[ CLINICAL COMMENTARY ]

EYTHOR KRISTJANSSON, PhD, ManipTher, BSc¹š@KB?7JH;B;7L;D" PhD, BPhty²

Sensorimotor Function and

Dizziness in Neck Pain: Implications
for Assessment and Management
ersistent neck pain of greater than 6 months’ duration is a mobile part of the vertebral column. Its

P
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frequent occurrence in both men and women,41 and patients mobility comes at the expense of its me-
chanical stability.7,22 The highly developed
with neck pain are the second largest group (after patients with
proprioceptive system provides neuro-
low back pain) attending physical therapy and chiropractic muscular control to the mobile cervical
clinics for relief of their symptoms.2 Further research shows that spine and allows efficient utilization of
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

about one third of patients diagnosed with whiplash-associated the vital organs in the head42 via unique
disorder (WAD) (a variety of clinical manifestations due to bony or connections to the vestibular and visual
systems.22,77,80,87,109 This may explain why
soft tissue neck injuries following an an ineffective treatment. Preventing a the cervical spine is an extremely vulner-
acceleration-deceleration energy portion of patients with neck pain able structure, especially where trauma
transfer sustained from a mo- to enter the chronic phase of their is involved (eg, whiplash injury), and is a
tor vehicle accident119) only gain condition represents a great chal- source of a plethora of symptoms that do
SUPPLEMENTAL
short-term relief by conven- VIDEO ONLINE lenge for clinicians. not arise from any other musculoskeletal
tional musculoskeletal interven- The cervical spine, especially region of the body.58
Journal of Orthopaedic & Sports Physical Therapy®

tions,12,82,123 which, by definition, are the upper cervical spine, is the most Disturbances to the afferent input
from the cervical region in those with
T SYNOPSIS: The term sensorimotor describes might be an important factor in the maintenance, neck pain may be a possible cause of
all the afferent, efferent, and central integration recurrence, or progression of various symptoms in symptoms such as dizziness, unsteadi-
and processing components involved in maintain- some patients with neck pain. In these cases, more ness, and visual disturbances, as well as
ing stability in the postural control system through specific and novel treatment methods are needed signs of altered postural stability, cervical
intrinsic motor-control properties. The scope of which progressively address neck position and proprioception, and head and eye move-
this paper is to highlight the sensorimotor deficits movement sense, as well as cervicogenic oculomo- ment control. Conventional approaches
that can arise from altered cervical afferent tor disturbances, postural stability, and cervico- to management may be sufficient for pa-
input. From a clinical orthopaedic perspective, genic dizziness. In this commentary we review the
tients with neck pain with minimal sen-
the peripheral mechanoreceptors are the most most relevant theoretical and practical knowledge
important in functional joint stability; but in the on this matter and implications for clinical assess-
sorimotor proprioceptive disturbances.
cervical region they are also important for postural ment and management, and we propose future However, clinical experience and research
stability, as well as head and eye movement directions for research. indicates that significant sensorimotor
control. Consequently, conventional musculosk- proprioceptive disturbances in the cervi-
TB;L;BE<;L?:;D9;0 Level 5. J Orthop Sports
eletal intervention approaches may be sufficient cal spine might be an important factor in
Phys Ther 2009;39(5):364-377. doi:10.2519/
only for patients with neck pain and minimal the maintenance, recurrence, or progres-
jospt.2009.2834
sensorimotor proprioceptive disturbances. Clinical
sion of various symptoms in patients with
experience and research indicates that significant TA;OMEH:I0 cervical, head, postural stability,
sensorimotor cervical proprioceptive disturbances proprioception, sensorimotor neck pain.52,122 Thus, addressing these
deficits is likely to be an important step

1
Physical Therapist and Researcher, Faculty of Medicine, The University of Iceland, Reykjavik, Iceland. 2 Physical Therapist and Researcher/Lecturer, Neck pain and Whiplash
Research Unit, Division of Physiotherapy, University of Queensland, Australia. Address correspondence to Eythor Kristjansson, Skipholt 50c, IS-105 Reykjavik, Iceland. E-mail:
eythork@simnet.is

364 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 towards better management of some pa- 

tients with neck pain. 

The scope of this paper is to high-  

light the sensorimotor deficits that can 
 
arise from altered cervical afferent input.
While the cervical spine should always 

be considered in the differential diagno-
sis of dizziness and unsteadiness, as well
as visual disturbances, other potential
causes, such as peripheral or central ves-
 CNS integration
tibular pathology and pathology in the 
central nervous system (CNS) along with
vertebrobasilar insufficiency, must also
be considered and excluded.57 The mere



combination of dizziness and neck pain
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should not be interpreted as necessar- 
 



ily indicating the neck to be the source 




of the dizziness.64 Dizziness and visual

disturbances as a consequence of altered 

afferent input from the cervical spine 

Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

structures are a controversial subject and

not widely accepted by the medical pro-
fession. The primary reason for this lack <?=KH;'$Input from the rest of the body is also an important source of information for the postural control
of recognition is that conventional testing system. The feet are peculiar in this respect as they aid in determining body sway relative to the ground.
Abbreviation: CNS, central nervous system.
methods cannot verify the patient’s sub-
jective complaints in most instances.57
Generally, cervicogenic deficits appear to equilibrium). Postural control provides play the first violin in the proprioceptive
be more subtle and less severe when com- a stable body platform for the efficient ensemble, while other mechanoreceptors,
pared to those that present with primary execution of focal or goal-directed move- such as the joint receptors and golgi ten-
Journal of Orthopaedic & Sports Physical Therapy®

CNS or vestibular system pathologies.31,134 ments.56 <?=KH;' provides an overview of don organs, fine tune the muscle spindle
Nevertheless, the presence of CNS signs the subsystems in the postural control information, predominantly by reflex ef-
in the absence of a diagnosis or other ex- system. The somatosensory, vestibular, fects on the H-motoneurones.116
planation should be considered a red flag and visual systems are the subsystems The dense network of mechanorecep-
and the physical therapist should imme- that provide sensory input to the postural tors in the soft tissues in this region not
diately refer the patient to a physician for control system. only controls multiple degrees of freedom
further workup. The Somatosensory Subsystem This of movements about each of its joints but,
system encompasses all of the mecha- more importantly, gives the CNS infor-
J^[9[hl_YWbIf_d[WdZj^[FeijkhWb noreceptive information arising from mation about the orientation of the head
9edjhebIoij[c the periphery43 which leads to the per- with respect to the rest of the body via
The postural control system includes all ception of pain, temperature, touch, and direct neurophysiological connections to
the sensorimotor and musculoskeletal proprioception.110 The proprioceptive the vestibular and visual systems. Soma-
components involved in the control of system of the cervical spine, in particular, tosensory information from the cervical
2 important behavioral goals: postural is extremely well developed, as reflected region is the only region that has this
orientation and postural equilibrium. by an abundance of mechanoreceptors, direct access to the sense of balance and
Postural orientation is the relative posi- especially from the H-muscle spindles sense of sight.23,57
tioning of the body segments with respect in the deep segmental upper cervical The Vestibular Subsystem This system is
to each other and to the environment, muscles.73,76,122 The H-muscle spindle sys- specially designed to maintain adequate
whereas postural equilibrium is the state tem serves as the final common pathway postural tone in the muscles of the trunk
in which all the forces acting on the body for the regulation of the muscle stiffness and extremities to provide overall bal-
tend to keep the body in a desired posi- required for various neuromuscular per- ance during posture and locomotion.
tion and orientation (static equilibrium) formances.116 Muscle spindle afferents Neck, eye, trunk, and limb muscle reflex-
or to move in a controlled way (dynamic appear particularly important, as they es evolved to meet these requirements.

