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Manual Therapy

Volume 13, Issue 1, February 2008, Pages 2-11
Manual Therapy

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Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control

https://doi.org/10.1016/j.math.2007.06.003Get rights and content

Abstract

The receptors in the cervical spine have important connections to the vestibular and visual apparatus as well as several areas of the central nervous system. Dysfunction of the cervical receptors in neck disorders can alter afferent input subsequently changing the integration, timing and tuning of sensorimotor control. Measurable changes in cervical joint position sense, eye movement control and postural stability and reports of dizziness and unsteadiness by patients with neck disorders can be related to such alterations to sensorimotor control.

It is advocated that assessment and management of abnormal cervical somatosensory input and sensorimotor control in neck pain patients is as important as considering lower limb proprioceptive retraining following an ankle or knee injury. Afferent information from the cervical receptors can be altered via a number of mechanisms such as trauma, functional impairment of the receptors, changes in muscle spindle sensitivity and the vast effects of pain at many levels of the nervous system. Recommendations for clinical assessment and management of such sensorimotor control disturbances in neck disorders are presented based on the evidence available to date.

Introduction

Sensorimotor control of stable upright posture and head and eye movement relies on afferent information from the vestibular, visual and proprioceptive systems, which converge in several areas throughout the central nervous system. The cervical spine has an important role in providing the proprioceptive input and this is reflected in the abundance of cervical mechanoreceptors and their central and reflex connections to the vestibular, visual and central nervous systems.

Muscle spindles in the cervical region are found in high densities especially in the suboccipital region where there are up to 200 muscle spindles per gram of muscle. This number is considerable when compared to the first lumbrical in the thumb where there are 16 muscle spindles per gram (Kulkarni et al., 2001; Boyd Clark et al., 2002; Liu et al., 2003). The cervical muscles, especially the suboccipital muscles, relay information to and receive information from the central nervous system and there are specific connections between the cervical receptors and the visual and vestibular apparatus and the sympathetic nervous system (Selbie et al., 1993; Bolton et al., 1998; Corneil et al., 2002; Hellstrom et al., 2005). The cervical afferents are also involved in three reflexes influencing head, eye and postural stability: the cervico-collic reflex (CCR), the cervico-ocular reflex (COR) and the tonic neck reflex (TNR). These reflexes work in conjunction with other reflexes, which are influenced by vestibular and visual input for coordinated stability of the head, eyes and posture. The CCR activates neck muscles in response to stretch to assist in the maintenance of head position (Peterson, 2004). The COR works with the vestibuloocular reflex and optokinetic reflex, acting on the extraocular muscles, to assist clear vision with movement (Mergner et al., 1998). The TNR is integrated with the vestibulospinal reflex to achieve postural stability (Yamagata et al., 1991) (Fig. 1).

The importance of the cervical central and reflex connections can be realized from response to artificial disturbances to the cervical afferents in asymptomatic individuals. Sectioning of the cervical nerves or anaesthetic injections into the neck causes nystagmus, disequilibrium and severe ataxia (DeJong and DeJong, 1977; Ishikawa et al., 1998). Vibration of neck muscles, which is thought to stimulate muscle spindle afferents, induces several disturbances in asymptomatic individuals including changes to eye and head position, alterations to body sway and the velocity and direction of gait and running (Lennerstrand et al., 1996; Bove et al., 2002; Courtine et al., 2003). Similar effects have been demonstrated by either simple isometric neck muscle contractions or induced neck muscle fatigue (Gosselin et al., 2004; Schmid and Schieppati, 2005; Vuillerme et al., 2005). Such disturbances are thought to result from a mismatch between abnormal information from the cervical spine and normal information from the vestibular and visual systems.

Section snippets

Disturbances in sensorimotor control in neck disorders

Considering the experimental evidence, it is not surprising that disturbances in cervical joint position sense (JPS) (Revel et al., 1991; Heikkila and Astrom, 1996; Treleaven et al., 2003), postural stability (Karlberg et al., 1996; Sjostrom et al., 2003; Treleaven and Jull et al., 2005a, Treleaven and Jull et al., 2005b; Field et al., 2007) and oculomotor control, such as altered smooth pursuit and saccadic eye movement (Tjell et al., 2003; Treleaven and Jull et al., 2005a, Treleaven and Jull

Clinical assessment of sensorimotor control disturbances in neck disorders

Based on the evidence to date, the assessment of sensorimotor control in the neck pain patient should include: investigation of the symptom of dizziness and unsteadiness and measurement of cervical joint position error, postural stability and oculomotor control. The clinician though should be aware of other possible causes of the disturbances and interview the patient and choose tests accordingly to determine the most likely cause. With respect to dizziness, the description, temporal pattern,

Management of sensorimotor control disturbances in neck disorders

The findings of the assessment will direct and tailor the most appropriate management of sensorimotor control disturbances in the individual patient with a neck disorder. It is suggested that management include both local treatment to the neck to decrease pain and improve neuromuscular function in combination with tailored sensorimotor exercises to improve any deficits in cervical JPS, oculomotor control and postural stability. This addresses the causes of abnormal cervical mechanoreceptor

Conclusion

Given the importance of the neck for postural stability, head and eye movement control, as well as the nature of the changes in sensorimotor control seen in those with neck disorders, assessment and management of such disturbances should form an important part of the multimodal approach to neck disorders. This should include addressing the causes of the altered cervical somatosensory input such as improving neuromuscular function and decreasing pain and inflammation as well as a tailored

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