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Cervical Proprioception and Its Relationship with Neck Pain Intensity

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Cervical Proprioception and Its Relationship with Neck Pain Intensity Reddy et al. BMC Musculoskeletal Disorders (2019) 20:447 https://doi.org/10.1186/s12891-019-2846-z RESEARCH ARTICLE Open Access Cervical proprioception and its relationship with neck pain intensity in subjects with cervical spondylosis Ravi Shankar Reddy1* , Jaya Shanker Tedla1, Snehil Dixit1 and Mohammed Abohashrh2 Abstract Background: Cervical proprioception is critical in the maintenance of posture and movements, so its assessment in different cervical conditions has gained importance in recent clinical practice. Studies reporting this assessment in subjects with cervical spondylosis (CS) have not previously been investigated. The goals of the study are (1) comparison of joint position error (JPE) in subjects with CS to healthy control group. (2) Correlation of neck pain intensity to cervical proprioception in patients with CS. Methods: In a Cross-sectional study, 132 subjects with CS and 132 healthy age-matched control subjects were evaluated for cervical JPE with the cervical range of motion device. The subjects were blindfolded and repositioned their heads to a target position, which was determined by the examiner previously and their repositioning accuracy (absolute error in degrees) was measured in the frontal (flexion and extension) and transverse planes (left rotation and right rotation). The CS subjects resting neck pain intensity was assessed using visual analog scale (VAS). Results: CS subjects showed statistically significantly larger JPEs compared to healthy control subjects in all the directions tested (flexion - 95% CI = 2.38–3.55, p < 0.001, extension - 95% CI =3.26–4.33, p < 0.001, left rotation - 95% CI = 2.64 - 3.83, p < 0.001, right rotation − 95% CI = 3.77–4.76, p < 0.001). The mean JPE errors in the CS group ranged from 6.27° to 8.28° and in the control group ranged from 2.36° to 4.48°. Pearson’s correlation coefficient showed a significant and positive relationship between neck pain intensity and cervical proprioception (p ≤ 0.001). Conclusions: Proprioception is impaired in subjects with CS when compared to healthy control group. Higher pain intensity was associated with greater cervical JPE in patients with CS. Keywords: Neck pain, Cervical spondylosis, Proprioception, Pain intensity Background the upper extremity, which will lead to significant dis- Cervical spondylosis (CS) is an age-related chronic ability and functional limitations [3]. degenerative condition of the cervical spine with a Proprioception is a sense of bodily movement position, prevalence rate of 3.3 patients per 1000 people in the which includes position sense (joint position sense) and general population [1, 2]. The usual occurrence of CS is movement sense (kinesthesia) [4]. The ascending pro- at C5-C6 and C6-C7 levels, although higher levels may prioceptive information reaches the central nervous also be involved [3]. Even though age-related degener- system via the afferent pathway contributing to move- ation is the primary cause of degeneration, in younger ment and postural neuromuscular control [4]. The patients injuries to the cervical disc can affect this de- cervical muscles have abundant muscle spindle density generative process. Subjects with CS usually present with that reflects a rich proprioceptive system, which contrib- complaints of pain, tingling, numbness and weakness in utes to enhanced sensorimotor function and thereby play an important role in maintaining static and dynamic postures with effective motor control [5]. * Correspondence: [email protected] 1Department of Medical Rehabilitation (Physical Therapy), College of Applied Studies have shown that cervical position sense is vital Medical Sciences, King Khalid University, Abha 61421, Saudi Arabia in maintaining joint stability under static and dynamic Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Reddy et al. BMC Musculoskeletal Disorders (2019) 20:447 Page 2 of 7 conditions and the development of clinical pain is orthopedic or neuro-medicine clinic to physical therapy. predisposed by impaired proprioception [6]. Cervical CS is defined as “neck pain subjects with the radiological proprioception is quantified by joint position error (JPE) findings confirming cervical degeneration (degenerative measured in degrees. In CS, if the non-specific nature of changes in the intervertebral discs, osteophytosis of the problems is paired with impaired cervical proprioception, vertebral bodies, hypertrophy of the facets and laminal it is more likely that position sensibility is primarily arches, and ligamentous and segmental instability) and affected by impairment in cervical muscles, joints, or cervical range is limited when compared