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 365
 [ CLINICAL COMMENTARY ]
The specialized mechanoreceptors in the where vestibular, ocular, and proprio- and head movement illusions,69,79,126 and
semicircular canals are sensitized during ceptive information is integrated.129 The has been shown to influence postural
changes in rate of motion; that is, angu- CCN also has important connections to stability and the velocity and direction
lar velocity, and the specialized mecha- the VNC.94 This allows the postural con- of gait and running.9,18,79 Even wearing a
noreceptors in the otolith systems of the trol system to quickly receive information restrictive brace (hard collar) for 5 days
utricular and saccular maculae provide about the position and movement of the or being exposed to sustained isometric
information about the position and veloc- head in relation to the body and to inte- neck muscle contraction has been dem-
ity of the head relative to the direction of grate cervical information with that from onstrated to lead to altered eye move-
the forces of gravity.50 Sensory informa- the labyrinths and eyes so that different ment control, increased postural sway,
tion from the vestibular system converges information from the subsystems can be and disturbed head-neck awareness in
in all nuclei comprising the vestibular compared and equalized. healthy persons.21,39,66,98,113,114,140
nuclear complex (VNC) via the vestibular Reflex Pathways Close connections be- The upper cervical region has an
nerve and in the cerebellum.95 tween the cervical somatosensory, vestibular, abundance of muscle spindle receptors
The Visual Subsystem Vision plays a and visual systems are also demonstrated in and greater contributions to reflex ac-
dominant role in the guidance of move- a number of reflexes influencing head ori- tivity and connections to the visual and
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ments and this is reflected by the fact entation, postural stability, and eye move- vestibular systems when compared to the
that when somatosensory inputs and vi- ment control.89,102 The cervicocollic reflex, lower cervical spine.77,80,93,94 This might
sion disagree, it is usually the visual ver- the cervico-ocular reflex, and the tonic neck suggest that patients with neck pain with
sion of events that prevails.121 The visual reflex are generated by cervical afferents upper cervical complaints have greater
postural system consists of 3 different eye and work in conjunction with other ves- potential for balance and visual distur-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

movement systems: the smooth pursuit tibular and visual reflexes for coordinated bances than those with complaints from
system, the saccadic system, and the op- stability of posture, as well as head and the lower cervical spine.128
tokinetic system.129 The smooth pursuit eye movement control. The cervicocollic In patients with neck pain, there are
system stabilizes images of smoothly reflex works with the vestibulocollic reflex several mechanisms that could disturb
moving targets on the fovea by slow eye to activate neck muscles and protect the cervical afferent activity. Sensitivity of
movements. The saccadic system, on the cervical spine against overrotation.102,103 the receptors can be affected by chemi-
other hand, is responsible for rapid, small The cervico-ocular reflex works with the cal changes brought about by ischemic
movements of both eyes simultaneously vestibulo-ocular and optokinetic reflexes or inflammatory events,127 as well as re-
in changing a point of fixation. The op- to control the extraocular muscles, creat- flex joint inhibition of the muscle spin-
Journal of Orthopaedic & Sports Physical Therapy®

tokinetic system stabilizes images on the ing clear vision with head movement. The dles.86,127,142 Pain at many levels of the
entire retina whenever the entire visual tonic neck reflex maintains a stable pos- CNS can change muscle spindle sensi-
field is moving (eg, when walking).129 ture via alteration in limb muscle activity tivity and alter the cortical representa-
when the body moves with respect to the tion and modulation of cervical afferent
H[b[lWdjD[khef^oi_ebe]_YWb9edd[Yj_edi head and is integrated with the vestibu- input.34,78,127 Psychosocial distress also
There are many direct neurophysiological lospinal reflex.145 has the potential to alter muscle spindle
connections between these 3 subsystems activity via activation of the sympathetic
and from the cervical region to the pos- JH7DIB7J?D=H;B;L7DJ nervous system.101 Functional impair-
tural control system, which provides fur- H;I;7H9>?DJE9B?D?97B ment of the muscles, such as increased
ther evidence for the plausability of the FH79J?9; fatigability,28 and degenerative changes,
varied signs and symptoms that occur as such as fiber transformation,139 fatty in-
a consequence of disturbed cervical affer- filtration, and atrophy of the neck mus-

T
he importance of the above
ent input in those with neck pain. neurophysiological connections be- cles,25,72,88 may alter their proprioceptive
Mechanoreceptor input from the tween the cervical spine structures capabilities, joint mechanics, and muscle
uppermost cervical segments (Occiput- and the vestibular and visual systems spindle sensitivity, thus affecting cervical
Atlas, Atlas-Axis, Axis-C3), particularly is demonstrated by the adverse effects afferent input.20
from the upper cervical spine muscles, on postural stability and eye and head Sensorimotor control deficits such
has direct access to the VNC and the movement control following artificial dis- as disturbances to head-neck aware-
superior colliculus, a reflex centre for turbance to cervical afferents in healthy ness,45,73,81,107,136 neck movement control,74
coordination between vision and neck human subjects. For example, stimula- postural stability,1,84,90,112,118,135,138 and oc-
movement.17 It also converges in the tion of the muscle spindle afferents, via ulomotor control53,124,129,134 can present in
central cervical nucleus (CCN),94 which neck muscle vibration induces eye posi- patients with idiopathic neck pain and
serves as a pathway to the cerebellum tion changes, visual illusory movements, in those not specifically complaining of

