratory which was undertaken in the context of a broad program of research into neck pain disorders.

IMPLICATIONS

Early research validated manual examination of the upper cervical segments against anaesthetic nerve blocks, which was vital to clinical diagnosis of cervicogenic headache. Further studies identified reduced cervical motion, altered motor control of the neck flexors, reduced strength of flexor and extensor muscles, and occasional presentation of mechanosensitivity of the upper cervical dura. Single measures are variable and not reliable in diagnosis. We proved that a pattern of reduced motion, upper cervical joint signs and impaired deep neck flexor function accurately identified cervicogenic headache and differentiated it from migraine and tension-type headache. The pattern was validated against placebo controlled diagnostic nerve blocks. A large multicentre clinical trial determined that a combined program of manipulative therapy and motor control exercise is effective in the management of cervicogenic headache and outcomes are maintained in the long term. More specific research into cervical related sensorimotor controlled is warranted in cervicogenic headache. Further adequately powered clinical trials of current research informed multimodal programs are advocated to further strengthen the evidence base for conservative management of cervicogenic headache.

Lunar and mars gravity induce similar changes in spinal motor control as microgravity

Introduction: Once more, plans are underway to send humans to the Moon or possibly even to Mars. It is therefore, important to know potential physiological effects of a prolonged stay in space and to minimize possible health risks to astronauts. It has been shown that spinal motor control strategies change during microgravity induced by parabolic flight. The way in which spinal motor control strategies change during partial microgravity, such as that encountered on the Moon and on Mars, is not known. Methods: Spinal motor control measurements were performed during Earth, lunar, Mars, and micro-gravity conditions and two hypergravity conditions of a parabola. Three proxy measures of spinal motor control were recorded: spinal stiffness of lumbar L3 vertebra using the impulse response, muscle activity of lumbar flexors and extensors using surface electromyography, and lumbar curvature using two curvature distance sensors placed at the upper and lower lumbar spine. The participants were six females and six males, with a mean age of 33 years (standard deviation: 7 years). Results: Gravity condition had a statistically significant (Friedmann tests) effect spinal stiffness (p < 0.001); on EMG measures (multifidus (p = 0.047), transversus abdominis (p < 0.001), and psoas (p < 0.001) muscles) and on upper lumbar curvature sensor (p < 0.001). No effect was found on the erector spinae muscle (p = 0.063) or lower curvature sensor (p = 0.170). Post hoc tests revealed a significant increase in stiffness under micro-, lunar-, and Martian gravity conditions (all p's < 0.034). Spinal stiffness decreased under both hypergravity conditions (all p's ≤ 0.012) and decreased during the second hypergravity compared to the first hypergravity condition (p = 0.012). Discussion: Micro-, lunar-, and Martian gravity conditions resulted in similar increases in spinal stiffness, a decrease in transversus abdominis muscle activity, with no change in psoas muscle activity and thus modulation of spinal motor stabilization strategy compared to those observed under Earth's gravity. These findings suggest that the spine is highly sensitive to gravity transitions but that Lunar and Martian gravity are below that required for normal modulation of spinal motor stabilization strategy and thus may be associated with LBP and/or IVD risk without the definition of countermeasures.

Post-Traumatic Craniocervical Disorders From a Postural Control Perspective: A Narrative Review

Mild traumatic brain injury (mTBI) and whiplash injury (WI) may lead to long-term disabling consequences known as post-concussive syndrome (PCS) and whiplash-associated disorders (WADs). PCS and WAD patients commonly complain of conditions encompassing dizziness, vertigo, headache, neck pain, visual complaints, anxiety, and neurocognitive dysfunctions. A proper medical work-up is a priority in order to rule out any acute treatable consequences. However investigations may remain poorly conclusive. Gathered in the head and neck structures, the ocular sensorimotor, the vestibular, and the cervical proprioceptive systems, all involved in postural control, may be damaged by mTBI or WI. Their dysfunctions are associated with a wide range of functional disorders including symptoms reported by PCS and WAD patients. In addition, the stomatognathic system needs to be specifically assessed particularly when associated to WI. Evidence for considering the post-traumatic impairment of these systems in PCS and WAD-related symptoms is still lacking but seems promising. Furthermore, few studies have considered the assessment and/or treatment of these widely interconnected systems from a comprehensive perspective. We argue that further research focusing on consequences of mTBI and WI on the systems involved in the postural control are necessary in order to bring new perspective of treatment.

Possible autonomic or cranial nerve symptoms triggered during sustained neck rotation in persistent headache post-concussion: a retrospective observational cross-sectional study

OBJECTIVES

To examine and categorize symptoms occurring within 60 s of vertebrobasilar-insufficiency (VBI) testing (left- and right-neck rotation) in individuals with persistent post-traumatic headache.

BACKGROUND

As part of routine clinical cervical screening in our patients, we found extended VBI testing often triggered additional symptoms. Therefore, we aimed to document the prevalence and precise symptoms occurring during each movement direction of this test and determine any demographic or baseline signs or symptoms associated with a positive test.

METHODS

A retrospective medical record review on military personnel receiving treatment for persistent post-traumatic headache was performed. Participants were grouped according to presence of non-headache related symptoms triggered during the tests. Frequency, onset, and symptom characteristics reported were categorized as potentially vascular and/or possible autonomic or cranial nerve in nature.

RESULTS

At least one symptom was reported by 81.3% of 123 patients. Of these, 54% reported symptoms in one and 46% in both directions of rotation, yielding 146 abnormal tests. Most reported symptoms were tear disruption (41%), altered ocular-motor-control (25%), and blepharospasm (16%). Enlisted individuals and those with altered baseline facial sensation were more likely to have a positive test.

CONCLUSIONS

The majority reported symptoms not typical of VBI within 60 seconds of sustained neck rotation. Further study is needed to better understand the mechanisms and clinical relevance.

Acute effects of instrument assisted soft tissue mobilization technique on pain and joint position error in individuals with chronic neck pain: a double-blind, randomized controlled trial

PURPOSE/AIM

The aim of this study was to determine the acute effects of IASTM on cervical joint position error and pain in individuals with chronic neck pain.

