Neck pain – why physios should include sensorimotor rehabilitation

5 min read. Posted in Neck
Written by Matthew Tom info

Neck pain is one of the most common and recurrent musculoskeletal disorders, with global numbers of people affected by neck pain in 2020 reaching 203 million (1). Traditionally, neck rehabilitation in physiotherapy has centred on manual therapy and Range Of Motion (ROM) exercises to restore movement. It has been suggested that a focus on reducing pain without addressing physical impairments may be a reason for more recurrent episodes (2). We now know the neck has a significant role in sensorimotor function and subserves the specialised organs of the head, including the eyes, ears, tongue and nose. This highly-adapted sensorimotor ability allows us to coordinate our head and eye movement rapidly according to our environment, and maintain postural balance and stability during movement. In this light, optimising our rehabilitation through a range of approaches beyond typical cervical ROM exercises is imperative to adequately address all aspects of neck function and reduce the recurrence rate of this problem.

In this blog, we’ll discuss Chris Worsfold’s Masterclass on Sensorimotor Rehabilitation of the Neck and how to include this knowledge in your practice.

 

Sensorimotor function – why we need to address it with neck pain

The neck has a significant sensorimotor function due to the high density of muscle spindles in the small, deep suboccipital neck muscles. Input from these muscles is integrated in the brain with input from the visual and vestibular systems via two reflexes; the Cervico-Ocular Relfex (COR) and Vestibulo-Ocular Reflex (VOR), respectively. Lengthening of the deep neck musculature muscle spindles, combined with fluid movement in the vestibular system during head movement, sends signals to the eye muscles to move the eyeball at a certain direction and rate to maintain focus on our environment, based on our head movement (3). A delay or change in the signals from the neck to the brain, potentially due to whiplash trauma or ongoing neck pain, causes a mismatch between the cervical and vestibular input provided, and a subsequent disparity where the brain and eye cannot coordinate where they should be in space. This can lead to a range of symptoms including unsteadiness, dizziness, giddiness, difficulty concentrating and visual fatigue, among others.

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The pillars of sensorimotor function

This sensorimotor role comprises of three pillars:

  • Proprioception
  • Oculomotor control
  • Postural stability

Proprioception

This refers to our awareness of body position and orientation. Muscle spindles detect changes in muscle length and therefore joint movement, communicating signals back to the brain on where our joint is in space (3). In the peripheral joints, we can assess this by comparing one side to the contralateral limb, for example with an ankle sprain, by comparing single leg balance left and right. In the neck, without a contralateral side to compare to, we can assess this with the Joint Position Error (JPE) test–using a laser and target, we can assess the patient’s ability to find a neutral neck position when returning from left and right cervical rotation, with the eyes closed. This assessment has demonstrated good reliability and validity in assessing cervical spine proprioception.

Oculomotor control (eye movement control)

To assess eye movement control, we can use the Smooth Pursuit Test (SPT) and Smooth Pursuit Neck Torsion Test (SPNTT) to assess eye movement control of a moving target with the neck first in neutral, and then in rotation. By using both of these tests, we can differentiate the source of ‘sensorimotor symptoms’ such as unsteadiness or dizziness, between the cervical spine and other causes. If symptoms or eye control are significantly worse with the neck in rotation compared to neutral, this may indicate the issue is stemming from the cervical spine rather than, for example, the vestibular system (3).

Postural stability

Our ability to maintain postural stability or balance can also be significantly challenged in cases of whiplash or persistent neck pain, in both static and dynamic situations. Studies have shown 50% of non-dizzy whiplash patients were unable to perform a tandem stance position with their eyes closed due to loss of balance, with almost 75% of dizzy whiplash patients unable to perform this task (4). In his Masterclass, Chris Worsfold recommends a battery of balance tests incorporating comfortable, narrow and tandem stances, with eyes open and closed, as a routine assessment for any patient with neck pain.

 

Sensorimotor rehabilitation

As a general principle, in our rehabilitation we need to ‘work on what turns on the symptoms’, whether that be postural stability training, eye movement control training, proprioceptive training or more likely a combination of each.

This can be achieved through simple methods such as balance exercises with varying bases of support (postural stability), smooth pursuit tracking exercises (oculomotor control) and joint position error training (proprioception), using either the laser or a target on a mirror at home. It’s important to keep challenging the sensorimotor system in exercise by varying speed, range of movement, the amount and type of visual input, frequency and duration of training–this is paramount to ensure the neck can meet the demands of everyday life. Studies support this, with evidence showing proprioceptive and oculomotor exercises for six weeks reduced neck pain and disability by 16% on the Neck Disability Index in those with chronic neck pain (5). A five-week balance training program has also shown strong improvements in reducing neck pain (6).

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Wrapping up

Neck pain is one of the most common musculoskeletal problems we see in clinics, and with a high recurrence rate, addressing all aspects of neck function is essential. The sensorimotor role of the neck is critical to everyday life, allowing us to rapidly coordinate head and eye movement and maintain clear visual focus and balance during movement. By assessing and improving the three pillars of proprioception, eye movement control and postural stability, we can improve the sensorimotor role of the neck, improve rehabilitation outcomes for those with neck pain and reduce the recurrence rate of this problem.

If you want to know about how expert Chris Worsfold manages sensorimotor neck rehabilitation in further detail, check out his full Masterclass here.

Want to learn more about neck pain?

Chris Worsfold has done a Masterclass lecture series for us on:

“Sensorimotor rehabilitation of the neck”

You can try Masterclass for FREE now with our 7-day trial!

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References

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