366 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 dizziness, unsteadiness, or visual dis- and then converted into degrees (angle segmental support and control has been
turbances as symptoms.31,73,130 However, = tan-1[error distance/90 cm]). Thus demonstrated15,85 and clinical research
these sensorimotor control deficits have an approximately 7.1-cm error distance indicates that many patients with neck
been shown to be more pronounced in would translate to a meaningful error of pain have inadequate support from these
patients with whiplash injury and those 4.5° (as long as the subject is sitting 90 muscles.26,29,62 Insufficiency in the pre-
with complaints of dizziness, unsteadi- cm from the wall) and is called the joint programmed activation of the cervical
ness, or visual disturbances.128,130,134,136 position error (JPE).107,111 JPE can be as- muscles, altered motor control recruit-
Furthermore, there does not appear to be sessed on return from all active cervical ment patterns, and increased fatigabil-
a direct relationship between the impair- movements. Errors of greater than 4.5° ity have also been found in patients with
ments, such that an individual patient are thought to suggest impairment in re- neck pain.27,28 Further, the measured in-
may present with dysfunction in either 1 location accuracy of the head-neck.107,111 creased activation of the superficial cervi-
or several systems, and thus evaluation of Patients might also demonstrate jerky or cal musculature in those with neck pain
each area of sensorimotor control should altered movement patterns, overshoot- is thought to be a compensation for poor
be considered appropriate for all patients ing of the position in order to gain more passive or active segmental support.28,73
with neck pain.133 proprioceptive feedback for the task, or These changes in muscle function
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“searching” for the position. Occasionally have potential to overload painful cervi-
:_ijkhX[Z>[WZ#D[Ya7mWh[d[ii patients will also experience a reproduc- cal structures and affect cervical move-
Clinical Research Relocation tests that tion of dizziness and/or unsteadiness ment sense and control. This may cause
either relocate the natural head posture with the task. A computerized method uncertainty for the patient, automatically
or the head to a set point in range have for assessing position sense in the clini- leading to further increased muscle cocon-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

most commonly been used to verify poor cal setting is currently being developed. traction,36 diminishing range of motion
awareness of the head-neck region in pa- The goal is to improve measurement ac- for self-protection of the cervical spine
tients with neck pain to reflect impaired curacy and to provide more sophisticated movements. This could reduce the fre-
cervical position sense. These methods feedback than the laser beam method, quency and duration of muscle relaxation
address a patient’s ability to consciously while ensuring that each patient can start periods, causing release of inflammatory
indicate when a prespecified position the treatment for improving head-neck substances and promoting a vicious cy-
has been reproduced. Impairments have awareness at his/her impairment level. cle.6 Patients with chronic whiplash pres-
been demonstrated by these methods ent as a difficult clinical condition as the
in subjects with neck pain of both idio- :_ijkhX[ZD[YaCel[c[dj9edjheb initial trauma can also compromise joint
Journal of Orthopaedic & Sports Physical Therapy®

pathic and traumatic origin (ie, whiplash Clinical Research Despite many attempts stability by permanent changes in tissue
injury).45,73,81,107,136 Patients who overshoot to quantify intersegmental movements in compliance or cause direct damage to
targets when position sense is measured the spine and to describe the movements the mechanoreceptors and their axons,
may have disordered cervicocollic reflex qualitatively, no method has yet been vali- because they have lower tensile strength
inhibition.103 dated to reliably detect minor segmental than the surrounding collagen fibers.73,87
Clinical Presentation Patients with neck instabilities in the cervical spine.35 Minor Recently a computerized method to
pain seem to have a poor awareness of segmental instabilities or segmental hyper- measure accuracy of head and neck move-
their head-neck posture, and some in- mobilities, therefore, remain an intensely ment called “the Fly” was developed.74 It
deed complain about “a wobbling head,”75 controversial topic, as there is no con- measures the patient’s ability to correct
which may be resultant of impaired cervi- sensus about its precise definition.3,100,125 cervical spine movements on a moment-
cal position sense. Nevertheless, early spinal degenerative to-moment basis, while moving the head-
Clinical Assessment Cervical position change has been recognized as a potential neck. This method has demonstrated
sense can be assessed clinically by using a physiological basis for minor segmental impaired head-neck movement accuracy
laser pointer mounted onto a lightweight instabilities,19 and, recently, segmental in patients with a history of whiplash in-
headband. Patients are asked to focus on hypermobility was demonstrated in the jury when compared to controls.74
the natural resting head position for a few lower cervical spine in some women with Clinical Presentation Subjective com-
seconds, sitting 90 cm away from a wall. chronic whiplash.76 In these individuals, plaints of a painful stiff neck are often ac-
With the eyes closed, they actively move management directed towards the sta- companied by associated complaints like
the head and then try to come back to bilizing musculature and optimal neuro- “my neck movements feel jerky,” “intense
the resting position as accurately as pos- muscular control of movement is thought tiredness in the back of the neck,” and
sible. The difference between the starting to be particularly important. “the head feels heavy.”75 Clinicians often
and resting position of the laser beam on The importance of the deep stabiliz- suspect these patients to have disturbed
the wall can be measured in centimeters ing musculature of the neck for spinal neck movement control as a consequence

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 367
 [ CLINICAL COMMENTARY ]
of the aforementioned clinical research the vestibular system, has the potential dem stance position has also been seen
findings. to disturb an intact vestibular subsys- in those with neck pain when compared
Clinical Assessment In the Fly,74 the tem.32,55,93,95 This makes the patient—in to asymptomatic individuals.31,90,135,138 Re-
patient sits in front of a computer with this case a patient with neck pain and cently, it has been suggested that cervical
sensors on the head, which accurately faulty neck mechanoreceptor input—less muscle fatigue may be an important con-
measure the positions and movements of able to utilize internal vestibular orient- tributing factor to altered postural stabil-
the head-neck in space. Two cursors are ing information to resolve inaccurate in- ity in those with neck pain.120 One study
visible on the computer screen: 1 cursor formation from the somatosensory and has demonstrated a correlation between
is black, indicating the movements of the visual subsystems.112 This is in accordance fatty infiltration of the suboccipital mus-
head-neck, and the other cursor is blue, with the “sensory mismatch” theory, cles and balance deficits,88 and further
derived from the Fly software program. which holds that sensations of dizziness research into this hypothesis is currently
At the very beginning of the test, both and unsteadiness arise because of a con- underway.
cursors match each other in the middle flict between the converging input from Clinical Presentation Cervical induced
of the screen. Then the blue cursor starts the different sensory subsystems and the dizziness is characterized by subjective
to move, tracing slow and unpredictable expected sensory patterns.10 complaints of unsteadiness, insecurity,
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movement patterns of short duration. Clinical research and experience indi- and lightheadedness.58,64 Some patients
The patient is instructed to follow the Fly cates that some patients with neck pain also complain about a feeling of spinning,
with the black cursor by moving the head- do not seem to be aware that they have but this is more like a feeling of “spinning
neck as accurately as possible. The devia- standing balance disturbances until their in the head” rather than spinning of the
tion or amplitude accuracy between the standing balance is challenged.11,74 A pos- patient or the surroundings, as in typical
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