METHODS

A total of 39 individuals with chronic neck pain were included in this study. Participants were randomized into three groups: Instrument-assisted soft-tissue mobilization(IASTM (n = 13), sham (n = 13), and control (n = 13). In the IASTM group, intervention was applied to the sternocleidomastoid and trapezius muscles with an application time of 45 s and a frequency of 60 beats/min. In the sham group, IASTM was applied at a 90° angle without pressure. The control group did not receive any intervention. The pain severity and joint position error(JPE) were evaluated before and after the intervention, by using the visual analogue scale and a cervical range of motion device.

RESULTS

The effects of time and treatment group on visual analogue scale(VAS) score were statistically significant (p = .001). Instrument-assisted soft-tissue mobilization was more effective in VAS score than sham and control group (p < .001). Significant improvement was found in JPE in all range of motions of the cervical region in the instrument-assisted soft-tissue mobilization group (p < .05). In the sham group, significant improvements were observed in cervical extension, left rotation, and left lateral flexion movements in JPE during each cervical spine active movement (p < .05). Instrument-assisted soft-tissue mobilization group was more effective in JPE all directions than sham and control group.

CONCLUSIONS

Instrument-assisted soft-tissue mobilization may be a useful technique in individuals with chronic neck pain. Instrument-assisted soft-tissue mobilization decreases VAS and improves JPE.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04882397 (05 August 2021).

Sports-related concussion: assessing the comprehension, collaboration, and contribution of chiropractors

Over the last 2 decades, sports-related concussion (SRC) awareness and management have evolved from an emphasis on complete cognitive and physical rest to evidence-based protocols and interventions. Chiropractors are primary care providers with exposure to athletes and teams in collision sports and, in addition, manage patients with concussion-like symptoms including neck pain, dizziness, and headache. With SRC frequently occurring in the absence of a medical practitioner, the role of allied health practitioners like chiropractors should be emphasised when it comes to the recognition, assessment, and management of SRC. This commentary discusses the potential contribution of chiropractors in SRC and the specific role their expertise in the cervical spine may play in symptom evaluation and management. A PubMed and Google scholar review of the chiropractic SRC literature suggests that the chiropractic profession appears under-represented in concussion research in athletic populations compared to other medical and allied health fields. This includes an absence of chiropractic clinicians with a focus on SRC participating in the Concussion in Sport Group (CISG) and the International Consensus Conferences on Concussion. Furthermore, with evolving evidence suggesting the importance of cervicogenic manifestations in SRC, there is an opportunity for chiropractors to participate in SRC diagnosis and management more fully and contribute scientifically to an area of specialised knowledge and training. With a dearth of chiropractic orientated SRC science, clinical SRC expertise, and clinical chiropractic representation in the CISG; it is incumbent on chiropractic clinicians and scientists to take up this opportunity through meaningful contribution and involvement in the SRC field.

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.

Proprioceptive Cervicogenic Dizziness: A Narrative Review of Pathogenesis, Diagnosis, and Treatment

Basic science and clinical evidence suggest that cervical spine disorders can lead to dizziness. The cervical spine has highly developed proprioceptive receptors, whose input information is integrated with the visual and vestibular systems in the central nervous system, acting on the neck and eye muscles to maintain the coordinative motion of the head, eyes, neck, and body through various reflex activities. When the cervical proprioceptive input changes due to the mismatch or conflict between vestibular, visual, and proprioceptive inputs, cervicogenic dizziness may occur. The diagnosis of cervicogenic dizziness can be determined based on clinical features, diagnostic tests, and the exclusion of other possible sources of dizziness. The cervical torsion test appears to be the best diagnostic method for cervicogenic dizziness. Based on the available evidence, we first developed the diagnostic criteria for cervicogenic dizziness. Treatment for cervicogenic dizziness is similar to that for neck pain, and manual therapy is most widely recommended.

Rückenschmerzen und erhöhtes Bandscheibenvorfallrisiko bei Astronauten während und nach Raumfahrtmissionen

Rückenschmerzen zu Beginn einer Raumfahrtmission sowie ein erhöhtes Risiko für Bandscheibenvorfälle (Diskusprolaps) nach der Rückkehr ist ein seit Langem bekanntes medizinisches Problem der bemannten Raumfahrt. Mit dem Bestreben, den Mond permanent zu besiedeln, wird der Erhalt der körperlichen Gesundheit in einer für den Menschen fremden Umgebung ein zentraler Faktor. Im Vergleich zu den Apollo-Flügen zum Mond in den 1970er-Jahren sollen die Aufenthalte auf dem Mond in Zukunft nicht nur ein paar Tage dauern, sondern Monate, was neue Gesundheitsrisiken mit sich bringt. Durch die Entfernung zur Erde und den dadurch eingeschränkten Zugang zu medizinischen Leistungen wird es ferner viel schwieriger oder gar unmöglich, bei Notfällen schnell einzugreifen. Deshalb sind neue Ideen zur Bewältigung der medizinischen Herausforderungen gefragt.

The University of Kansas Health System Outpatient Clinical Concussion Comprehensive Protocol: An Interdisciplinary Approach

Objective:

The concussion team at The University of Kansas Health System outpatient rehabilitation spine center is comprised of experienced multi-disciplinary experts including physical therapists and a speech language pathologist. The team set forth with a purpose of creating and organizing an internal physical therapy clinical recommendation protocol for initial evaluations and subsequent treatments for the concussed patient. The aim of this paper is to share these recommendation protocols with other therapy teams and provide a foundational layout for treating the patient with post-concussion symptoms in an outpatient physical therapy clinical setting.

Study design:

Clinical recommendation protocol provides guidance for patients ages 10+ from initial evaluation through discharge with emphasis on evidence-based research in the areas of: oculomotor, cervical, vestibular, post-concussion migraine influence, mood disorders(such as anxiety and depression), exertion, and cognitive communicative dysfunction.

