Review Title: Manual Therapy with Rehabilitation of Cervical Sensorimotor Control for Neck Pain +MP3

Research Review By Dr. Michael Haneline©


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Date Posted:

March 2023

Study Title:

Effectiveness of adding rehabilitation of cervical related sensorimotor control to manual therapy and exercise for neck pain: A randomized controlled trial


Sremakaew M, Jull G, Treleaven J & Uthaikhup S

Author's Affiliations:

Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand; School of Health and Rehabilitation Sciences, The University of Queensland, Australia

Publication Information:

Musculoskeletal Science and Practice 2023 Feb; 63: 102690.

Background Information:

Between 50% and 85% of persons with neck pain do not attain complete resolution of their symptoms (1), possibly due to altered afferent/sensory input from cervical proprioceptors (2). Research has shown that such altered afferentation can result in impaired joint proprioception, reduced head and eye movement control and postural instability, with subsequent decreased physical performance and increased concerns about falling in older persons (3).

Manual therapy and specific therapeutic exercise are accepted modalities in the management of neck pain and have been shown to improve sensorimotor deficits, including joint position sense (JPS) and balance. However, it is not known whether improvements in cervical proprioception and balance are due to sensorimotor training, the specific type of sensorimotor training or the neck intervention.

Therefore, to determine which are the most efficient and effective treatment strategies for patients with neck pain and sensorimotor deficits, a randomized controlled trial was designed to study the effectiveness of adding cervical JPS/oculomotor control (OC) and/or balance exercises to local neck treatment (manual therapy and therapeutic exercise) on measures of joint position error (JPE) and postural sway.

Pertinent Results:

Out of 268 people who volunteered to participate in the study, 152 of them were enrolled. Follow-up was excellent, with only 2 participants lost at 6-months and only 5 at 12-months.

13.2% of participants reported having neck discomfort after the first treatment, which disappeared within 24 hours. No significant adverse events were reported.

Most (80%) of the participants practiced their exercises during the 6-week treatment period, but that reduced to 40% 3 months after treatment was completed and to only 20% after 6 months (sounds like patients in real practice, right?). 14 participants (9.2%) took NSAIDs for their neck pain at some point during the 12-month period; however, no one reported seeking nor receiving additional treatment.

The factorial analysis revealed no three-way interactions between time, JPS/OC and balance. Also, there were no two-way interactions between JPS/OC and balance for cervical JPE, nor between JPS/OC and balance for postural sway.

There were significant and large effects of JPS/OC and balance interventions for JPE in rotation, but not in extension. This indicates that adding either JPS/OC or balance exercises for JPE in rotation was more effective than not adding them.

The effect of balance exercise on JPE was significant for all neck neutral conditions with medium to large effect sizes. However, the addition of JPS/OC exercises provided no additional effect on balance outcomes.

The combined local neck treatment (NT) + JPS/OC + Balance group attained the greatest reduction in JPE in rotation as compared to the NT only group, although each group that received sensorimotor training (NT + JPS/OC and NT + Balance) had a greater reduction in JPE in rotation as compared to the NT only group. Groups that received balance training had a greater reduction in sway area in all neck neutral conditions as compared to the NT only group.

Significant improvements (although with small effect sizes) were found for the VAS and NDI scores. Thus, adding either JPS/OC or balance exercises provided additional benefit for VAS and NDI scores. However, there were no significant improvements for dizziness, ROM, gait speed, satisfaction, PSFS and SF-36.

All sensorimotor training groups (NT + JPS/OC, NT + Balance and NT + JPS/OC + Balance) showed a significantly greater reduction in VAS and NDI scores at 6- and 12-months than the NT only group.

All intervention groups showed significant improvements in all primary and secondary outcomes immediately after treatment and maintained at 3-, 6- and 12-month follow-ups, except cervical JPE in rotation in the NT group, which was not maintained over time.

Clinical Application & Conclusions:

Adding specific sensorimotor training to manual therapy and therapeutic exercise more effectively addressed the physical deficits in cervical proprioception and balance than neck treatment (NT) alone. Similarly, adding sensorimotor training helped maintain improvements in neck pain and disability better than NT alone at 6- and 12-month follow-ups.

Every intervention in this study, including NT alone, improved the primary outcomes of JPS and balance as well as the secondary outcomes of pain, neck disability, range of movement, dizziness, gait speed, functional status, satisfaction, and quality of life. These improvements were robust (medium to large effect sizes) and were maintained at the 12-month follow-up.