2 cursors is continuously recorded dur- sible explanation is that the symptoms vertigo of vestibular origin.58 Often cervi-
ing 3 randomly ordered test sequences.74 of cervicogenic dizziness may abate once cal dizziness presents as a tipsy state as
The Fly method has recently been revised the CNS has adapted to the altered neu- a consequence of “noise” in the postural
and can be used to grade the deficits of rophysiological inputs, even though the control system and may be accompanied
movement control in patients with neck underlying dysfunction remains.16 It is by nausea. It is rarely described as strong
pain much more accurately than the prior hypothesized that the vestibular and the attacks of dizziness or vertigo.136
Fly method, and, consequently, a treat- somatosensory subsystems may compen- The subjective complaints are often
ment can be prescribed that starts at each sate for the balance disturbances by in- more pronounced early in the morn-
patient’s impairment level. Hitherto, the creasing the muscle stiffness in the body ing when the neck is stiff and late in the
Journal of Orthopaedic & Sports Physical Therapy®

laser method (as used for joint position as a whole,11 which may also explain the afternoon as the patient becomes tired.
sense) has been used by some therapists unrelenting hyperactivity in the muscu- Quick movements of the cervical spine,
to trace an intricate pattern such as a lature in some patients with neck pain.24 especially in the transverse plane but also
figure-of-eight placed on the wall 90 cm This may serve as one explanation for in the sagittal plane, most commonly pro-
in front of the patient. A subjective clini- why some patients with WAD develop voke these symptoms; but they may also
cal judgment can be made based on the fibromyalgia.13,14 It is, therefore, impor- occur when watching moving objects94 or
patient’s ability to trace the pattern ac- tant to screen patients with neck pain for walking in the dark.
curately and smoothly. balance disturbances, even in the absence Clinical Assessment Karlberg et al65
of subjective complaints about balance proposed a scientific method to measure
:_ijkhX[ZFeijkhWbIjWX_b_jo0:_pp_d[ii problems. cervical-related balance disturbances
WdZ%ehKdij[WZ_d[ii Several studies have demonstrated dis- in individuals with acute neck pain, but
Clinical Research Cervical induced bal- turbed postural stability in patients with this method has not yet been validated to
ance disturbances can be caused by sever- neck pain,1,31,67,68,84,90,104,118,135,138 especially measure more longstanding cervicogenic
al different pathophysiological processes, in those with neck pain from whiplash balance disturbances where compensa-
including irritation of the sympathetic injury and those complaining of dizzi- tory mechanisms might be present. A
vertebral plexus, vertebrobasilar insuf- ness.31,135 Most of the research has been clinical diagnosis of cervical-induced diz-
ficiency, and sensorimotor disturbanc- conducted with respect to static stand- ziness and/or unsteadiness is, therefore,
es from the cervical spine structures.4 ing balance where an increase in postural a diagnosis of exclusion of other possible
Emerging evidence draws attention to the sway or rigidity is noted even in simple causes.65 However, research suggests
last explanation.74,84,136,141 Altered sensory tests of standing comfortably on a firm that balance disturbances in neck pain
input, especially mediated via the direct surface with eyes closed. An increased present differently than those with a ves-
neurophysiological connections between rate of failure to maintain stability for tibular disorder, in whom balance distur-
the upper cervical spine structures and 30 seconds in the more challenging tan- bances appear to be easily noticeable on

368 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 difficult tests, such as narrow stance on steps completed on and off a 7.5-cm step will have further implications for the con-
a foam surface, when compared to those in 15 seconds for each limb. trol of neck posture and movement, and,
with whiplash, who showed more subtle Thus clinicians should consider such again, could contribute to a vicious cycle
deficits in all tests.65,137 At present, clini- dynamic tests particularly for patients of altered cervical afferent input and al-
cal tests of postural stability are not use- with neck pain complaining of dizziness, tered sensorimotor control.5
ful to differentiate between a vestibular unsteadiness, or loss of balance. Norma- The smooth pursuit neck torsion test
or neck etiology of balance disturbances. tive values for these tests are generally developed by Tjell et al129 is considered
But, as mentioned, the clinical presen- provided for elders (65-80 years of age; to be specific for detecting eye move-
tation of these 2 conditions is different. DGI score, 21/24; timed 10-meter walk ment disturbances due to altered cervi-
Nevertheless, balance in comfortable with head turns, 15 steps in 8 seconds; cal afferent input. This test measures the
and narrow stance with the eyes open and the step test, 14-15 steps).63,104 How- difference in smooth pursuit eye move-
and closed should be assessed with the ever, a recent study looked at a younger ment control with the head and trunk in
patient standing on a firm surface then group of subjects between 43 and 57 a neutral position, compared to when the
a soft surface, such as a piece of 10-cm- years of age.83 Normative values provid- trunk and neck are rotated relative to the
thick dense foam. Inability to maintain ed in this study were a DGI score of 23 stationary head.130 A decrease in velocity
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stance for 30 seconds, noticeably large to 24, a timed 10-meter walk with head gain of smooth pursuit eye movements
increases in sway, slower responses to turns of 15 steps in 8 seconds, and a step when the head is in a relatively torsioned
correct sway, or rigidity to prevent sway test of 21 steps.83 Further research into (rotated) position, when compared to
are considered abnormal responses. The younger subjects (less than 40 years of the neutral position, is only seen in those
patient’s ability to maintain tandem and age) is required. with neck pain (ie, not in those with ves-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

single-leg stance on a firm surface with tibular or CNS disorders) and is most evi-
eyes open and closed for up to 30 seconds EYkbecejeh:_ijkhXWdY[i dent in those with whiplash and in those
can also be assessed; although care in in- Clinical Research Deficits in oculomotor complaining of dizziness.129,130,134
terpretation of the results in these more control, such as decreased smooth pur- Recently, a pilot trial of case studies
difficult tests is needed in older individu- suit velocity gain, altered velocity and la- of individuals with whiplash reporting
als, where the ability to maintain tandem tency of saccadic eye movements, and an visual disturbances indicated deficits in
stance can be impaired in normal adults increased gain of the cervico-ocular re- head-eye coordination when compared
above the age of 45 years.31,138 flex have been seen in patients with neck to control subjects.40 Specifically, a de-
To date, little research has been con- pain.38,47,53,70,91,124,129,130,134,141 In people with creased range of head movement during
Journal of Orthopaedic & Sports Physical Therapy®

ducted to determine any changes to func- vestibular disorders and in the elderly, an gaze fixation, a decreased head velocity
tional or dynamic balance in individuals increased gain of the cervico-ocular reflex during tasks involving head-eye coordi-
with neck pain; however, disturbances is considered a compensation response nation, and compensatory head move-
to the velocity and direction of gait and to a decrease in vestibulo-ocular gain. 92 ments during isolated eye rotation were
running have been seen in response to However, a compensatory decrease in noted that suggest disturbances in gaze
neck muscle vibration in asymptomatic the vestibulo-ocular gain has not been stability and head-eye coordination in
control subjects,9,18 and, recently, older seen in those with an increased cervico- some of those with whiplash.40
patients (65-80 years of age) with neck ocular gain secondary to whiplash, and Clinical Presentation Patients with neck
pain demonstrated significant differ- this imbalance between the reflexes has pain sometimes complain about symp-
ences in the dynamic gait index (DGI), been suggested as a potential cause of toms relating to the visual system such
timed 10-meter walk with head turns, disturbances to the visual system.92 There as blurred vision, reduced visual field,
and the step test, when compared to is also some evidence that eye movement grey spots appearing in the visual field,
elders without neck pain.63,104 The DGI dysfunction may be associated with a temporary blinding, photophobia, and
rates the control of 8 functional mobil- poorer prognosis in those with a whiplash disordered fusion.57,143 These visual dis-
ity tasks that include walking at comfort- injury.52,53 Altered cervical somatosensory turbances may explain reading problems
able and changing speeds, walking with input is thought to adversely influence eye reported by some patients with neck
horizontal and vertical head movements, movement control. Further, there is also pain.37 Diplopia, which is common in pa-
walking, pivot turning, stepping over some evidence that normal reflexive neck tients with vertebrobasilar insufficiency,
and around an object, and walking up muscle activity seen during eye move- is rare in somatic neck dysfunctions. If
and down stairs.144 The timed 10-meter ments in individuals without neck pain patients with neck pain report double
walk with head turns48 measures the time is altered with respect to timing in those vision, it is most often not true diplopia
and number of steps taken to complete with neck pain.5 Abnormal neck muscle but rather the contours of an object that
the task.8 The step test54 is the number of activity associated with eye movement become unclear.57