Results:

Finding a written, comprehensive clinical resource protocol for post-concussion outpatient evaluation(s) and treatment strategies can be difficult. This document serves as a resource for other outpatient concussion rehabilitation clinics, providing rationale, and objective measurement tools, for assessing and treating concussion patients. To the authors’ knowledge, no other research has produced a practical, efficient evaluation tool to be utilized at bed side, condensing evidence-based research into an easy-to-use form.

Conclusion:

The University of Kansas Health System outpatient concussion rehabilitation center developed clinical recommendation protocols for concussion care. The intent was to standardize assessment and treatment for concussion patients and to share these objective measurement tools and procedures, focused on a team approach of concussion providers, as a clinical outline for both the novice and seasoned clinician specializing in the field of concussion work in an outpatient rehabilitation setting.

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.

Oculomotor performance in patients with neck pain: Does it matter which angle of neck torsion is used in smooth pursuit eye movement test and is the agreement between angles dependent on target movement amplitude and velocity?

BACKGROUND

Neck torsion manoeuvre is thought to affect eye movement control via afferent sensory drive in neck pain disorders patients. Literature reports inconsistencies regarding the angle of neck torsion most commonly used across the studies.

OBJECTIVES

The goal of this study was to determine the level of agreement in oculomotor performance between two most commonly used neck torsion angles during smooth pursuit neck torsion test (SPNT).

DESIGN

A cross-sectional design was used in thirty-two neck pain patients and thirty-two healthy individuals.

METHOD

Gain and SPNT_diff were measured during SPNT test at 30° and 45° of neck torsion angle, at 30°, 40° and 50° of target movement amplitudes and three different target movement velocities (20°s^-1, 30°s^-1 and 40°s^-1) using eye tracking device. Bland-Altman plots and correlation analysis were used to study the agreement between the two angles.

RESULTS

Small to medium correlations and wide bias confidence intervals suggest medium level of agreement in gain or SPNT_diff between the two neck torsion angles for chronic neck pain patients, but higher in healthy individuals. Higher agreement in gain was observed at lager target movement amplitudes and at slower target movement velocities, however this trend was not observed for SPNT_diff.

CONCLUSION

Level of agreement between the two angles in SPNT test depends on the amplitude and velocity of the moving target. In cases when subjects within the same study are not able to perform 45° of neck torsion, 50° amplitude and 20°s^-1 velocity of target movement are more suitable to reach higher agreement between the angles.

Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness

BACKGROUND

Patients with cervicogenic dizziness (CGD) present with dizziness, cervical spine dysfunctions, and postural imbalance, symptoms that can significantly impact their daily functioning.

OBJECTIVES

To provide evidence-based recommendations for the management of patients with CGD.

METHODS

Three databases were searched for randomized controlled trials (RCTs) (last search 15 May 2021). Outcome measures included dizziness, cervical spine, and balance parameters. Cochrane standard methodological procedures were used and included the RoB 2.0 and GRADE. Where possible, RCTs were pooled for meta-analysis.

RESULTS

Thirteen RCTs (n = 898 patients) of high (two RCTs), moderate (five RCTs), and low (six RCTs) methodological quality were analyzed. Six RCTs were included in the meta-analysis. Only three RCTs specified the cause of CGD. They showed inconsistent findings for the effectiveness of exercise therapy in patients with traumatic CGD. Manual therapy and manual therapy combined with exercise therapy may reduce CGD, cervical spine, and balance dysfunctions.

CONCLUSION

There is moderate quality of evidence that manual therapy reduces CGD, cervical spine, and balance symptoms. When manual therapy is combined with exercise therapy, the positive effect on CGD, cervical spine, and balance symptoms is even stronger. However, the quality of the evidence here is very low.

Is Altered Oculomotor Control during Smooth Pursuit Neck Torsion Test Related to Subjective Visual Complaints in Patients with Neck Pain Disorders?

Subjective visual complaints are commonly reported in patients with neck pain, but their relation to objectively measured oculomotor functions during smooth pursuit neck torsion tests (SPNTs) has not yet been investigated. The aim of the study was to analyse classification accuracy of visual symptom intensity and frequency based on SPNT results. Forty-three patients with neck pain were referred by orthopaedic outpatient clinics where they were required to fill out 16-item proformas of visual complaints. Infrared video-oculography was used to measure smooth pursuit eye movements during neutral and neck torsion positions. Parameters of gain and SPNT difference (SPNT_diff) were taken into the Naïve Bayes model as classifiers, while intensity and frequency of visual symptoms were taken as predicted class. Intensity and, to a lesser degree, frequency of visual symptoms previously associated with neck pain or focal vision disorders (computer vision syndrome) showed better classification accuracy using gain at neck torsion position, indicating cervical driven visual disturbances. Moreover, SPNT_diff presented with slightly lower classification accuracy as compared to gain at neck torsion position. Our study confirmed the relationship between cervical driven oculomotor deficits and some visual complaints (concentrating to read, words moving on page, blurred vision, difficulty judging distance, sore eyes, heavy eyes, red eyes, and eyes strain).

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.

An Investigation of Sensorimotor Impairments in Individuals 4 weeks to 6 months following mild traumatic brain injury

OBJECTIVE

To identify whether adults 4 weeks to 6 months post mild traumatic brain injury (mTBI) have sensorimotor impairments when compared to healthy controls. A secondary aim was to determine if impairments were evident irrespective of participant perceived absence of symptoms.

DESIGN

Observational cohort study SETTING: Tertiary University and Hospital PARTICIPANTS: Participants included 113 individuals aged 18 to 60 years consisting of 39 controls with no prior concussion history, and 74 individuals, 4 weeks to 6 months post mTBI of which 35 considered themselves asymptomatic (Asymp), and 37 symptomatic (Symp).

MAIN OUTCOME MEASURES

Assessments of oculomotor, vestibulo-ocular reflex (VOR) control, balance, single and dual task tandem walk (TTW-S, TTW-D) and vestibular positional testing.