Clinicians who provide manual therapy should consider adding specific sensorimotor training to their usual local neck treatment protocols to better address impaired JPS and balance in persons with neck pain. The addition of sensorimotor training maximizes improvements in measures of JPS and balance and it helps maintain improvements in neck pain and disability in the long-term. This concept of combining manual therapy with sensorimotor training becomes more relevant in an aging population, who become more at risk of falls and other balance-related issues.

Study Methods:

This was a randomized controlled trial which utilized an assessor blinded 2 x 2 factorial design, in which 4 independent variables were compared using the following 4 intervention groups:
  1. local neck treatment (NT);
  2. NT + JPS/oculomotor exercises (JPS/OC);
  3. NT + balance exercises; and
  4. all treatments combined.
Treatment Descriptions:
  • Local neck treatment (NT) consisted of cervical mobilization applied to the symptomatic cervical segments and therapeutic exercise.
  • Local neck treatment plus cervical joint position sense (JPS)/oculomotor control (OC) exercises comprised tailored proprioceptive/oculomotor control exercises (head repositioning, movement tracing and oculomotor exercises) which were added to NT.
  • Local neck treatment plus balance exercises included static and dynamic balance and gait exercises which were progressed by closing eyes, altering the support surface, concurrent voluntary movements, or increasing speed.
  • Local neck treatment plus cervical joint position sense/oculomotor control and balance exercises included a combination of local neck treatment, cervical joint proprioceptive sense/oculomotor control and balance exercises.
Participants included persons aged 18–70 years with neck pain and with cervical proprioception and balance impairments. To be considered eligible, participants had to have had idiopathic neck pain for at least 3 months with a Neck Disability Index score of ≥ 10/100.

Exclusion criteria:
  • History of neck and head trauma,
  • known or suspected vestibular pathology,
  • musculoskeletal or neurological conditions that could affect balance,
  • cognitive impairment,
  • taking four or more medications, and
  • treatment for a neck disorder in the past 12 months.
A blinded independent assessor performed baseline and follow-up assessments post-treatment and at 3, 6, and 12 months. Twelve treatment sessions were provided by experienced physiotherapists over a 6-week intervention period. The physiotherapists were blinded to outcome assessments but not treatment allocation.

The study’s primary outcome measure was joint position error (JPE) as determined by a laser-pointer attached to a lightweight headband, tested 3 times. Secondary outcomes included the following.
  • Gait speed as measured by the 10m walk test.
  • Dizziness intensity over the past week, measured using a 0-100 mm visual analogue scale (VAS).
  • Average neck pain intensity in the past week using a 0-100 mm VAS.
  • Neck disability in the past week as measured by the self-rated Thai version of the NDI.
  • Cervical range of motion measured 3 times and averaged using a cervical range of motion (CROM) goniometer.
  • Functional ability status using the patient-specific functional scale (PSFS).
  • Health-related quality of life using the Thai version of Short Form-36.
  • Global perceived benefit of treatment as measured on a 7-point Likert scale which ranged from no benefit to maximum benefit.

Study Strengths / Weaknesses:

This was a well-done study that utilized a 2 x 2 factorial design to better analyze and compare the study’s 4 independent variables. Participant compliance was very good, with only a 4.6% loss to follow-up. Participants were asked to keep logbooks of their exercise program which showed excellent adherence to the 6-week exercise program, with 20% of them continuing their exercises to 12 months. No participants reported seeking additional treatments during the 12-month period and only 9% of participants took medication for their neck pain.
There were a few study limitations, although they were not crucial and likely had little impact on the study’s findings. It was not possible to blind the participants or physiotherapists to the interventions; however, participants were blinded to the hypotheses to minimize performance bias. Given that the participants were mostly middle-aged adults (typical age group of neck pain sufferers), the findings of the study may not be generalizable to other age groups. Only 42% of participants reported dizziness and its intensity was low.

Additional References:

  1. Carroll L, Hogg-Johnson S, van der Velde G, et al. Course and prognostic factors for neck pain in the general population: results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. J Manip Physiol Ther 2009; 32 (2 Suppl. l): S87–S96.
  2. Roijezon U, Clark N, Treleaven J. Proprioception in musculoskeletal rehabilitation. Part 1: basic science and principles of assessment and clinical interventions. Man Ther 2015; 20(3): 368–77.
  3. Kendall J, Boyle E, Hartvigsen J, et al. Neck pain, concerns of falling and physical performance in community-dwelling Danish citizens over 75 years of age: a cross-sectional study. Scand J Publ Health 2016; 44(7): 695–701.

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