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 369
 [ CLINICAL COMMENTARY ]
Clinical Assessment While we are just the patient having the available rotation between the cervical somatosensory, ves-
starting to develop clinical assessment range of motion and ability to perform tibular, and visual systems, and second-
methods, it is currently suggested that the task accurately when not fixating the ary adaptive changes in the sensorimotor
the clinical examination of oculomotor patient’s gaze, patients with neck pain control system need also to be consid-
control in those with neck pain should often40 are unable to keep focus or move ered. This is of the utmost importance to
include a qualitative analysis of eye follow the head as far or as quickly or smoothly understand for the optimal management
(smooth pursuit) while keeping the head as asymptomatic individuals (45°). They of patients with neck pain, as secondary
still (comparing neck neutral to neck tor- may also deviate into cervical lateral flex- disturbances in the vestibular and visual
sion), head movement while maintaining ion. Reproduction of dizziness and/or systems can occur via plasticity in the
focus on an object (gaze stability), head blurred vision may occur. This is similar CNS.115 Therefore, a combined approach
and eye movement coordination, and to the dynamic visual acuity test used for is likely to best address the perpetuation
quick movements of the eyes to refocus those with vestibular disorders; however, of a vicious cycle of events where second-
(saccades). head movement is performed actively and ary adaptive changes in the sensorimotor
Clinical assessment of eye movement slowly rather than passively and quickly. control system could lead to altered cervi-
in those with neck pain can be conducted This approach is better suited to cervical- cal muscle function and joint mechanics
Downloaded from www.jospt.org at on September 8, 2015. For personal use only. No other uses without permission.

by assessing the quality of eye movements related gaze disorders, as the cervical af- further altering cervical afferent input.
and eye movement control, as well as any ferents are stimulated at lower movement
reproduction of symptoms during the frequencies compared to fast movements 7ZZh[ii_d]7bj[h[Z9[hl_YWb7÷[h[dj
tests described below. Such tests are not that stimulate the vestibular afferents.49 ?dfkj
exclusive to, nor can specifically differen- Saccadic Eye Movement The patient Physical therapy interventions such as
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tiate, those with cervical disorders and quickly moves the eyes to fix his/her gaze pain management, manipulative therapy,
are often used in those with vestibular or between several targets. The targets are active range-of-motion exercises, and ex-
CNS disorders; although some tests have placed in several different movement ercises to improve neuromuscular control
been modified in an attempt to bias a cer- directions. Inability to fixate on target, will all be important in reducing possible
vical component to the testing. overshooting the target, and taking more causes of altered afferent cervical input
Smooth Pursuit The patient is asked than 2 eye movements to reach the tar- and subsequent disturbances to senso-
to accurately and smoothly follow a get might indicate a poor performance. rimotor control. Some physical interven-
slow-moving target with his/her eyes, Again reproduction of dizziness and or tions have been shown to improve aspects
while keeping the head still. The target is blurred vision may also occur. of sensorimotor deficits. For example,
Journal of Orthopaedic & Sports Physical Therapy®

moved from side to side. Quick saccadic Eye-Head Coordination The patient manipulative therapy has been shown
eye movements to catch up to the target first moves the eyes to a point to focus to improve joint position sense and diz-
rather than smooth eye movement, espe- and then, while maintaining focus, moves ziness46,99,105,106; specific neuromuscular
cially during midrange eye movement, the head to that point. This can be per- control training60 has improved cervi-
are an indication of impairment in the formed to the left and right, and up and cal position sense; and cervical muscle
task.134 Reproduction of dizziness and down. Asymptomatic individuals are able endurance training has been suggested
blurred vision may also occur. Deteriora- to perform isolated eye and head move- to improve balance.120 Acupuncture has
tion of eye follow (increase in catch-up ments and maintain focus. Often, pa- also been demonstrated to improve cer-
saccades), when the patient’s trunk is tients with neck pain are unable to keep vical joint position sense, vertigo,46 and
subsequently turned to 45° (in either di- their head still while their eyes move or standing balance. 30 However, clinical
rection), while the head is kept still, sug- lose focus during the head movements.40 experience suggests that this alone may
gests a cervical afferent component to the Eye and head movements to follow a not be sufficient nor the most efficient
deficits as seen on the smooth-pursuit trunk or an arm movement can also be way of addressing all of the sensorimotor
neck torsion test.129 If a poor performance assessed. deficits.56
is noted when the head is in neutral, and
is unchanged by adding neck torsion by 9B?D?97BC7D7=;C;DJ 7ZZh[ii_d]I[YedZWho7ZWfj_l[9^Wd][i
rotating the trunk 45°, this would imply _dj^[I[dieh_cejeh9edjhebIoij[c
a CNS disorder. Addressing any secondary effects on the

E
vidence to date would suggest
Gaze Stability The patient is asked to that management of disturbed sen- visual and vestibular systems will also be
focus on a point directly in front of him/ sorimotor control due to cervical so- important in the management of senso-
her and maintain visual focus as the pa- matosensory dysfunction might need to rimotor control disturbances in those with
tient actively moves the head into rota- address the local causes of abnormal cer- neck pain.33,51 This is where a tailored ap-
tion and flexion and extension. Despite vical afferent input. The important links proach to sensorimotor control becomes

