|Year : 2015 | Volume
| Issue : 2 | Page : 127-130
Cervical proprioception evaluation using cervical range of motion device: A narrative review
Ravi Shankar Reddy, Khalid A Alahmari
Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
|Date of Web Publication||6-May-2015|
Ravi Shankar Reddy
Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, P.O. Box No. 3665, Guraiger, Abha
Source of Support: None, Conflict of Interest: None
Cervical proprioception is very important for optimal neck performance in sports. Cervical muscles have numerous connections with vestibular, visual and higher centres and interactions with these can produce effective proprioceptive input. Dysfunction of cervical proprioception because of different sports injuries need to be evaluated. Common tests used in the evaluation of cervical proprioception include head reposition accuracy (HRA) tests. HRA tests commonly undertaken are repositioning to the neutral head position and repositioning into target head position. Cervical range of motion device is an effective, easy and convenient tool to measure cervical proprioception. This information should assist sports physiotherapists and health care providers who deal with cervical injuries in sports or any neck conditions.
تقببم استقبال الحس العنقي العميق باستخدام جهاز حركة العنق
يعدّ استقبال الحسّ العنقي العميق مهمّا جدا للحصول على أداء أمثل للعنق في مجال الرياضة. ولدى عضلات العنق اتصالات عديدة بالمركز الدهليزي ومركز الرؤية والمراكز العليا للدماغ، والتفاعلات مع هذه المراكز ينتج عنها مردود فعّال في استقبال الحس العنقي العميق. وقد يتأثر الحس العنقي العميق بسبب الإصابات الرياضية المخنلفة .
وتشمل الاختبارات الشائعة المستخدمة في تقييم استقبال الحس العنقي العميق اختبار دقة تغييروضع الرأس الذي يتم بإعادة تمركز الرأس المحايد ووضعه في موضع الرأس المستهدف. ويعدّ جهاز حركة العنق أداة فعّالة وسهلة ومريحة لقياس استقبال الحس العميق للعنق. هذه المعلومات ستكون مفيدة الرياضيين واختصاصي العلاج الطبيعيّ ومقدمي الرعاية الصحيّة الذين يتعاملون مع إصابات العنق في الألعاب الرياضية.
Keywords: Cervical, kinaesthesia, proprioception, reposition error
|How to cite this article:|
Reddy RS, Alahmari KA. Cervical proprioception evaluation using cervical range of motion device: A narrative review. Saudi J Sports Med 2015;15:127-30
|How to cite this URL:|
Reddy RS, Alahmari KA. Cervical proprioception evaluation using cervical range of motion device: A narrative review. Saudi J Sports Med [serial online] 2015 [cited 2023 Dec 8];15:127-30. Available from: https://www.sjosm.org/text.asp?2015/15/2/127/156342
| Introduction|| |
Proprioception is a term commonly used to describe the ascending information by the afferent receptors towards the central nervous system (CNS) contributing to the neuromuscular control of movement and encompasses the sensation of joint movement (kinaesthesia) and joint position (joint position sense).  The Spatial orientation is a key process necessary for several normal functions such as coordinating movement and maintaining posture. , 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 CNS. , 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 CNSs. ,,,
Importance of assessing cervical proprioception in sports
Traumatic minor cervical strains are common place in high-impact sports (e.g., tackling) and premature degenerative changes have been documented in sports people exposed to recurrent impact trauma (e.g., scrummaging in rugby) or repetitive forces (e.g., Formula 1 racing drivers, jockeys).  Cervical spine injuries can result in the damage of sense receptors which surround and innervate cervical structures.  These sensors are muscle spindles, situated in inter-vertebral and dorsal muscles, which transmit information about changes in muscle length to the CNS. , There is evidence of inhibition of gamma motor neurons, due to the pain after injury, which results in incorrect information from muscle spindles to the CNS and in incorrect proprioceptive sense.  This is important in sports, because moving to any object requires precise sense of the head and neck position.
