ASSOCIATION BETWEEN CERVICOCEPHALIC KINESTHETIC SENSIBILITY AND CHARACTERISTICS OF MECHANICAL NECK PAIN

ASSOCIATION BETWEEN CERVICOCEPHALIC
KINESTHETIC SENSIBILITY AND
CHARACTERISTICS OF MECHANICAL NECK PAIN
Eman S. Fayez * ; Mostafa M Khalifa ** ;
Abdelaziz Abdelaziz Elsherif ***
and Sandra M. Ahmed ****
* Professor of Physical Therapy for Neuromuscular Disorders and its Surgery ,Faculty
of Physical Therapy, Cairo University
** Researcher of physical therapy for Neuromuscular Disorders and its Surgery, Faculty
of Physical Therapy, Cairo University.
*** Lecturer of Physical Therapy for Neuromuscular Disorders and its Surgery ,Faculty
of Physical Therapy, Cairo University
**** Professor of Neurology, Faculty of Medicine, Cairo University
Key Words: Mechanical Neck Pain, Kinesthetic Sensibility, Neck
Proprioception.
ABSTRACT
Background: Dysfunction of neck kinesthetic sensibility characterized
by increased movement irregularities and movement errors during
reposition tasks has been shown in middle-aged subjects with chronic
neck pain. However, pain can also induce changes in muscle spindle
discharge or the central output of the nervous system. Aim of study: To
determine a relationship between impaired cervicocephalic kinesthetic
sensibility and mechanical neck pain characteristics.
Procedures: Sixty patients with mechanical neck pain repositioned their
heads to the neutral head position a in sagittal and transverse plane.
When the subjects reach the reference position, the subject‟s relocation
accuracy was measured in degrees using the CROM device. The
Northwick neck pain questionnaire (NPQ) has proved to be a useful tool
in neck pain studies, correlating with objective measurements of neck
pain characteristics. Results: there was positive significant correlation
between NPQ score and flexion, rotation reposition error. Conclusion:
Disturbed kinesthetic sensibility was correlated with changes in the
mechanical neck pain characteristics.
INTRODUCTION:
Neck pain is a musculoskeletal symptom associated with disability
and significant economic health costs. Neck pain has been classified as 1 of
the top 2 largest reasons for disability caused by musculoskeletal pain
conditions by the Global Burden of Disease studies. It has been reported that
70% of the general population will experience neck pain at some time
during their lives; however, the global point prevalence is 4.9%[1].
Egypt. J. of Appl. Sci., 35(12) 2020 118-135
Neck pain shows a high rate of recurrence and chronicity. Three out of
10 neck pain patients will develop chronic symptoms that last more than 6
months whereas 34% will show symptoms for more than 12 months[2].
Some studies have demonstrated an association between range,
velocity and smoothness of cervical motion and patients' subjective reports
of pain intensity and disability, and also fear of neck motion[3].
Some investigators assume that proprioception deficit might be a
factor predisposing to pain and injury via poor motor control. Understanding
the proprioceptive function alterations in the presence of chronic neck pain
(CNP) thus seems necessary for evaluation and rehabilitation of these
patients[4].
Several authors have speculated that imprecision in the proprioceptive
system could contribute to or cause persistent pain, via peripheral and
central mechanisms[5].
An impaired position sense disturbs both neuronal and muscular control
of the normal cervical joint function, which may result in the untimely
production of unbalanced muscle force and place the joint at risk of trauma [6].
Dysfunction of kinesthetic sensibility characterized by increased
movement irregularities and movement errors during reposition tasks has
been shown in middle-aged subjects with chronic neck pain. However, pain
can also induce changes in muscle spindle discharge or the central output of
the nervous system[7].
Disturbed kinesthetic sensitivity has been implicated in the functional
instability of joints and their susceptibility to reinjury, chronic pain, and
even degenerative joint disease[8].
The relationship of pain and changes in motor control has been shown
in several studies and is seen as protective reaction of the body to limit
provocation of the painful area. This, in the long run, can cause further
damage, exacerbate the symptoms through peripheral and central nervous
system sensitization (lowering of pain threshold), and promote dysfunctional
movement patterns [9].
An important function of the cervical spine is quick and precise head
movement in reaction to surrounding stimuli. Consequently, research into
impairments associated with altered cervical kinematics, such as velocity and
accuracy of movement, in those with neck pain has been gaining attention[3].
This study was designed to correlate cervicocephalic kinesthetic
sensibility and characteristics of mechanical neck pain.