370 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 important. There is evidence that specific coordination, and gaze stability60,108,124 improved neck pain and disability and
treatment programs that have trained have resulted in improvements not only range of motion.108 Recently, a vestibular
cervical joint position sense, eye-neck in sensorimotor impairments but also rehabilitation program improved balance
and dizziness in patients with whiplash
Example Exercise Program for injury.44 Again, it is unknown whether
J78B;' such an approach provided in isolation is
Cervicogenic Dizziness/Unsteadiness 97
able to address all of the deficits or is the
1. Oculomotor exercises standing on an unstable surface (foam) most efficient approach.
 š ;o[cel[c[djim_j^j^[^[WZijWj_edWho"j^[fWj_[djcel[ij^[[o[iX[jm[[d(XbWYaZeji"'cWfWhj"edj^[mWbb
 š J^[[o[i\ebbemWjWh][jcel_d]i_Z[jei_Z[WdZkfWdZZemd"m_j^j^[^[WZijWj_edWho ?dYehfehWj_d]CWdkWbJ^[hWfo%
($ ;o[#d[YaYeehZ_dWj_ed[n[hY_i[iijWdZ_d]edWdkdijWXb[ikh\WY[\eWc ;n[hY_i[iWdZJW_beh[ZI[dieh_cejeh
9edjheb7ffheWY^[i
 š J^[fWj_[djcel[ij^[[o[iÓhijjeWjWh][jWdZj^[dj^[^[WZ"[dikh_d]j^[[o[iWh[a[fj\eYki[Zedj^[jWh][j$
The movements are rotations to the left and right, respectively Intertwining manual therapy/exercises
 š J^[fWj_[djÓn[ij^[]Wp[edWXbWYaZejedj^[mWbb"Wj'cZ_ijWdY["WdZcel[ij^[^[WZ_dj^[jhWdil[hi[fbWd[ approaches with tailored sensorimotor
(rotation left and right) and in the sagittal plane (up and down) control programs would seem an ap-
Downloaded from www.jospt.org at on September 8, 2015. For personal use only. No other uses without permission.

 š Cel[c[djie\j^[[o[ijej^[b[\jWij^[^[WZ_ii_ckbjWd[ekibocel_d]jej^[effei_j[i_Z[_["h_]^jWdZl_Y[l[hiW propriate approach, as it will address the

3. Walking on uneven and on narrow surfaces (tandem) primary causes of the altered cervical af-
 š Fhe]h[ii_ed_djef[h\ehc_d]lWh_ekijWiaim^_b[mWba_d]"ikY^Wij^hem_d]WdZYWjY^_d]WXWbb"WdZ[o[#d[Ya
ferent input as well as secondary adaptive
coordination exercises (eg, following a stationary or moving object while walking) changes. There is evidence that an exer-
4. Standing balance exercises: standing feet apart, feet together, and tandem, on an uneven surface, foam, balance board, cise program combining manipulation,
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

and trampoline proprioceptive neuromuscular facilita-

 š J^[fWj_[djfhWYj_Y[iijWdZ_d]XWbWdY[m_j^j^[_h[o[ief[dWdZYbei[Z"m^_b[f[h\ehc_d]lWh_ekif[hjkhXWj_edi tion, acupressure on trigger points, and
(eg, arm movements and exercises with a ball) range-of-motion exercises, intertwined
 š ;o[#d[YaYeehZ_dWj_ed[n[hY_i[iWh[Wbie_dYehfehWj[Z_djej^[i[jWiai with exercises to improve head reloca-
5. One of the latest sessions is performed outdoors, practicing walking on uneven surfaces like sand and stones, as well as tion accuracy, significantly improved the
uphill and downhill
physical status of individuals with neck
 š :_÷[h[djjWiaiWh[f[h\ehc[Zm^_b[mWba_d][]"cel_d]j^[^[WZm^_b[\ebbem_d]Ôo_d]X_hZi"mWjY^_d]Ôo_d]X_hZieh pain compared to a control neck pain
moving persons/cars with the head stationary)
group of similar patients treated with
6. Instructions for home exercises every day are given in accordance with the above information and advice.99 Recently, a pi-
Journal of Orthopaedic & Sports Physical Therapy®

lot trial of a combined progam that used

eye-neck coordination, balance, and task-
Multimodal Physical Therapy dependent exercises, in conjunction with
J78B;(
Treatment Approach 59,61 retraining the deep cervical flexors and
1. Manual therapy in conjunction with neuromuscular control training to ensure long-term benefits in reduction of
position and movement sense (J78B; '),
segmental dysfunction demonstrated significant improvements
($ FW_dh[b_[\ in postural stability in those with chronic
3. Advice and reassurance
whiplash.97
However, research into the efficacy of
*$ 7Yj_lWj_ede\Z[[fd[YaÔ[nehiWdZiYWfkbWhijWX_b_p[hi$<ehcWbjhW_d_d]jm_Y[f[hZWo\eYki_d]edj^[Yehh[Yj
movement pattern initially and progressing to ensure adequate tonic holding capacity and endurance such a broad, intertwining approach is in
5. Retraining cervical and scapular postural musculature several times per day with postural correction in sitting and its infancy and the following guidelines
standing for the intertwined treatment program
6. Training for neck extensors in 4 point kneeling are built on both available clinical re-
7. Joint position and movement sense training, balance, and eye movement retraining (J78B;)) search into this area and clinical expe-
8. Cocontraction exercises
rience. The specifics of such programs
can be found in recent publications by
9. Ergonomic and postural advice, graded return to activity
Jull et al59 and Treleaven.131,132 J78B; (
10. Progression of sensorimotor exercises as able (J78B;))
summarizes an example of a typical ap-
11. Exercises to improve cervical range of motion performed in conjunction with the neuromuscular control training.
proach for combining the tailored sen-
Coordinated movement control especially of neck extension and return to neutral
sorimotor approach with other aspects
'($ H[jhW_dfWjj[hdie\iYWfkbWhYedjhebZkh_d]\kdYj_edWbWYj_l_joikY^Wijof_d]WdZehWhc[b[lWj_ed"Wim[bbWiZ[Yh[Wi_d]
unwanted muscle activity in the superficial musculature to decrease excessive strain placed on the cervical structures of physical therapy treatment. J78B; )
13. Endurance and strengthening training at progressive loads (eg, graded head lift, extension holds through range as needed)
outlines specific tasks and progressions
suggested for the tailored sensorimo-

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 371
 [ CLINICAL COMMENTARY ]
of different exercises are required. Exer-
Examples of Tasks and Progressions
cises should be performed at a speed and
J78B;) to Improve Sensorimotor Control
range of movement that allow the patient
in Neck Disorders
to perform with precision and continuous
7_c JWia Fhe]h[ii_ed correction, gradually increasing speed
Cervical position With laser on headband for feedback, š ;o[iYbei[Z"Y^[Ya[o[ief[d and range as able. Exercises should also
sense relocate back to neutral head posi- š H[beYWj[jefe_dji_dhWd][fbWY[ZedmWbb"[o[i  be performed in a position where preci-
tion from all head movements with closed, check eyes open
eyes open š ?dYh[Wi[if[[Z
sion is paramount, progressing to more
š F[h\ehc_dijWdZ_d] difficult positions, such as tandem stance,
š F[h\ehcedkdijWXb[ikh\WY[ on soft surface, etc.
Cervical movement With laser mounted on headband š ?dYh[Wi[if[[Z The observed individuality in senso-
sense practice tracing over a pattern placed š Ceh[Z_øYkbjWdZ_djh_YWj[fWjj[hd
on the wall, eyes open š IcWbbÓd[hcel[c[dji
rimotor disturbances in patients with
neck pain suggests that it may be im-
Eye follow Sitting in a neutral neck position, š I_jm_j^d[Ya_dh[bWj_l[d[Yajehi_edfei_j_ed
keeping the head still and the hands š ;o[ikfWdZZemd">fWjj[hd portant to develop specific rehabilitation
in the laps. Moving the laser light š ?dYh[Wi[if[[Z programs for specific dysfunctions and to
Downloaded from www.jospt.org at on September 8, 2015. For personal use only. No other uses without permission.