In respect to the receptors providing proprioceptive information for the CNS, the high densities and complex arrays of spindles found in cervical muscles suggest that these receptors play a key role. , There is some evidence suggesting that ensemble encoding of discharge patterns from muscle spindles is relayed to the CNS and that a pattern recognition system is used to establish joint position and movement.  Sensory information from neck proprioceptive receptors is processed in tandem with information from the vestibular system. ,,,, There are extensive anatomical connections between neck proprioceptive inputs and vestibular inputs. If positional information from the vestibular system is inaccurate or fails to be appropriately integrated in the CNS, errors in head position may occur, resulting in an inaccurate reference for head and neck position sense, and conversely if neck proprioceptive information is inaccurate, then control of head position may be affected. The cerebellum and cortex also play a role in control of head position, providing feed forward and modulatory influences depending on the task requirements. ,,,
Position-matching tasks have been the most popular means of testing position sense in the cervical spine.  These allow the appreciation of absolute, constant and variable errors in positioning and have been shown to be reliable.  The results of such tests indicate that errors are relatively low (2-5°). , It is evident that impairments in position sense are observed in individuals who have experienced whiplash-type injuries and individuals with chronic head and neck pain of nontraumatic origin (e.g., cervical spondylosis). , While researchers advocate comprehensive retraining protocols, which include eye and neck motion targeting tasks and coordination exercises, as well as co-contraction exercises to reduce such impairments and may be of benefit. ,,
Proprioceptive repositioning testing in cervical spine
Recently, increasing attention has been paid to the assessment proprioception in patients with neck pain. The head reposition accuracy (HRA) tests (a frequently adapted method of determining neck proprioception) have been used to examine each subject's ability to return their head to a predetermined position without visual cues after they have moved. , HRA tests commonly undertaken are: (i) Repositioning to the neutral head position (NHP) and (ii) repositioning into target head position (THP). The NHP test measures the subject's ability to actively reposition their head to their self-selected neutral position. The THP test measures the individual's ability to actively reposition the head to a previously demonstrated target position. The ability to do this has been reported to be impaired in patients with chronic neck pain. ,
Common methods of assessing cervical proprioception
The common methods used in the literature to assess cervical proprioception include cervical range of motion (CROM) device, electromagnetic tracking system (FASTRAK), Rod and Frame test, ultrasound based coordinate measuring system (70P), CA6000 spinal motion analyzer, laser pointer method. ,,,,, CROM device is effectively used in clinical set up, easy to apply and cost effective. The CROM device possesses several advantages for clinical practice because it can be managed by one rater and requires no advanced time-consuming calculations. CROM can be used for on field evaluation of cervical proprioception during the sports; it can be carried easily and requires minimal time for evaluation. It shows cervical proprioception errors in degrees straight away without time consuming calculations. CROM device has good criterion validity (r = 0.89-0.99) and reliability (intra-class-correlation coefficient [ICC] = 0.92-0.96). ,
Cervical range of motion device
The CROM device is a type of goniometer designed specifically for the cervical spine and was used to measure CROM. The CROM device has been evaluated most often, with seven studies assessing its reliability on healthy volunteers or symptomatic patients. ,, The CROM has three inclinometers, one to measure in each plane, and is strapped to the head. One gravity dial meter measures flexion and extension, another gravity dial meter measures lateral flexion and a compass meter measures rotation with its accuracy reinforced by two magnets placed over the subject's shoulders. The advantage of the CROM over a single inclinometer method is that it does not need to be moved to measure movement in another plane. Studies have declared it superior to the universal goniometer and visual estimation and superior to a single inclinometer. ,,
Assessment of cervical proprioception using cervical range of motion device
Head reposition accuracy tests: NHP and THP tests are common tests used to assess cervical proprioception. Two HRA tests should be undertaken: (i) Repositioning to the NHP and (ii) repositioning into THP. The test procedures should be the same as those described by Lee et al.  The NHP test measures the subject's ability to actively reposition their head to their self-selected neutral position. The THP test measures the individual's ability to actively reposition the head to a previously demonstrated target position.