RESULTS

Poorer balance and tandem walk performance, and a higher frequency of positive oculomotor, VOR and vestibular positional tests were evident in the mTBI group compared to controls. In particular ≥ 2 positive oculomotor findings were evident in 53.7% of the participants with mTBI compared to 10.8 % of controls. The mTBI group who considered themselves recovered (Asymp) demonstrated significantly increased TWT-D time, and a higher proportion 53% had ≥ 2 positive oculomotor tests compared to controls.

CONCLUSION

Persistent sensorimotor impairments, particularly evidenced by disturbed oculomotor function and deficits in dual task tandem walking were identified among adults 4 weeks to 6 months post mTBI. These disturbances were evident regardless of whether ongoing symptoms were reported. The findings support recommendations for routine clinical assessment of sensorimotor function post mTBI with implications for injury prevention.

Effects of dry needling of the obliquus capitis inferior on sensorimotor control and cervical mobility in people with neck pain: A double-blind, randomized sham-controlled trial

BACKGROUND

Impairments of sensorimotor control relating to head and eye movement control and postural stability are often present in people with neck pain. The upper cervical spine and particularly the obliquus capitis inferior (OCI) play an important proprioceptive role; and its impairment may alter cervical sensorimotor control. Dry needling (DN) is a valid technique to target the OCI.

OBJECTIVES

To investigate if a single DN session of the OCI muscle improves head and eye movement control-related outcomes, postural stability, and cervical mobility in people with neck pain.

METHODS

Forty people with neck pain were randomly assigned to receive a single session of DN or sham needling of the OCI. Cervical joint position error (JPE), cervical movement sense, standing balance and oculomotor control were examined at baseline, immediately post-intervention, and at one-week follow-up. Active cervical rotation range of motion and the flexion rotation test were used to examine the global and upper cervical rotation mobility, respectively.

RESULTS

Linear mixed-models revealed that the DN group showed a decrease of JPE immediately post-intervention compared to the sham group (mean difference [MD]= -0.93°; 95% confidence interval [CI]: -1.85, -0.02) which was maintained at one-week follow-up (MD= -1.64°; 95%CI: -2.85, -0.43). No effects on standing balance or cervical movement sense were observed in both groups. Upper cervical mobility showed an increase immediately after DN compared to the sham group (MD= 5.14°; 95%CI: 0.77, 9.75) which remained stable at one-week follow-up (MD= 6.98°; 95%CI: 1.31, 12.40). Both group showed an immediate increase in global cervical mobility (MD= -0.14°; 95%CI: -5.29, 4.89).

CONCLUSION

The results from the current study suggest that a single session of DN of the OCI reduces JPE deficits and increases upper cervical mobility in patients with neck pain. Future trials should examine if the addition of this technique to sensorimotor control training add further benefits in the management of neck pain.

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.

Virtual Reality Exercises in an Interdisciplinary Rehabilitation Programme for Persons with Chronic Neck Pain: a Feasibility Study

Objective

To investigate the feasibility of a virtual reality exercise intervention within an interdisciplinary rehabilitation programme for persons with chronic neck pain. The effects of the intervention on symptom severity, variables related to chronic neck pain, and patients' experience of exercises were assessed.

Methods

Nine women and 3 men participated in a 6-week virtual reality exercise intervention during an interdisciplinary rehabilitation programme. Symptom severity was rated before and after each session of virtual reality exercise, using questionnaires before and after the interdisciplinary rehabilitation programme, and questions about participants' experiences.

Results

Neck pain symptoms increased temporarily during the exercises, but no lasting deterioration was found after the interdisciplinary rehabilitation programme. Depression, pain interference, pain control, sleep and kinesiophobia improved significantly after the programme. Participants experienced that the virtual reality exercises increased motivation to exercise and provided a focus other than pain. However, the equipment was heavy; and exercising was tiring and reminded them of their challenges.

Conclusion

This study indicates that virtual reality exercises as part of an interdisciplinary rehabilitation programme are feasible and safe for patients with chronic neck pain. Pain symptoms may increase temporarily during the exercises. Virtual reality exercises may support participants by increasing motivation to exercise and providing helpful feedback. Further research into the added value of virtual reality exercises in an interdisciplinary rehabilitation programme for patients with chronic neck pain is warranted.

Watching Your Neck: The Influence of Real-Time Visual Feedback on Cervical Joint Position Sense in Chronic Neck Pain

Patients with neck pain demonstrate a variety of sensorimotor impairments, such as decreased cervical joint position sense (CJPS) acuity, which might also be associated with an impaired internal body representation. The present study evaluated the effect of real-time visual feedback of the individual's own neck on CJPS compared to observing a book. Twenty-three patients with neck pain participated in the experiment and received the interventions in randomized order on separate days in a within-subject pretest-posttest design. Before and immediately after each intervention, CJPS was measured by a therapist blinded to the intervention. The results demonstrate a significantly different development of CJPS (p = .04), with increased CJPS acuity after observing one's own neck and decreased acuity after observing a book. Real-time visual feedback of the neck improved CJPS acuity in patients with neck pain without active movements of the neck, indicating the importance of central nervous system processing for CJPS acuity.

An upper cervical spine treatment protocol for cervicogenic dizziness: a randomized controlled trial

INTRODUCTION

Physiotherapy is a common treatment used for cervicogenic dizziness (CD). Treatment of the cervical spine using manual therapy techniques shows moderate evidence in favor of its use. International criteria for the treatment of the cervical spine have been described. Detecting patients' contraindications is the most important safety consideration. International criteria and recommendations for treatment of the cervical spine have been described, as well as safety criteria. A safe traction-manipulation intervention protocol is therefore possible. However, the effects of this protocol on dizziness intensity and dizziness-related disability have not been studied.

OBJECTIVE

To analyze the effects of a traction-manipulation protocol in patients with CD.

METHODS

The patients were referred by an otoneurologist, and after inclusion were randomly divided into a control group and an intervention group. The intervention was based on the application of a traction-manipulation protocol in the resting position. Dizziness intensity, self-reported disability, and cervical range of motion with and without a fixed gaze were assessed. All data were collected beforehand and at two days and four weeks after intervention.

