MasterclassSensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control
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
References (66)
- et al.
Evaluation of head-to-trunk control in whiplash patients using digital CranioCorpoGraphy during a stepping test
Gait and Posture
(2005) - et al.
Influences of neck afferents on sympathetic and respiratory nerve activity
Brain Research Bulletin
(1998) Management of Posttraumatic vertigo
Otolaryngology - Head and Neck Surgery
(2005)Unravelling the complexity of muscle impairment in chronic neck pain
Manual Therapy
(2004)- et al.
Effects of neck extensor muscles fatigue on balance
Clinical Biomechanics
(2004) - et al.
Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study
Manual Therapy
(2000) - et al.
Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin
Archives of Physical Medicine and Rehabilitation
(1996) - et al.
A new clinical test for cervicocephalic kinesthetic sensibility: “the fly”
Archives of Physical Medicine and Rehabilitation
(2004) - et al.
Inhibition of motor system excitability at cortical and spinal level by tonic muscle pain
Clinical Neurophysiology
(2001) - et al.
The distribution and morphological characteristics of axons innervating the periodontal ligament of reimplanted teeth in cats
Archives of Oral Biology
(1993)
Improvement after chiropractic care in cervicocephalic kinesthetic sensibility and subjective pain intensity in patients with nontraumatic chronic neck pain
Journal of Manipulative and Physiological Therapeutics
Manual therapy treatment of cervicogenic dizziness: a systematic review
Manual Therapy
Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study
Archives of Physical Medicine and Rehabilitation
Development of motor system dysfunction following whiplash injury
Pain
Influences on the fusimotor-muscle spindle system from chemosensitive nerve endings in the cervical facet joints in the cat; possible implications for whiplash induced disorders
Pain
The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash
Manual Therapy
Postural control during quiet standing following cervical muscular fatigue: effects of changes in sensory inputs
Neuroscience Letters
Disorders of the vestibular system
Neck muscle vibration and spatial orientation during stepping in place in humans
Journal of Neurophysiology
Muscle spindle distribution, morphology, and density in the longis colli and multifidus muscles of the cervical spine
Spine
Distribution of A-delta and C-fiber receptors in the cervical facet joint capsule and their response to stretch
Journal of Bone and Joint Surgery. (American Volume)
Neck muscle responses to stimulation of monkey superior colliculus. I. Topography and manipulation of stimulation parameters
Journal of Neurophysiology
Gait-dependent integration of neck muscle afferent input
Neuroreport
Fatty infiltration in the cervical extensor muscles in persistent whiplash-associated disorders—a magnetic resonance imaging analysis
Spine
Acupuncture treatment for balance disorders following whiplash injury
Acupuncture and Electro-Therapeutics Research
Whiplash injury. A clinical review with emphasis on neurootological aspects
Clinical Otolaryngology
Cortical reorganisation and chronic pain: implications for rehabilitation
Journal of Rehabilitation Medicine
Dizziness among patients with whiplash-associated disorder: a randomized controlled trial
Journal of Rehabilitation Medicine
Cervicocephalic kinesthetic sensibility in patients with whiplash injury
Scandinavian Journal of Rehabilitation Medicine
Responses of muscle spindles in feline dorsal neck muscles to electrical stimulation of the cervical sympathetic nerve
Experimental Brain Research
Vestibular rehabilitation
Cited by (282)
Effect of a slump posture on pain, proprioception, and electrical activity of the muscles in office workers with chronic non-specific neck pain. A retrospective study
2024, Journal of Bodywork and Movement TherapiesThe reliability and validity of a novel wearable inertial sensor to measure the cervical proprioception
2024, Medical Engineering and PhysicsExercise-induced hypoalgesia in chronic neck pain: A narrative review
2024, Sports Medicine and Health ScienceDifferences of diaphragmatic muscle contraction between female patients with chronic neck pain and asymptomatic controls: A case-control study based on ultrasonography
2024, Musculoskeletal Science and PracticeDecoding the impact of driving postures: Comparing neck pain, mobility, proprioception in car and bike drivers with and without Forward Head Posture
2023, Journal of Transport and Health