After explaining the testing procedure the investigator should blindfold the subject with a travel eye mask and the CROM device should be securely fixed on the head of the subject. The participants should be instructed to sit upright with their feet flat on the floor, their back against the chair backrest and facing straight ahead, this position should be established as their self-selected "NHP" The CROM unit should be placed on top of the head and attached posteriorly using the Velcro strap. The magnetic part of the unit will be then placed so that it will sit squarely over the shoulders. The investigator should calibrate the CROM device to a NHP. A webbing strap should be used to minimize shoulder and trunk movement during the reposition test.
Neutral head position test
The subjects should be instructed to rotate the head fully to the left or right and back to what they considered the starting point in a controlled fashion. When the subjects reaches the reference position the subject's relocation accuracy should be measured in degrees with CROM device.
Target head position test
In the second repositioning test (THP) the investigator will move the subject's head slowly to the predetermined target position, 50% of maximum range of motion. The speed of passive neck motion will be very slow as higher speeds have been associated with significant differences in vestibular function according to age. , The head should be maintained in the target position for 3 s, and the subject will be asked to remember that position and the head was brought to neutral position and then the subject will be asked to reposition actively by moving the head to the target position. When the subjects reaches the reference position the subject's relocation accuracy was measured in degrees with CROM device.
The THP repositioning tests should be performed in the six directions (flexion, extension, right side flexion, left side flexion, right rotation, left rotation). The order of testing NHP and THP six directions of movements should be randomized using simple chit method. Three trials should be undertaken in each direction of movement and the mean of these trials (mean error) should be used for analysis. No feedback about repositioning performance should be given during the testing and all tests should be administered by the same investigator. The entire procedure will take approximately 15 min for each subject.
Studies assessing cervical proprioception using cervical range of motion device
Johanna Wibault et al. compared HRA using the CROM device between individuals with cervical radiculopathy caused by disc disease (CDD; n = 71) and neck-healthy individuals (n = 173); and to evaluate the test retest reliability of the CROM device in individuals with CDD, and criterion validity between the CROM device and a laser in neck healthy individuals, with quantification of measurement errors.  Parameters of reliability and validity were expressed with ICCs, and measurement errors with standard error of measurement (SEM) and Bland Altman limits of agreement. HRA (Mdn, interquartile range) differed significantly between individuals with CDD and neck-healthy individuals after rotation right 2.7 (6.0), 1.7 (2.7); and rotation left 2.7 (3.3), 1.3 (2.7) (P < ¼ 0.021); 31% of individuals with CDD were classified as having impairment in HRA. The test-retest reliability of the CROM device in individuals with CDD showed ICCs of 0.79-0.85, and SEMs of 1.4-2. The criterion validity between the CROM device and the laser in neck-healthy individuals showed ICCs of 0.43-0.91 and SEMs of 0.8-1.3. The results support the use of the CROM device for quantifying HRA impairment in individuals with CDD in clinical practice.
| Conclusion|| |
Cervical range of motion device is an easy and effective tool to evaluate cervical proprioception in clinical practice. Future studies are required to see the test retest reliability of CROM device to see if the device can measure the cervical proprioception in a reliable fashion. CROM should also be used in different cervical pathologies or differ cervical injuries to assess cervical proprioception. This information should assist sports physiotherapists and health care providers who deal with cervical injuries in sports or any neck conditions.
| References|| |
Riemann BL, Lephart SM. The sensorimotor system, part I: The physiologic basis of functional joint stability. J Athl Train 2002;37:71-9.
Riemann BL, Lephart SM. The Sensorimotor System, Part II: The Role of Proprioception in Motor Control and Functional Joint Stability. J Athl Train 2002;37:80-4.
Girirajsinh JC. Effect of Sensory-Motor Control (SMC) Training with Deep Cervical Flexor (DCF) Training on Pain, Disability, Postural Stability and Head and Eye Movement Control in Chronic Neck Pain Patients, Rajiv Gandhi University of Health Sciences; 2010.
Treleaven J. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control - Part 2: Case studies. Man Ther 2008;13:266-75.
