What are we Missing while treating Neck Pain?



Neck Pain is the most common complain observed in individuals ranging from 14 years to 80 years mainly due to technology. 25% of the day is spent either on the phone, laptops/desktops, tablets, television etc.

When a Client walks into the clinic with a complaint of Neck pain, every physiotherapist’s approach includes:

1) Evaluation: mobility, strength, and motion of the cervical, thoracic and shoulder joints and muscles

2) Intervention: manual therapy, strengthening, stretching and relaxation of cervical, thoracic and shoulders and

3) Patient Education: Home exercise program (HEP), avoidance of technology and ergonomic advice.

After certain visits, the client feels better and gets discharged. But 80% of these clients come back with a complaint of same or worsen neck pain.

What could be the reason for Recurrence?

There are various possibilities including non-compliant with HEP, bad posture and ergonomics and/or vigorous use of technology again.

But the Major Reason for reoccurrence of neck pain is Impaired Proprioception(sensorimotor control). Disturbance of proprioception may be an important factor in maintenance, recurrence, and an increase of symptoms (1)

Why is Proprioception Responsible?


The highly developed proprioceptive system provides neuromuscular control to the mobile cervical spine and allows efficient utilization of the vital organs in the head via unique connections to the vestibular and visual systems. This may explain why the cervical spine is an extremely vulnerable structure and is a source of a plethora of symptoms that do not arise from any other musculoskeletal region of the body. Disturbances to the afferent input from the cervical region in those with neck pain may be a possible cause of symptoms such as dizziness, unsteadiness, and visual disturbances, as well as signs of altered postural stability, cervical proprioception, and head and eye movement control. (1)

Causes of impaired afferent input can be musculoskeletal disorders such as trauma, swelling, pain, ischemia, fatigue, as well as pathophysiological changes of the peripheral or central nervous system (1,2). This can lead to decreased sensorimotor control, which can furthermore provoke worse long-term effects (1). Inhibiting the causes and improving proprioception might be a key for a positive treatment effect (1).

Thus Evaluating Sensorimotor system and incorporating its intervention in the neck pain protocol is essential to avoid recurrence pain.


How to Evaluate Proprioception (Sensorimotor System)?


1) Head-Neck Awareness:



Cervical joint position sense (also known as joint position error) can be assessed by using a laser pointer fixed on a headband. Patients sit in 90 cm distance in front of a wall, their head in a natural resting position, the beam of the laser pointer marked on the wall. The task is to move the head actively (with the eyes closed) into rotation, flexion, extension or lateral flexion and back to the starting position. The difference between the starting and end position can be measured in centimeters [1,3,4].


2) Cervical Movement Sense:



There are several interesting devices to test the accuracy of head/neck movements like “The Fly” or “virtual reality”. These are computer programs, where targets move unpredictably on the screen, and the patient has to follow them by head movements (with a device on the head) [1,3,4,5]. I assume, that not every physiotherapy practice has the possibility to own this equipment. So there is – not yet validated – an alternative to use a laser pointer on the head, to trace for example a “figure 8 pattern”, accuracy and smoothness can be evaluated [1]. One disadvantage is, that the factor of unpredictability is not provided; this method might be easier for patients, than the computer programs.


3) Postural Stability:



Can be assessed by stopping time in unspecific balance tests like comfort and narrow stance on firm or soft surface, tandem stance or single leg stance with open or closed eyes. In these tests, we have to be aware of the age and other diagnoses, which can influence the result. Another possibility to assess balance is the dynamic gait index (DGI) (1).


4) Head Eye Coordination:




Different aspects of oculomotor functions have to be assessed [1,4]. Della Casa et al. developed a test battery to assess oculomotor dysfunctions: The patient has to perform different tasks: move his eyes as quickly as possible from the right to the left side and back (saccadic eye movement), while trying not to move the head; move the head, while looking all the time at the same spot (gaze stability); move the eyes to a defined spot and then move the head into the same direction (rotation) separately [6].


5) Cervical Movement Control:




This term might look similar to “cervical movement sense”, but there is a difference: “Movement sense” aims to assess accuracy and smoothness of neck movement, while the aim of assessing “movement control” is to find evasive movements of the cervical spine during movement tasks. A test battery of 8 different movement tests is suggested by Patroncini et al.. Patients have to perform extension of the cervicothoracic junction, upper body forward-backward movement, bilateral shoulder elevation, unilateral shoulder flexion, arm flexion 90° with weight, forward bending in standing, neck flexion in the supine position and pro-/retraction, the therapist is checking for evasive movements of the cervical spine [7].

Keep Following the other blog to understand how to intervene Sensorimotor System.



1) Kristjansson, E., & Treleaven, J. (2009). Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther, 39(5), 364-377. doi:10.2519/jospt.2009.2834

2) Clark, N. C., Röijezon, U., & Treleaven, J. (2015). Proprioception in musculoskeletal rehabilitation. Part 2: Clinical assessment and intervention. Man Ther, 20(3), 378-387. doi:10.1016/j.math.2015.01.009

3) Michiels, S., De Hertogh, W., Truijen, S., November, D., Wuyts, F., & Van de Heyning, P. (2013). The assessment of cervical sensory-motor control: a systematic review focusing on measuring methods and their clinimetric characteristics. Gait Posture, 38(1), 1-7. doi:10.1016/j.gaitpost.2012.10.007

4) Treleaven, J. (2008). Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control–Part 2: case studies. Man Ther, 13(3), 266-275. doi:10.1016/j.math.2007.11.002

5) Kristjansson, E., & Oddsdottir, G. L. (2010). “The Fly”: a new clinical assessment and treatment method for deficits of movement control in the cervical spine: reliability and validity. Spine (Phila Pa 1976), 35(23), E1298-1305. doi:10.1097/BRS.0b013e3181e7fc0a

6) Della Casa, E., Affolter Helbling, J., Meichtry, A., Luomajoki, H., & Kool, J. (2014). Head-eye movement control tests in patients with chronic neck pain; inter-observer reliability and discriminative validity. BMC Musculoskelet Disord, 15, 16. doi:10.1186/1471-2474-15-16

7) Patroncini, M., Hannig, S., Meichtry, A., & Luomajoki, H. (2014). Reliability of movement control tests on the cervical spine. BMC Musculoskelet Disord, 15, 402. doi:10.1186/1471-2474-15-402

Dr. Mansi Parikh,

Co-Founder EndoRush App

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