RESULTS

At the two-days follow-up, statistically significant differences in favor of the intervention were observed between groups in the primary outcomes of dizziness intensity (p < .001) and Dizziness Handicap Inventory (p < .001), and at the four-week follow-up in dizziness intensity (p < .001) and Dizziness Handicap Inventory (p < .001).

CONCLUSIONS

The traction-manipulation protocol reduces the intensity of dizziness, the patient's self-perceived disability, and improves cervical mobility with and without fixed gaze.

Effectiveness of deep cervical fascial manipulation and yoga postures on pain, function, and oculomotor control in patients with mechanical neck pain: study protocol of a pragmatic, parallel-group, randomized, controlled trial

INTRODUCTION

Mechanical neck pain (MNP) is a commonly occurring musculoskeletal condition that is usually managed using electrical modalities, joint mobilization techniques, and therapeutic exercises, but has limited evidence of their efficacy. Pathology (densification) of the deep cervical fascia that occurs due to the increased viscosity of hyaluronic acid (HA) may induce neck pain and associated painful symptoms of the upper quarter region. Fascial manipulation (FM) and yoga poses are considered to reduce the thixotropy of the ground substances of the deep fascia and improve muscle function. The purpose of this study is to investigate the effect of FM and sequential yoga poses (SYP) when compared to the usual care on pain, function, and oculomotor control in MNP.

METHODS

This FaCe-Man trial will recruit 160 patients with subacute and chronic mechanical neck pain diagnosed using predefined criteria. Participants will be randomized to either the intervention group or the usual care group, using a random allocation ratio of 1:1. Patients in the intervention group will receive FM (4 sessions in 4 weeks) and SYP (12 weeks) whereas the standard care group will receive cervical mobilization/ thoracic manipulation (4 sessions in 4 weeks) and therapeutic exercises (12 weeks). The primary outcome is the change in the numeric pain rating scale (NPRS). The secondary outcomes include changes in the patient-specific functional scale and oculomotor control, myofascial stiffness, fear-avoidance behavior questionnaire, and elbow extension range of motion during neurodynamics test 1.

DISCUSSION

If found effective, FM along with SYP investigated in this trial can be considered as a treatment strategy in the management of mechanical neck pain. Considering the magnitude of the problem, and the pragmatic and patient-centered approach to be followed, it is worth investigating this trial.

TRIAL REGISTRATION

ClinicalTrials.gov CTRI/2020/01/022934 . Registered on January 24, 2020 with ctri.nic.in. Clinical Trials Registry - India.

Evaluation attempt of own body sensing amongst persons with and without scoliosis

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a common structural spine deformity affecting 2%-4% of adolescents. Due to the unknown cause of idiopathic scoliosis, its therapy is a long-term and often unsatisfactory process. In the literature, it is often suggested that problems related to the feeling of one's own body are caused by AIS.

OBJECTIVE

The aim of this study was to assess the feeling of one's own body among children with and without scoliosis on the example of feeling the head position, pelvis shape and balance.

METHOD

The research included 62 children: 30 with scoliosis and 25 without diagnosed scoliosis with an age range between 11 to 19 years. The minimum scoliosis value was 7∘ and the maximum was 53∘. The average value was 25∘. During the study, three functional tests were used: Cervical Joint Position Error Test (CJPET), Clinical Test of Sensory Integration on Balance (CTSIB) and Body proportion demonstration test (BPDT).

RESULTS

The results of the tests showed statistically significant differences (CJPET p= 3.54*10-14, CTSIB p= 0.0376, BPDT p= 0.0127). However, none of the studies showed a correlation between the results of people with scoliosis and the value of their Cobb angles.

An irritability-based approach to whiplash-associated concussion rehabilitation: a case series

BACKGROUND

An estimated 45% of concussions are reported to be related to motor vehicle collisions (MVC). However, limited research exists involving the treatment of MVC-related concussion, especially when combined with whiplash-associated disorders (WAD). Purpose: The purpose of this case series is to examine the patient response to an irritability-based approach to the physiological, cervical, and vestibulo-ocular trajectories in patients with diagnosed concussion and WAD disorder following an MVC. Case Description: Three patients clinically diagnosed by a neurologist with WAD and concussion following a rear-end MVC were evaluated and treated in an outpatient physical therapy setting. Each individual was progressed through an irritability-based treatment approach based on individual symptom presentation. Outcomes: Following therapy, 2 of 3 patients reported full resolution of subjective symptoms with a negative Vestibular Oculo-motor Screening All patients exceeded their predicted goals based on Focus on Therapeutic Outcomes score.

CONCLUSION

This case series demonstrated successful treatment of all three individuals with concussion and concurrent WAD. Two of three individuals demonstrated full resolution of subjective symptoms and objective impairments at the end of treatment. Further research is warranted into the effectiveness of a multi-factorial approach to address the highly variable symptom profile of individuals with concussion and WAD.

The contemporary model of vertebral column joint dysfunction and impact of high-velocity, low-amplitude controlled vertebral thrusts on neuromuscular function

Purpose

There is growing evidence that vertebral column function and dysfunction play a vital role in neuromuscular control. This invited review summarises the evidence about how vertebral column dysfunction, known as a central segmental motor control (CSMC) problem, alters neuromuscular function and how spinal adjustments (high-velocity, low-amplitude or HVLA thrusts directed at a CSMC problem) and spinal manipulation (HVLA thrusts directed at segments of the vertebral column that may not have clinical indicators of a CSMC problem) alters neuromuscular function.

Methods

The current review elucidates the peripheral mechanisms by which CSMC problems, the spinal adjustment or spinal manipulation alter the afferent input from the paravertebral tissues. It summarises the contemporary model that provides a biologically plausible explanation for CSMC problems, the manipulable spinal lesion. This review also summarises the contemporary, biologically plausible understanding about how spinal adjustments enable more efficient production of muscular force. The evidence showing how spinal dysfunction, spinal manipulation and spinal adjustments alter central multimodal integration and motor control centres will be covered in a second invited review.