Procedures:
I. Patients selection:
Correlational study conducted on sixty subjects with mechanical neck
pain. The subjects were diagnosed, and referred from a neurologist. The
patients were selected from helmya military hospital. Ethical committee
119 Egypt. J. of Appl. Sci., 35(12) 2020
approval was obtained from the ethical committee of the Faculty of Physical
Therapy, Cairo University, Egypt
Inclusion criteria include: the patients had insidious neck pain for 3
months. Their age ranged from 18 to 30 years. Neck pain was the main
presenting complaint and neck movements reproduced neck pain. Patients
had sufficient cognitive abilities that enables them to understand and follow
instructions (Mini-Mental State Examination (MMSE) scale >24).
Exclusion Criteria include: Pregnant females, patients with tumors (spinal
tumors), spinal fracture, polyneuropathy, caudaequina syndrome and cord
compression, previous spinal surgery, degenerative spondylolisthesis and
medically or psychologically unstable patients.
II. Instrumentations:
1- Cervical Range of Motion device (CROM) as an objective assessment
device for cervicocephalic kinesthetic sensibility:
The cervical range of motion (CROM) device figure (1) is one of the
tools available clinically to measure cervical ROM. The CROM device consists
of a plastic frame placed on the head over the nose and the ears, secured by a
Velcro strap[10].The cervical range of motion (CROM) device measures
cervical ROM for rotation, flexion/extension, and lateral flexion using 3
separate inclinometers attached to a frame similar to eyeglasses : the first
inclinometer in the transverse plane for rotation, the second inclinometer in the
sagittal plane for flexion/extension, and the third inclinometer in the frontal
plane for lateral flexion. The rotation inclinometer has a magnetic needle,
whereas the flexion/extension and the lateral flexion inclinometers have gravity
needles. A magnetic necklace is worn by the subject to produce the magnetic
field required to move the rotation inclinometer‟s needle when the head is
rotated. A moveable ring on each inclinometer is used to set the zero position.
Finally, all the inclinometers are marked in 2° increments[11].
Figure (1): CROM device.
Egypt. J. of Appl. Sci., 35(12) 2020 120
2- The Northwick Park Neck Pain Questionnaire as an assessment
method of pain characteristics:
Among the different questionnaires available for out Come measures,
the Northwick neck pain questionnaire (NPQ) has proved to be a useful tool
in neck pain studies, correlating with objective measurements[12].The NPQ
is a self-administered questionnaire which includes 9 sections on daily
activities that may be affected by neck pain: intensity, sleeping, numbness,
duration, carrying, reading/television, work, social and driving. The NPQ
had three items linked to body function categories and five items linked to
activity and participation categories. Two items (item 4: „Duration of
symptoms‟ and item 10: „Comparison of current state with the last time the
questionnaire was completed‟) could not be linked to any ICF
category[13].Among the different questionnaires available for outcome
measures, the NPQ has proved to be a useful tool in neck pain studies,
correlating with objective measurements [14]. It has been validated in
patients with neck pain in several countries and languages, and also with
acceptable test–retest reliability[15]. The Arabic version of NPQ is valid,
reliable and appropriate for use in Arabic-speaking patients with
physiological neck pain in Egypt. Thus, this tool will be invaluable to
clinicians and researchers working with neck pain patients in Egypt[16].
III. Assessment Protocol:
Our participants underwent the following battery of evaluation:
Clinical assessment includes: full history taking, general medical
examination and neurological evaluation and general neurological
examination sheet (Appendix I). On approval to participate in the study, all
subjects signed an informed consent form after receiving full information on
the purpose of study, procedure, possible benefits, privacy and use of data,
and their rights to withdraw from the study when even they want. All
subjects were evaluated using the same procedures.
A. Assessment of cervicocephalic kinesthetic sensibility using CROM:
Figure (2): Assessment of rotation and flexion repositioning error
121 Egypt. J. of Appl. Sci., 35(12) 2020
The subjects sit upright in a comfortable position and looked straight
ahead (i.e., in neutral head position) and advised not to move their shoulders
for the rest of the test. The CROM was placed on top of the head and was
attached posteriorly using the Velcro strap. The magnetic part of the unit
was then placed so that it would set squarely over the shoulders. The
investigator calibrated the CROM device to a neutral head position. For the
cervicocephalic kinesthetic sensibility tests, subjects were asked to keep
their head in the neutral position and were told to close their eyes throughout
the subsequent tests. The test was the head-to-neutral head position
repositioning test [17]. The subjects were instructed to turn their head fully
to the left and back to what they believed to be the starting point in a
controlled fashion without opening their eyes. When the subjects reached
the reference position, the subject‟s relocation accuracy was measured in
degrees using the CROM device. The repositioning tests were done in the
sagittal and transverse planes. When the subjects reached the reference
position, their relocation accuracy was measured in degrees using the
CROM device. Each test trial position was carried out three times, and the
average of the three trials was used for analysis. Joint position sense (JPS)
was analyzed by calculating the angular displacement error of active angle
repositioning of cervical movement (the absolute value of the difference
between the reference angle and subject‟s reposition angle).