with age- capsules and, secondarily, by alteration in afferent proprio- matched healthy subjects.” Subjects were included if the ceptive tuning and integration [7, 8]. In CS, there may be neck pain was the main presenting complaint, and if impaired mechanoreceptor’s feedback, which might con- neck movements reproduced neck pain. Subjects with a tribute to cervical muscle atrophy and joint degenerative history of neurologic disease, whiplash injury, cervical changes resulting in unpredictable “giving away.” [8, 9] myelopathy, any inflammatory arthritis, tumors, infec- An impaired position sense disturbs both neuronal tion involving the cervical spine, and vertebrobasilar and muscular control of the normal cervical joint func- artery insufficiency were excluded. For the age-matched tion, which may result in the untimely production of healthy control subjects to be considered for inclusion, unbalanced muscle force and place the joint at risk of the subjects must have age-matched normal cervical trauma [8, 9]. spine ROM in all the planes, with no history of cervical Cervical pain can originate from a local spot or can spine injury, dizziness, or vertigo, or any other musculo- spread to distant areas and develop into chronic syn- skeletal complaints. All the subjects included in the drome in subjects with CS [8, 9]. Acute pain transform- study signed a consent form and the King Khalid Uni- ing into chronic pain is a complex process and not fully versity Ethics Committee approved the study (REC # understood by researchers, and thereby the intensity of 2016-01-06). pain is a focus of research on subjects with neck pain [9–11]. Lee et al. conducted a study to show if there is Cervical JPE testing any association between temporal aspects of pain (Pain The testing procedures implemented in this study are frequency, duration, intensity) and cervical position those adopted by Lee et al. [6]. The subjects sat upright sense in subjects with subclinical neck pain [6]. The in the chair with back straight, head facing straight neck pain intensity did not show consistent effect with ahead, and feet touching the ground, and this position cervical proprioceptive ability. Lee did not see consistent was selected as the neutral head position. The study association may be because he sub grouped subjects as procedure was explained to all the subjects and stand- mild, moderate and severe pain intensity groups and ard instructions were given during their testing phase. compared the proprioception errors rather than seeing A travel eye mask was used to blindfold the subject association between each subject pain intensity to his and a Velcro strap was used to fix and limit trunk proprioceptive ability. To date, there are no studies that and shoulder movement during the JPE testing pro- showed a consistent relationship between neck pain cedure (Figs. 1 and 2). intensity and cervical proprioception, possibly because The examiner secured the cervical range of motion neck pain intensity is not easily quantified due to its (CROM) unit on the subject’s head with the Velcro strap subjective nature, particularly if neck pain is subclinical and the magnetic yoke of the CROM device was ar- or occasional. Another approach is to evaluate the ranged on the subject’s shoulder with arrow mark placed temporal aspect of pain intensity and its influence on to the north. With the above position maintained, the neck proprioception in CS subjects. Therefore, the examiner calibrated the CROM device to a neutral purpose of the study is to see the comparison of joint position. CROM is a valid device to measure cervical position error in subjects with CS to healthy control ROM and intratester reliability ranged from 0.62 to 0.91 group and to see a relationship between neck pain inten- and inter-tester reliability ranged from 0.74 to 0.87 [12]. sity and cervical proprioception in patients with CS. The To evaluate the JPE, the examiner held the subject’s hypothesis of the study is that 1) cervical JPE will be head and moved slowly to the target head position, greater in CS group compared to healthy control group. which is 50% of the maximum CROM (which was previ- 2) Higher cervical pain intensity will be associated with ously recorded by the examiner) [13] and held there for greater cervical JPE in subjects with CS. a period of 3 s. The subjects then memorized that target position and then the examiner slowly brought the sub- Methods ject’s head back to the neutral position. The subjects Our study is a cross-sectional analysis and the subjects then were advised to reach the target position actively by in this study’s sample were patients aged 30 to 60 years moving the head and when subject reached the target experiencing neck pain due to CS and referred from the position the reposition accuracy error was determined in Reddy et al.
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