Results

Many studies have shown spinal adjustments increase voluntary force and prevent fatigue, which mainly occurs due to altered supraspinal excitability and multimodal integration. The literature suggests physical injury, pain, inflammation, and acute or chronic physiological or psychological stress can alter the vertebral column’s central neural motor control, leading to a CSMC problem. The many gaps in the literature have been identified, along with suggestions for future studies.

Conclusion

Spinal adjustments of CSMC problems impact motor control in a variety of ways. These include increasing muscle force and preventing fatigue. These changes in neuromuscular function most likely occur due to changes in supraspinal excitability. The current contemporary model of the CSMC problem, and our understanding of the mechanisms of spinal adjustments, provide a biologically plausible explanation for how the vertebral column’s central neural motor control can dysfunction, can lead to a self-perpetuating central segmental motor control problem, and how HVLA spinal adjustments can improve neuromuscular function.

From Provider to Advocate: The Complexities of Traumatic Brain Injury Prompt the Evolution of Provider Engagement

Treating a patient with traumatic brain injury requires an interdisciplinary approach because of the pervasive, profound and protean manifestations of this condition. In this review, key aspects of the medical history and review of systems will be described in order to highlight how the role of any provider must evolve to become a better patient advocate. Although this review is written from the vantage point of a vision care provider, it is hoped that patients, caregivers and providers will recognize the need for a team approach.

Association between musculoskeletal function and postural balance in patients with long-lasting dizziness. A cross-sectional study

BACKGROUND AND PURPOSE

Reduced balance and musculoskeletal pain are frequently reported among patients with long-lasting dizziness. However, the association between musculoskeletal function and postural sway among these patients has not been examined. The objective of this study was to examine if there is an association between aspects of musculoskeletal function and postural balance in patients with long-lasting dizziness.

METHODS

This was a cross-sectional study, using data of 105 outpatients with long-lasting dizziness. Aspects of musculoskeletal function was assessed by examining body flexibility, grip strength, preferred and fast walking speed, in addition to musculoskeletal pain. Musculoskeletal pain was evaluated using the Subjective Health Complaints questionnaire. Postural balance was assessed by path length of postural sway by using a balance platform on both firm and soft surfaces, with eyes open and closed. The association between musculoskeletal function and postural sway was assessed using linear regression analyses.

RESULTS

When adjusting for age and gender we found that on a firm surface, there was an association between increased musculoskeletal pain and increased postural sway measured with eyes open (p = 0.038). In addition, there was an association between decreased body flexibility and decreased postural sway with eyes open (p = 0.025). On a soft surface, decreased fast walking speed was associated with increased postural sway with eyes open (p = 0.027). In addition, decreased grip strength was associated with increased postural sway on a soft surface with eyes closed (p = 0.015).

DISCUSSION

The findings from this study imply that musculoskeletal function may associate with postural sway in patients with long-lasting dizziness, although the associations were weak.

Effects of exercise therapy plus manual therapy on muscle activity, latency timing and SPADI score in shoulder impingement syndrome

PURPOSE

The study aimed to compare the effects of exercise therapy plus manual therapy (ET plus MT) and exercise therapy (ET) alone on muscle activity, muscle onset latency timing and shoulder pain and disability index-Hindi (SPADI-H) score in athletes with shoulder impingement syndrome (SIS).

MATERIALS AND METHOD

Overhead male athletes diagnosed with SIS were randomly allocated into ET plus MT group(n = 40) and ET group(n = 40). Muscle activity, muscle onset latency timings and SPADI-H score were assessed. Both the groups performed 8 weeks of intervention and were evaluated at baseline, 4th and 8th weeks.

RESULT

ET plus MT group was more effective in increasing muscle activity, optimising latency timings and decreasing SPADI score when compared to ET group alone(p < 0.05). After treatment muscle activity and SPADI-H improved in both groups (p < 0.05).

CONCLUSION

ET plus MT was superior for improving muscle activity, muscle onset latency timing and SPADI score compared to ET alone.

Postural balance and oculomotor control are influenced by neck kinaesthetic functions in elite ice hockey players

BACKGROUND

Research indicates that neck kinaesthetic awareness plays an important role in oculomotor and balance control, however the relationship has not been studied in athletes. As performance in ice hockey demands visual perception acuity during skating, while constantly shifting between unilateral and bilateral stances in sports specific posture more in-depth relationship should be studied.

RESEARCH QUESTION

What is the relationship between neck kinaesthetic awareness, postural balance and eye movement control in professional ice hockey players and non-trained individuals?

METHODS

In this observational study, centre-of-pressure was measured using force plate in twenty-eight hockey players and thirty non-trained participants during different stances in eyes-opened and eyes-closed conditions. Butterfly test and Head-to-Neutral Relocation test were performed to assess neck kinaesthesia. Horizontal smooth pursuit eye movements were measured using video-oculography. Linear regression was used to determine the relationship between neck kinaesthesia, body sway and oculomotor control.

RESULTS

Time-on-target in Butterfly test was able to predict low to medium proportions of variance in amplitude and velocity parameters for single leg stances in hockey players (R² = .220-.698). Head-to-Neutral Relocation test was able to predict low to medium proportion of variance in average eye movement velocity during first 100 milliseconds of smooth pursuit initiation for both groups (R² = .262-.541).

SIGNIFICANCE

Findings from our study suggest that cervical spine afferent input plays an important role in maintaining unilateral postural balance in hockey players, with less evidence presented in controls. Sports specific posture or upper body loading could lead to adaptations in neck proprioception, not frequently considered when searching for balance related injury risk factors or performance deficits. Our study suggests, that in addition to balance control, neck kinaesthesia can also affect oculomotor performance which was present in both groups. This is especially evident when initiating changes in eye movement direction.

How similar are whiplash and mild traumatic brain injury? A systematic review

INTRODUCTION

Mild traumatic brain injury (mTBI) and whiplash are two pathologies which appear in the follow-up of a cranio-cervical trauma. The objective of this study is to review their definitions, to discuss each entity.

METHODS

Whiplash and mTBI were defined. Then, a systematic literature review was carried out using the Pubmed database. Relevant studies after 1995 were selected, with 16 articles describing a link between whiplash and mTBI. 8 articles were analyzed after reading their abstracts.