back and forth across the wall, while š ?dYh[Wi[hWd][e\cel[c[dji

following the laser with the eyes š F[h\ehc_dijWdZ_d]
use objective and quantitative methods
š F[h\ehcedkdijWXb[ikh\WY[ for evaluation of the effects of rehabili-
Saccades Quickly move and focus to selected dots š ?dYh[Wi[Z_ijWdY[ tation.117 The primary sensorimotor defi-
on a wall š 7ZZXkioXWYa]hekdZikY^Wiijh_f[i cits and the consequential compensatory
Gaze stability Maintain gaze on a dot on the wall as š <_n]Wp["Ybei[[o[i"cel[^[WZWdZef[d[o[ije  mechanisms can vary in one patient with
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

therapist passively moves the check if gaze was maintained neck pain to another.71 Good skills in
patients trunk and/or the head/neck š 9^Wd][j^[XWYa]hekdZe\j^[jWh][j"fbW_d"ijh_f[i"
Maintain gaze on a dot placed on the checks clinical examination and clinical reason-
wall or ceiling as patient actively š 9^Wd][\eYkife_djjemehZiehWXki_d[iiYWhZ ing are, therefore, mandatory for effective
moves the head/neck in all directions š ?dYh[Wi[if[[Z
š ?dYh[Wi[hWd][e\cej_ed
management.
š Fhe]h[ii\hecbo_d]jei_jj_d]jeijWdZ_d]
š F[h\ehcedkdijWXb[ikh\WY[ If[Y_ÓY;n[hY_i[i\ehKi[_dj^[JW_beh[Z
Eye-head Move eyes to a new focus point and š 7Yj_l[bocel[^[WZWdZ[o[ije][j^[hiWc[Z_h[Yj_ed I[dieh_cejehFhe]hWc
coordination then move head in the same direc- š Cel[[o[ied[Z_h[Yj_edWdZ^[WZeffei_j[Z_h[Yj_ed
tion and return to neutral š Cel[[o[iWdZ^[WZje][j^[hm^[df[h_f^[hWbl_i_ed Neck Proprioception New advances in
restricted physical therapy indicate that principles
Journal of Orthopaedic & Sports Physical Therapy®

š Cel[[o[i"^[WZ"d[Ya"WdZWhcm_j^ehm_j^ekjl_i_ed of motor control115 that address senso-

restricted
š HejWj[[o[i"^[WZ"d[Ya"WdZjhkdabeea_d]Wi\Wh  rimotor deficits in a more specific man-
behind as possible with or without vision restricted. ner may be important for patients with
š >ebZWjWh][j"a[[f[o[iÓn[ZWdZcel[jWh][j"^[WZ
and eyes move together complicated musculoskeletal problems.61
Coordination of movements is a core term
Balance Maintain standing position for 30 s š ;o[ief[dj^[dYbei[Z
š <_hcj^[die\jikh\WY[ in motor control and can be defined as
š :_÷[h[djijWdY[i0Yec\ehjWXb["dWhhem"jWdZ[c"  the sensorimotor processes that organize
single limb
š MWba_d]m_j^^[WZcel[c[djiÆhejWj_ed"Ô[n_edWdZ and activate large and small muscles with
 [nj[di_edÆcW_djW_d_d]Z_h[Yj_edWdZl[beY_joe\]W_j the optimal amount of force in the most
š F[h\ehc_d]eYkbecejehehcel[c[djehfei_j_ed 
efficient sequence.96
sense exercises while balance training
Currently, cervical joint position
* Adapted from Treleaven et al.131
sense can be retrained using a laser
pointer mounted onto a headband with
tor control program, although each in- lar habituation. If pain or headache is the light projected onto a wall, as de-
dividual’s response and effort during a exacerbated, the tasks can be attempted scribed in the section on assessment.
given intervention guides the treatment in more supported positions, such as in Patients practice relocating the head to
progression. lying, with less repetitions of each task a neutral position (guided by the laser
It is important that such a program and a graduated introduction to each beam) from their most difficult move-
does not produce an increase in pain or exercise. Each exercise should be per- ment directions (for example, rotation
headache, but some temporary exacerba- formed at least once, preferably twice to the right or following neck extension).
tion of dizziness, nausea, unsteadiness, per day. Three to 5, building to 10, rep- This can then be performed with the
and/or visual disturbances is acceptable. etitions per exercise should be sufficient eyes closed, using the laser for feedback
The latter is acceptable to allow vestibu- in most cases but can be less if a number with the eyes open on completion of the

372 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 task. The task can be progressed by ask- The oculomotor exercises performed
ing the patient to relocate the head posi- while moving the head can be imple-
tion to different points throughout the mented at the same time as retraining
range of motion (eg, left rotation 20°, cervical movement sense. Patients with
40°, and 60°) rather than the neutral severe neck pain may benefit by start-
head position. Performing these activi- ing the treatment regime by just moving
ties in more challenging standing posi- the eyes with the head stationary so as to
tions can also be used as a progression avoid symptom exacerbation.
for the exercises. Smooth pursuit can be practiced by
Cervical movement sense can be im- following a moving target with the eyes as
proved by moving the head, thus mov- accurately as possible, while keeping the
ing the laser, to trace patterns placed on head still. Performing this task in neck
a wall such as a figure-of-eight pattern. torsion positions will also be important
Patients can practice performing the to bias the cervical influence on the eyes.
<?=KH;($The balance exercises are combined with
task as accurately as possible, keeping Gaze stability can be practiced by fo-
Downloaded from www.jospt.org at on September 8, 2015. For personal use only. No other uses without permission.