B. Evaluation of the characteristics of mechanical cervical pain using
the Arabic version of the Northwick neck pain questionnaire (NPQ):
The NPQ consisted of nine items including pain intensity, duration of
symptoms, pins and needles or numbness at night, Pain affecting sleep,
effect on social life, carrying, reading/watching television (TV), working/
housework, and driving [18]. For each item, there were five potential
responses describing a greater degree of difficulty (0 = no difficulty to
4=severe difficulty). An overall percentage NDQ score was calculated by
adding together the scores for each item (0–36) and calculating a percentage
(total score/36 £ 100%). If items were not applicable, the total potential
score was reduced (e.g. one item not applicable, total score out of 32). The
NPQ had been validated in patients complaining of neck pain attending a
rheumatology clinic in the United Kingdom (UK) where mean scores for
each item were shown to correlate with intensity of pain[19].It had also been
shown to have acceptable test–retest reliability [20]and sensitivity to change.
Statistical Analysis
Descriptive statistics in form of mean, standard deviation, minimum,
maximum and frequency were conducted to present the measured variables.
Pearson Correlation Coefficient was conducted to investigate the correlation
between cervicocephalic kinesthetic sensibility (repositioning error) and
NPQ. Guidelines for interpreting the correlation coefficient: 0 indicates no
linear relationship. Values between 0 and 0.3 (0 and − 0.3) indicate a weak
Egypt. J. of Appl. Sci., 35(12) 2020 122
positive (negative) linear relationship. Values between 0.3 and 0.7 (-0.3 and
-0.7) indicate a moderate positive (negative) linear relationship. Values
between 0.7 and 1.0 (- 0.7 and -1.0) indicate a strong positive (negative)
linear relationship. the level of significance for all statistical tests was set at p
< 0.05. All statistical tests were performed through the statistical package for
social studies (SPSS) version 22 for windows. (IBM SPSS, Chicago, IL,
USA).
RESULTS
- General characteristics of the subjects:
Sixty subjects with mechanical neck pain participated in this study.
Their mean ± SD age, weight, height and BMI were 24.58 ± 3.12 years,
67.55 ± 5.56 kg, 165.66 ± 5.22 cm and 24.61 ± 1.73 kg/m² as shown in
table 1 and figure 1-4.
Table 1. Descriptive statistics for the age, weight, height and BMI of
the study group.
 ±SD Maximum Minimum
Age (years) 24.58 ± 3.12 29 18
Weight (kg) 67.55 ± 5.56 80 57
Height (cm) 165.66 ± 5.22 177 157
BMI (kg/m²) 24.61 ± 1.73 27.54 20.08
 : Mean SD: Standard Deviation
Figure (1). Mean age of the study group Figure (2).Mean weight of the study
group.
Figure (3). Mean height of the study group. Figure (4). Mean BMI of the study group.
123 Egypt. J. of Appl. Sci., 35(12) 2020
- Sex distribution:
The sex distribution of the study group revealed that there were 13
females with reported percentage of 22% while the number of males was
47 with reported percentage of 78% as shown in table (2) and
demonstrated in figure (5).
Table 2. The frequency distribution of sex in the study group:
Sex distribution
Females Males
No. (%) 13 (22%) 47 (78%)
Total 60 (100%)
Figure (5). Sex distribution of the study group.
- Descriptive statistics of NPQ score of the study group:
The mean ± SD NPQ score of the study group was 23.99 ± 9.92 with a
minimum value of 9.37 and maximum value of 50 as shown in table 3
and figure 6.
Table 3. Descriptive statistics of the NPQ score of the study group:
 ±SD Minimum Maximum
NPQ score 23.99 ± 9.92 9.37 50
 : Mean SD: Standard Deviation
Figure (6). Mean NPQ score of the study group.