RESULTS

Whiplash and mTBI have many similarities (symptoms, biomechanics, cognitive disorders, presence of diffuse axonal lesions on functional imaging) and some differences (in posture, more vestibular and balance disorders in whiplash). mTBIs result from linear accelerations between 60- 160g (gravity), studies on whiplash have shown that they can appear from 4.5g, which could explain biomechanically the frequent concomitant appearance. Cervical joint dysfunction can appear in persistent concussive syndrome, with upper cervical pain, less endurance of the cervical flexor muscles, and an increase in cervical stiffness leading to tension headache. This could explain neck pain in mTBI and headache in whiplash. An explanation to vestibular and cochlear disorders is given, and the two pathologies concomitantly could increase the symptoms.

CONCLUSION

To our knowledge, no studies define distinct boundaries between these two pathologies, which overlap on many points. An explanation is their concomitant onset, due to the biomechanics of the trauma and anatomical reasons. Larger-scale studies of rigorous scientific quality are needed to answer the question of the difference between whiplash and mTBI.

Co-morbidities to Vestibular Impairments-Some Concomitant Disorders in Young and Older Adults

Background: Dizziness and pain are common complaints that often appear concomitantly, with or without a causal relationship. However, these symptoms might maintain and exacerbate each other and other co-morbidities. Therefore, adequate rehabilitation may have to include an expanded focus on other deficits and preconditions, especially in older adults and in patients. Objective: To understand how frequently vestibular dysfunction coincided with medical conditions and aging, we studied two categories: Study 1: patients referred to a vestibular unit and Study 2: senior members in a fitness association. Method: Study 1: 49 patients [34 females/15 males; mean age 52 years (SEM 2.0)] seeking health care for balance disorders and vestibular deficits were asked in questionnaires about their perception of dizziness and pain, and emotional and functional strains. Study 2: 101 senior members in a fitness association [91 females/10 males; mean age 75 years (SEM 0.6)], were assessed for vestibular and balance deficits and for any co-morbidities. The participants were monitored for falls for 12 months after the initial assessments. Result: Study 1: Co-morbidity often existed between dizziness and pain (65%). The patients reported high emotional and functional strain related to their dizziness and pain. Patients older than 60 years reported longer durations of pain (p ≤ 0.028) but less emotional strain (p = 0.036), compared to younger patients. Study 2: 84% of the participants had a vestibular impairment, often without noticing any symptoms. Furthermore, 40% reported cardiovascular illnesses, 12% musculoskeletal disorders, and 63% reported other medical conditions. Forty-two percent experienced falls within 1 year after the initial assessments (thereof 42% in the group with vestibular deficits and 38% in the group without vestibular deficits). Conclusion: To enhance and preserve postural control, both in patients with vestibular deficits and in older adults, we suggest an expanded clinical perspective. Hence, we recommend detailed examinations of the vestibular system but simultaneously probing for possible co-morbidities. Since aging often entails deterioration of multimodal processes related to maintained mobility and postural stability, our results add focus on the importance of addressing balance disorders together with additional medical conditions.

Cervical Proprioception Impairment in Neck Pain-Pathophysiology, Clinical Evaluation, and Management: A Narrative Review

Neck pain is very common, but most of the causes are unknown, making diagnosis and treatment extremely challenging. Current studies have found that one of the main problems in patients with neck pain is the impairment of cervical proprioception, which subsequently leads to cervical sensorimotor control disturbances. Cervical spine has a very delicate proprioceptive system that plays a crucial role in controlling posture and balance. Cervical proprioceptive impairment in neck pain occurs through a variety of mechanisms. Experimental neck muscle pain induced by injection of hypertonic saline results in inhibition of the activation of painful muscle; chronic neck pain causes structural and functional impairment of cervical muscles; excessive activation of mechanoreceptors in degenerative cervical discs and facet joints produces a large number of erroneous sensory signals. Clinical examinations to assess the link between structural pathology and neck pain have been unsuccessful, opening the way for the development of function-based tests. To date, eight neck sensorimotor control tests have been reported to evaluate patients with chronic neck pain. Although some tests may involve different subsystems (such as oculomotor system and vestibular system), all tests measure sensorimotor control in the neck, and the most commonly used is cervical joint position error (JPE) test. Current studies support the effectiveness of exercises targeting different aspects of sensorimotor function, in particular retraining aimed at improving cervical proprioception and muscle coordination. Based on the available evidence, it is recommended that patients with neck pain should be assessed and managed for cervical proprioceptive impairment and sensorimotor control disturbances.

The association of concussion history and symptom presentation in combat sport athletes

OBJECTIVE

The purpose of this study was to describe the concussion-related symptoms reported among combat sport athletes with and without a history of concussion, and a history of neck injury.

DESIGN

Cross-sectional survey.

SETTING

Data were collected using an online survey instrument.

PARTICIPANTS

Three hundred and nine adult combat sport athletes.

MAIN OUTCOME MEASURES

Self-reported 12-month concussion history and neck injury history and a 22-item symptom checklist.

RESULTS

A history of concussion was reported by 19.1% of athletes, a history of neck injury was reported by 23.0%, and 13.6% reported both injuries. Neck pain was the most frequently reported symptom. Athletes with a history of injury had significantly greater proportions of 'high' total symptoms and symptom severity scores compared with athletes with no history of injury. Athletes with a history of concussion had 2.35 times higher odds of reporting 'high' total symptoms and symptoms severity scores.

CONCLUSION

Athletes with a history of concussion or neck injury have greater odds of presenting with higher symptom scores. The presence of high total symptom scores and high symptom severity scores may indicate a need for further investigation into domains commonly associated with concussion.