eye-neck coordination exercises, and task-dependent

the laser on the lines of the pattern. In cusing on a spot directly in front of the exercises.
both exercises accuracy should be en- patient. The patient moves the head into
couraged at the outset; but once this has movement directions of difficulty, main- extremes is vital for successful treatment
been established, the patient can attempt taining optimal movement and range of in patients with whiplash and those with
to perform the activities as quickly and as motion, while fixating the gaze on the fo- equilibrium disorders of cervical origin.128
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

accurately as possible. cus point. The patient can also move the This is important, as patients with neck
More sophisticated computerized ver- trunk, or the therapist can passively move pain may react with compensatory in-
sions of retraining of neck propriocep- the trunk, while the patient maintains fo- creased muscle activity in the neck and
tion, both position sense and movement cus on the point ahead. These tasks can be other regions to achieve stabilization.
sense, are currently being developed and progressed by altering the focus point (a This is ordinarly not a problem for pa-
designed to enhance treatment progres- word or group of words, such as a business tients with dizziness of noncervical ori-
sion, with graduated levels of difficulty card), the background behind the focus gins; but for the patient with neck pain,
built into the programs. The training of point (stripes or checks), the speed and such training may be harmful, as it leads
neck position sense is aimed at better range of the movement, restricting the pe- to augmented neck muscle tension in al-
Journal of Orthopaedic & Sports Physical Therapy®

perception of body posture, dissociation ripheral vision (wearing goggles blackened ready tensed neck muscles and a vicious
between body parts, and better aware- out at the sides), and/or by altering the po- circle of increased muscle activity and
ness of the body’s position in space, es- sition the patient is in to perform the task pain and altered cervical afferent input
pecially improvement of the patients’ (eg, standing instead of sitting). may develop, further exacerbating the
awareness of the head-neck and shoul- Eye-head coordination can be prac- cervicogenic dizziness.128
der girdle posture, and is dependent on ticed as it is assessed, with attention to Attempts at sustaining static stand-
proprioceptive, visual, auditory, and ves- correctly isolate eye and head movement ing balance for up to 30 seconds can be
tibular cues. In the training of movement and perform accurate cervical move- practiced according to the extent of im-
sense by the new Fly Exercise Program ment. These tasks can be progressed by pairment found on the initial assessment.
the patient begins to use additional de- using the eyes to follow arm and trunk Progressions can be made by altering the
grees of freedom by moving the cervical movements. Saccades can be practiced by stance position, closing the eyes, and/or
spine in larger ranges of movements and quickly moving the eyes from one point altering the support surface, such as us-
performing unpredictable, incrementally to another and refocusing. Again, these ing a soft surface or an unstable surface
difficult movement patterns at different tasks can be progressed by altering the such as a wobble board.
velocities. speed and range of the movement, re- Functional and more dynamic tasks,
Oculomotor Tasks Exercises to improve stricting the peripheral vision (wearing such as walking with head turns to the
oculomotor control can be divided into goggles blackened-out at the sides), and/ left and right or up and down while
exercises performed with the head sta- or by altering the position the patient is maintaining the direction and velocity
tionary and while the head is moving. in to perform the task (eg, standing in- of walking, can also be incorporated de-
The exercises with the head stationary stead of sitting). pending on the level of impairment. This
can be implemented at the same time as Postural Stability Generally, dizziness can be progressed by varying the walking
the exercises for improving head-neck is provoked with balance training. How- surface and speed of the activity, as well
awareness and cervical position sense. ever, care and slow progression without as the walking task (J78B;'"<?=KH;(.

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 373
 [ CLINICAL COMMENTARY ]
especially important for patients with
Postural stability-balance training neck pain, as their aforementioned subtle
General balance exercises/specific balance exercises impairments may not be readily detected
Integrating: by clinical examination alone. It is impor-
Movement control exercises Exercises for position sense tant for clinicians to monitor the status
Oculomotor exercises
With increasing complexity of a patient with neck pain by objective
Progressive Interaction

Exercises for movement sense

assessment and treatment tools, and to
Oculomotor exercises meet the demands from the third-party
Stationary head/moving head payers, who require that health care pro-
viders document the effectiveness of their
therapy. This will be an important area
Head-neck awareness exercises
With increasing complexity
for future research.T

Physical therapy/exercises including postural corrections and dissociation between body parts
H;<;H;D9;I
Downloaded from www.jospt.org at on September 8, 2015. For personal use only. No other uses without permission.

Start Number of treatment sessions End  '$ Alund M, Ledin T, Odkvist L, Larsson SE. Dy-
namic posturography among patients with
<?=KH;)$Suggested treatment planning showing progressive interaction of treatment interventions. common neck disorders. A study of 15 cases
with suspected cervical vertigo. J Vestib Res.
1993;3:383-389.
<?=KH;) provides a suggestion for the lenged. The training of position sense, oc-
 ($ Anderson G. Epidemiology of spinal disorders.
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

treatment planning for a patient with ulomotor control, and movement sense In: Frymoyer J, ed. The Adult Spine. New York,
neck pain who, at the same time, has all is integrated into the balance exercise NY: Raven Press; 1991:107-146.
the sensorimotor impairments that can program to enhance modulation of the  )$ Ashton-Miller J, Schultz A. Spine instability and
segmental hypermobility biomechanics: a call
possibly be of cervicogenic origin. Physical sensorimotor circuits in the CNS and to
for definition and standard use of terms. Semin
therapy/exercises are performed through- make the balance exercises progressively Spine Surg. 1991;3:136-148.
out the management to make favorable more difficult.  *$8Wbe^H">WbcW]o_=$Disorders of the Vestibular
conditions for the sensorimotor training System. New York, NY: Oxford University Press;
and to treat any compensatory reactions <KJKH;:?H;9J?EDI 1996.
 +$8[nWdZ[h9I"C[bbehH">eZ][iFM$;÷[Yje\
that may prevail after the sensorimotor gaze direction on neck muscle activity during
Journal of Orthopaedic & Sports Physical Therapy®

exercises have been performed. Disturbed

A
lmost all research on assess- cervical rotation. Exp Brain Res. (&&+1',-0*((#
head-neck awareness, which requires ment and management of senso- *)($^jjf0%%Zn$Ze_$eh]%'&$'&&-%i&&(('#&&+#
0048-4
normal range of motion, and oculomotor rimotor dysfunctions, including
 ,$ Björklund M. Effects of Repetitive Work on
disturbances are then addressed before cervicogenic dizziness, has been aimed at Proprioception and of Stretching on Sensory
training of disturbed neck movement patients with specific dysfunctions. In the Mechanisms: Implications for Work-Related
control. Normal oculomotor control is re- clinical setting, pragmatic multimodal Neuromuscular Disorders [dissertation]. Umeå,
Im[[Z[d0Kc[Kd_l[hi_jo1(&&*$
quired before training of disturbed neck intervention approaches, including sen-
 -$ Bogduk N, Mercer S. Biomechanics of the cervi-
movement control, as the patient has to be sorimotor training, will likely be needed cal spine. I: Normal kinematics. Clin Biomech
able to follow the target (the Fly) by mov- to address the heterogeneity of presenta- (Bristol, Avon). (&&&1'+0,))#,*.$
ing the head, using vision to appreciate tion of patients with neck pain; but there  .$ Bohannon RW. Comfortable and maximum
mWba_d]if[[Ze\WZkbjiW][Z(&#-/o[Whi0
the relative movements between the target is currently only a limited but growing
reference values and determinants. Age Ageing.
(the Fly) and the cursor on the head, which amount of research on such an approach. '//-1(,0'+#'/$
follows the Fly on the computer screen. Given that such pragmatic multimodal  /$ Bove M, Courtine G, Schieppati M. Neck
The same applies if a laser pointer is used research will be conducted in academia, muscle vibration and spatial orientation during
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374 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
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journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 377