Armstrong B, McNair P, Taylor D. Head and neck position sense. Sports Med 2008;38:101-17.
Armstrong BS, McNair PJ, Williams M. Head and neck position sense in whiplash patients and healthy individuals and the effect of the cranio-cervical flexion action. Clin Biomech (Bristol, Avon) 2005;20:675-84.
Loudon JK, Ruhl M, Field E. Ability to reproduce head position after whiplash injury. Spine (Phila Pa 1976) 1997;22:865-8.
Knox JJ, Beilstein DJ, Charles SD, Aarseth GA, Rayar S, Treleaven J, et al.
Changes in head and neck position have a greater effect on elbow joint position sense in people with whiplash-associated disorders. Clin J Pain 2006;22:512-8.
Ewing C, Thomas D, Lustick L, Becker E, Willems G, Muzzy W. The Effect of the Initial Position of the Head and Neck on the Dynamic Response of the Human Head and Neck to-Gx Impact Acceleration: SAE Technical Paper; 1975.
Gómez Alvarez CB, Rhodin M, Bobber MF, Meyer H, Weishaupt MA, Johnston C, et al.
The effect of head and neck position on the thoracolumbar kinematics in the unridden horse. Equine Vet J Suppl 2006; 36:445-51.
Teng CC, Chai H, Lai DM, Wang SF. Cervicocephalic kinesthetic sensibility in young and middle-aged adults with or without a history of mild neck pain. Man Ther 2007;12:22-8.
Jordan K. Assessment of published reliability studies for cervical spine range-of-motion measurement tools. J Manipulative Physiol Ther 2000;23:180-95.
Kristjansson E, Hardardottir L, Asmundardottir M, Gudmundsson K. A new clinical test for cervicocephalic kinesthetic sensibility: "The fly". Arch Phys Med Rehabil 2004;85:490-5.
Grod JP, Diakow PR. Effect of neck pain on verticality perception: A cohort study. Arch Phys Med Rehabil 2002;83:412-5.
Jasiewicz JM, Treleaven J, Condie P, Jull G. Wireless orientation sensors: Their suitability to measure head movement for neck pain assessment. Man Ther 2007;12:380-5.
Elsig S, Luomajoki H, Sattelmayer M, Taeymans J, Tal-Akabi A, Hilfiker R. Sensorimotor tests, such as movement control and laterality judgment accuracy, in persons with recurrent neck pain and controls. A case-control study. Man Ther 2014;19:555-61.
Tousignant M, Duclos E, Laflèche S, Mayer A, Tousignant-Laflamme Y, Brosseau L, et al.
Validity study for the cervical range of motion device used for lateral flexion in patients with neck pain. Spine (Phila Pa 1976) 2002;27:812-7.
Tousignant M, Smeesters C, Breton AM, Breton E, Corriveau H. Criterion validity study of the cervical range of motion (CROM) device for rotational range of motion on healthy adults. J Orthop Sports Phys Ther 2006;36:242-8.
Audette I, Dumas JP, Côté JN, De Serres SJ. Validity and between-day reliability of the cervical range of motion (CROM) device. J Orthop Sports Phys Ther 2010;40:318-23.
Wibault J, Vaillant J, Vuillerme N, Dedering Å, Peolsson A. Using the cervical range of motion (CROM) device to assess head repositioning accuracy in individuals with cervical radiculopathy in comparison to neck- healthy individuals. Man Ther 2013;18:403-9.
Lee HY, Teng CC, Chai HM, Wang SF. Test-retest reliability of cervicocephalic kinesthetic sensibility in three cardinal planes. Man Ther 2006;11:61-8.
Pathmanathan JS, Presnell R, Cromer JA, Cullen KE, Waitzman DM. Spatial characteristics of neurons in the central mesencephalic reticular formation (cMRF) of head-unrestrained monkeys. Exp Brain Res 2006;168:455-70.
Peterson BW, Goldberg J, Bilotto G, Fuller JH. Cervicocollic reflex: Its dynamic properties and interaction with vestibular reflexes. J Neurophysiol 1985;54:90-109.