Head Position and Posturography: A Novel Biomarker to Identify Concussion Sufferers

Balance control systems involve complex systems directing muscle activity to prevent internal and external influences that destabilize posture, especially when body positions change. The computerized dynamic posturography stability score has been established to be the most repeatable posturographic measure using variations of the modified Clinical Test of Sensory Integration in Balance (mCTSIB). However, the mCTSIB is a standard group of tests relying largely on eyes-open and -closed standing positions with the head in a neutral position, associated with probability of missing postural instabilities associated with head positions off the neutral plane. Postural stability scores are compromised with changes in head positions after concussion. The position of the head and neck induced by statically maintained head turns is associated with significantly lower stability scores than the standardized head neutral position of the mCTSIB in Post-Concussion Syndrome (PCS) subjects but not in normal healthy controls. This phenomenon may serve as a diagnostic biomarker to differentiate PCS subjects from normal ones as well as serving as a measurement with which to quantify function or the success or failure of a treatment. Head positions off the neutral plane provide novel biomarkers that identify and differentiate subjects suffering from PCS from healthy normal subjects.

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.

Misperception of Visual Verticality in Patients with Primary Headache Disorders: A Systematic Review with Meta-Analysis

Migraine and tension-type headache (TTH) are the two most prevalent primary headache disorders (PHDs) that may involve visual and vestibular impairments, neck pain, and postural unsteadiness. The perception of visual verticality (VV) has been studied in patients diagnosed with PHD to assess balance disorders showing varying findings. Our study aimed to assess the VV perception in patients diagnosed with PHD in comparison to healthy controls. A systematic review with meta-analysis was carried out in PubMed MEDLINE, Scopus, WOS, CINAHL, and SciELO. The Cohen standardized mean difference (SMD) was used to estimate the differences between exposed and healthy controls. Seven studies with 816 participants were included. The quality of included studies, according to the Newcastle–Ottawa Scale (NOS), was moderate (mean score of 5.2). Patients diagnosed with PHD showed a moderate misperception of VV as assessed with the subjective visual vertical (SVV) test (SMD = 0.530; 95% CI = 0.225, 0.836; p < 0.001). Specifically, a misperception of the SVV was found in patients with migraine (SMD = 0.369; 95% CI = 0.1, 0.638; p = 0.007) and with TTH (SMD = 1.122; 95% CI = 0.540, 1.704; p < 0.001). This review shows a misperception of VV in patients with migraine and TTH when assessed with the SVV test, being higher in patients with TTH, although the THH sample size was low.

Smooth Pursuit Eye-Movement Abnormalities Associated With Cervical Spine Whiplash: A Scientific Review and Case Report

Whiplash injuries may disrupt normal cervical afferent and efferent projections. Oculomotor abnormalities have been reported in chronic whiplash cases, but there is limited knowledge of their presence in acute whiplash and how acute assessment may target early intervention. We present a literature review and case study of a 22-year-old female presenting with an acute concussion and whiplash secondary to a high-speed motor vehicle collision. Smooth pursuit eye-movement abnormalities were observed in relative cervical rotation in the setting of clinical examination of cervicogenic dysfunction. Treatment was focused on cervical manual therapy. While concussive symptoms resolved after seven days, eye-tracking showed a mild improvement and continued to exist in relationship with cervicogenic dysfunction. After completing physical therapy twice weekly for two weeks and in-home exercises, clinical signs and symptoms of whiplash-associated cervicogenic dysfunction and abnormal smooth pursuit eye-movement resolved across all cervical positions. This case highlights the need for ocular-motor impairment assessment following acute whiplash, specifically during cervical rotation. Early intervention should focus on cervical manual therapy and may be important in supporting altered cervical afferents causing oculomotor dysfunctions following acute whiplash.

Visual Verticality Perception in Spinal Diseases: A Systematic Review and Meta-Analysis

Patients diagnosed with traumatic or non-traumatic spinal pain and idiopathic scoliosis frequently suffer from imbalance. The evaluation of the perception of verticality by means of visual tests emerges as a quick and easy tool for clinical management of the balance disorders. Several studies have assessed the visual perception of verticality in spinal diseases obtaining controversial results. The aim of our study is to analyze the perception of visual verticality in subjects with several spinal diseases in comparison with healthy subjects. A meta-analysis was carried out. PubMed MEDLINE, Scopus, WoS, CINAHL, and SciELO databases were searched until January 2020. The standardized mean difference (SMD) was calculated to analyze differences between patients and healthy controls. Fifteen studies with a total of 2052 patients were included. In comparison with healthy subjects, a misperception of verticality was found in patients with spinal pain when the perception of the verticality was assessed with the rod and frame test (SMD = 0.339; 95% confidence interval (CI) = 0.181, 0.497; p < 0.001). It seems that the perception of visual verticality is not altered in patients with idiopathic scoliosis (p = 0.294). The present meta-analysis shows a misperception of visual verticality only in patients with spinal pain.

Muscle fat infiltration following whiplash: A computed tomography and magnetic resonance imaging comparison

Here we present a secondary analysis from a parent database of 97 acutely injured participants enrolled in a prospective inception cohort study of whiplash recovery after motor vehicle collision (MVC). The purpose was to investigate the deep and superficial neck extensor muscles with peri-traumatic computed tomography (CT) and longitudinal measures of magnetic resonance imaging (MRI) in participants with varying levels of whiplash-related disability. Thirty-six underwent standard care imaging of the cervical spine with CT at a level-1 trauma designated emergency department. All 36 participants were assessed with MRI of the cervical spine at <1-week, 2-weeks, 3-, and 12-months post-injury and classified into three groups using initial pain severity and percentage scores on the Neck Disability Index (recovered (NDI of 0–8%), mild (NDI of 10–28%), or severe (NDI ≥ 30%)) at 3-months post MVC. CT muscle attenuation values were significantly correlated to muscle fat infiltration (MFI) on MRI at one-week post MVC. There was no significant difference in muscle attenuation across groups at the time of enrollment. A trend of lower muscle attenuation in the deep compared to the superficial extensors was observed in the severe group. MFI values in the deep muscles on MRI were significantly higher in the severe group when compared to the mild group at 1-year post MVC. This study provides further evidence that the magnitude of 1) deep MFI appears unique to those at risk of and eventually transitioning to chronic WAD and that 2) pre- or peri-traumatic muscular health, determined by CT muscle attenuation, may be contribute to our understanding of long-term recovery.