Egypt. J. of Appl. Sci., 35(12) 2020 124
- Descriptive statistics of repositioning error in head to neutral
position test:
Flexion reposition error
The mean ± SD flexion reposition error of the study group was 2.61 ±
2.17 degrees with a minimum value of 0 degrees and maximum value of
11 degrees as shown in table 4 and figure 7.
Extension reposition error
The mean ± SD extension reposition error of the study group was 3.45
± 1.97 degrees with a minimum value of 0 degrees and maximum value
of 8 degrees as shown in table 4 and figure 7.
Right rotation reposition error
The mean ± SD right rotation reposition error of the study group was
2.45 ± 1.96 degrees with a minimum value of 0 degrees and maximum
value of 9.3 degrees as shown in table 4 and figure 7.
left rotation reposition error
The mean ± SD left rotation reposition error of the study group was
3.16 ± 2.18 degrees with a minimum value of 0 degrees and maximum
value of 10.6 degrees as shown in table 4 and figure 7.
Table 4. Descriptive statistics of repositioning error in head to
neutral position test:
Repositioning error (degrees)  ±SD Minimum Maximum
Flexion 2.61 ± 2.17 0 11
Extension 3.45 ± 1.97 0 8
Right rotation 2.45 ± 1.96 0 9.3
Left rotation 3.16 ± 2.18 0 10.6
Figure (7). Mean repositioning error in head to neutral position test
of the study group.
 : Mean SD: Standard Deviation
125 Egypt. J. of Appl. Sci., 35(12) 2020
I- Relationship between NPQ score and repositioning error in head
to neutral position test of the study group:
The correlation between NPQ score and flexion reposition error
was moderate positive significant correlation (r = 0.511, p = 0.0001).
(Table 6, figure 9).
The correlation between NPQ score and extension reposition error
was weak negative non-significant correlation (r = -0.008, p = 0.95).
(Table 6, figure 10).
The correlation between NPQ score and right rotation reposition
error was moderate positive significant correlation (r = 0.330, p = 0.01).
(Table 6, figure 13).
The correlation between NPQ score and left rotation reposition
error was weak positive significant correlation (r = 0.274, p = 0.03).
(Table 6, figure 14).
Table 6. Correlation between NPQ score and repositioning error in
head to neutral position test of the study group:
Repositioning error (degrees) r value p value Sig
NPQ score
Flexion 0.511 0.0001 S
Extension -0.008 0.95 NS
Right rotation 0.330 0.01 S
Left rotation 0.274 0.03 S
r value: Pearson correlation
coefficient
p value: Probability
value
S:
Significant
NS: Nonsignificant
Figure (9). Correlation between NPQ score
and flexion reposition error in head to
neutral position.
Figure (10). Correlation between NPQ score
and extension reposition error in head to
neutral position.
Figure (13). Correlation between NPQ score
and right rotation reposition error in head
to neutral position.
Figure (14). Correlation between NPQ score
and left rotation reposition error in head to
neutral position.
Egypt. J. of Appl. Sci., 35(12) 2020 126
DISCUSSION:
The present study revealed that individuals with higher NPQ score could not
reproduce the neutral head position (NHP) as accurately when repositioning their
head. The results of the present work revealed that there was positive significant
correlation between NPQ score and flexion, rotation repositioning to neutral and
non-significant correlation between NPQ score and extension repositioning to
neutral. Rix and Bagust found that people with chronic idiopathic neck pain were
significantly worse than healthy controls when performing relocation to the neutral
head position from flexion (p<0.03). There were no significant differences between
groups (p>0.05) for relocation tasks from neck extension [21]. In the present work,
measurement was limited to the age between 18 and 30-year-old to limit the impact
of age on JPS, such that as age increases, joint position sense (JPS) reduces[22]. To
measure cervical proprioception, this study implemented the active head
repositioning to neutral position, which was previously used by several authors in
clinical settings and was found to be a reliable method. The number of testing trials
or movement repetitions in each direction was limited to three to minimize the
effect of fatigue of cervical muscles on joint position error (JPE). Different authors
recommended a greater number of trials in each testing direction to improve the
reliability of position sense measurement, but increasing the number of repetitions
could possibly lead to increased pain and fatigability, which might alter the test
results of JPEs in subjects with mechanical neck pain. Recurrent episode of neck
pain has reported to induce changes in the cervical mechanoreceptor function and to
affect the muscle spindle sensitivity. A modified interpretation of neck
proprioceptive signals in the center nervous system could also result in an offset in
the egocentric reference frame and interfere with the central control over the
activation of muscles. Accordingly, the diminished mechanoreceptor and muscle
spindle function, and the central misinterpretation of the proprioceptive inputs could
lead to the loss of cervicocephalic kinesthetic acuity[7].Arimi found no association
between cervical JPE and flexor muscle size and endurance. The most direct
conclusion on this finding might be that the proprioceptive functioning of the
cervical muscles, believed to be the most important proprioceptive afferent source
of the neck, performs independently from its structure and force-generating
capabilities. Spinal or supraspinal mechanisms had been proposed to be involved in
proprioceptive impairment in idiopathic CNP , which explains the lack of
relationship between muscle structure and proprioceptive functioning.[23]. Previous
laboratory studies had provided compelling evidence that pain is capable of
inducing changes in muscle spindle discharge and the proprioceptive properties of
brainstem neurons. Disturbance of the proprioceptive system has been shown to
interfere with motor control and it has been suggested that aberrant motor control
might expose the spinal components to abnormal and repetitive strain Numerous
authors had also reported an altered pattern of motor control in patients with neck
pain; However, given the cross-sectional nature of our study, it cannot be
determined whether the decrease observed in cervicocephalic kinesthetic sensibility
is a cause or result associated with changes in neck pain characteristics. It is
possible that neck pain and proprioceptive deficiency may both sustain and
perpetuate one another.
127 Egypt. J. of Appl. Sci., 35(12) 2020
APPENDX 1
Egypt. J. of Appl. Sci., 35(12) 2020 128
APPENDX II
129 Egypt. J. of Appl. Sci., 35(12) 2020
Egypt. J. of Appl. Sci., 35(12) 2020 130
131 Egypt. J. of Appl. Sci., 35(12) 2020
CONCLUSION:
The present study has provided further evidence that impairments
of cervicocephalic kinesthetic sensibility is associated with higher scores
of Northwick neck pain questionnaire. Future research should consider
the effects of proprioceptive training in the management of mechanical
neck pain.
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العلاقة بين الإحساس الحرکي لمرقبة وخصائص آلام الرقبة الميکانيکية
ايمان سمير فايز* ، مصطفي محمود محمد** ، عبد العزيز عبد العزيز محمد***
ساند ا ر محمد احمد****
* الأستاذ بقسم العلاج الطبيعي لاضط ا ربات الجياز العصبي العضمي وج ا رحتيا کمية العلاج الطبيعي جامعة
القاىرة
** باحث العلاج الطبيعي لاضط ا ربات الجياز العصبي العضمي وج ا رحتيا، کمية العلاج الطبيعي، جامعة القاىرة
***مدرس العلاج الطبيعي بقسم العلاج الطبيعي لاضط ا ربات الجياز العصبي العضمي وج ا رحتيا، کمية العلاج
الطبيعي، جامعة القاىرة
****أستاذ الأم ا رض العصبية، کمية الطب، جامعة القاىرة
المقدمة: - خمل الحساسية الحرکية لمرقبة يتميز بزيادة عدم انتظام الحرکة وأخطاء الحرکة أثناء
ميام إعادة الوضع وقد ظير في الأشخاص في منتصف العمر الذين يعانون من آلام الرقبة
المزمنة. الهدف من الد ا رسة :لتحديد العلاقة بين ضعف الحساسية الحرکية لمرقبة وخصائص
آلام الرقبة الميکانيکية. الطرق: أجريت ىذه الد ا رسة عمى ستين شخص يعانون من آلام الرقبة
الميکانيکية بإعادة وضع رؤوسيم إلى وضع ال أ رس المحايد في المستوى السيمي والعرضي.
Egypt. J. of Appl. Sci., 35(12) 2020 134
عندما تصل وضع ال ا رس إلى الموضع المرجعي، تم قياس دقة وضع ال ا رس بالدرجات باستخدام
أثبت استبيان نو رثويک لألم الرقبة أنو أداة مفيدة في د ا رسات آلام الرقبة، حيث .CROM جياز
يرتبط بالقياسات الموضوعية لخصائص آلام الرقبة. النتائج: أظيرت النتائج ما يمي: - توجد
علاقة ارتباط موجبة معنوية بين درجة استبيان نورثويک وخطأ الانثناء، وبين درجة استبيان
نورثويک وخطأ تغيير موضع الدو ا رن. الخلاصة: ان الحساسية الحرکية المضطربة لمرقبة مرتبطة
بتغير خصائص آلام الرقبة الميکانيکية.
الکممات الرئيسية: آلام الرقبة الميکانيکية، الحساسية الحرکية لمرقبة
135 Egypt. J. of Appl. Sci., 35(12) 2020