)36(

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RESEARCH ARTICLE

Investigating the Effect of Addition of Cervical Proprioceptive

Training to Conventional Physiotherapy on Visual, Vestibular and
Proprioceptive Dependency of Postural Control in Patients with
Chronic Non-Specific Neck Pain: A Randomized Controlled Clinical
Trial
Leila Goudarzi, PhD; Hamed Ghomashchi, PhD; Mohsen Vahedi, PhD;
Amir Hossien Kahlaee, PhD
Research performed at Rofeideh Rehabilitation Hospital, Tehran, Iran
Received: 5 September 2023 Accepted: 30 October 2023

Abstract
Objectives: While cervical proprioception deficit has been suggested as a contributing factor to clinical
consequences of chronic non-specific neck pain (CNSNP), the effect of addressing such impairments
on postural control strategies has remained unexplored. The aim of this study was to compare the
response of the postural control system to alteration of sensory afferents in CNSNP with asymptomatic
individuals. Furthermore, we examined whether proprioceptive training would yield superior outcomes
to routine physiotherapy for improvement of postural control, pain and disabi lity.

Methods: Center of pressure (CoP) variables of sixty CNSNP patients equally distributed in any of the
proprioception-specific or conventional physiotherapy groups and 30 asymptomatic participants were evaluated
under four standing conditions:1) normal, 2) foam, 3) cervical extension/eyes open and 4) cervical extension/eyes
closed standing.
Results: CoP anteroposterior range and anteroposterior and mediolateral velocity in patients were significantly
higher than the control group under condition 2 (P<0.05). Patients also demonstrated lower anteroposterior lyapunov
exponent under conditions 2 and 4 (P<0.05). Both interventions significantly decreased anteroposterior range and
anteroposterior velocity(P<0.05). Anteroposterior lyapunov exponent also increased under condition 2 (P<0.05)..
After the interventions, CoP anteroposterior range and anteroposterior velocity were significantly lower in the
proprioceptive exercise group than the conventional physiotherapy group (P<0.05). Anteroposterior lyapunov
exponent was also significantly higher in the proprioceptive exercise group (P<0.05).This while there was no
significant difference between these patients and control group participants in any of the CoP variables after
intervention.
Conclusion: Our results rejected the hypothesis that impaired neck proprioception in the presence of CNSNP is
compensated by overweighting other sources of sensory afferent information. The findings also revealed that while
proprioceptive exercises successfully returned postural strategies of CNSNP patients to those in asymptomatic
participants, they do not add to clinical recovery of these patients.
Level of evidence: I
Keywords: Chronic neck pain, Postural control, Proprioceptive training

Introduction

N eck pain is a highly prevalent condition leading to

disability and imposing considerable economic
burdens.1,2 According to estimates from the global burden
of the disease, neck pain is ranked as the 4th contributor to

Corresponding Author: Amir Hossein Kahlaee, Department of

Physiotherapy, University of Social Welfare and Rehabilitation
THE ONLINE VERSION OF THIS ARTICLE
Sciences, Tehran, Iran ABJS.MUMS.AC.IR
Email: [email protected]

Arch Bone Jt Surg. 2024; 1(1):36-50 Doi: 10.22038/ABJS.2023.74763.3462 http://abjs.mums.ac.ir

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VOLUME 12. NUMBER 1. January 2024

global disability.3,4 Between 50% to 75% of neck pain cases Rehabilitation Sciences and has been registered in Iranian
do not fully recover and continue to experience recurrent Registry of Clinical Trials at 2020-01-12 with registration
pain episodes5,6 indicating that our understanding of the number IRCT20191130045552N1. The Human Ethical
contributing mechanisms to chronic neck pain (CNP) may Committee of the *** granted ethical permission for the
be inadequate. recruitment of the study (approval ID:
The motor control approach has received considerable IR.USWR.REC.1398.095).
attention explaining the contributing mechanisms and
consequences of mechanical, non-traumatic neck pain.7 Randomization
Previous studies have indicated postural control deficits in The random sequence was utilized through Random
patients with neck pain, particularly under challenging Permutations by using a randomized number table designed
conditions such as closed eyes or standing on an unstable by an external office (www.Randomization.com ). [Figure
surface.8,9 While cervical proprioception impairment has 1]. The utilization of this method provides the researcher a
been suggested as a possible cause,10 the exact mechanism predetermined random order, established by the software,
of postural deficits has never been identified. Impaired ensuring that the allocation of each participant is
proprioceptive inputs from the cervical region has also determined prior to recruitment. Subjects would be
been suggested to augment mechanical overloading of the admitted to the study in the order of their entrance.27
neck.11,12 The literature includes controversial findings on Randomization was performed on chronic non-specific neck
cervical spine proprioceptive acuity and functioning.While pain (CNSNP) patients meeting our inclusion criteria. The
some studies found impaired cervical proprioception in therapist responsible for administering the treatment was
patients with CNP13-15 and demonstrated clinical notified of the group allocation for each subject via a sealed
improvement after implementation of proprioceptive opaque envelope. The assessment of physical condition and
exercises,16-18 other studies have revealed intact neck review of medical history were carried out by a post-
proprioceptive accuracy in individuals with chronic neck graduate physical therapist with 18 years of clinical
pain.19,20 All peripheral inputs, including the experience in the field. The study adhered to the ethical
proprioception, visual and vestibular clues are integrated principles outlined in the Helsinki Declaration. The data
within the central nervous system (CNS) to establish an collection extended for 2 years (May2020-march2022).
internal reference framework of the body referred to as Blinding
body schema.21,22 Inadequate or deficient cervical Participants received general information on research
proprioceptive inputs associated with CNP may potentially purpose and contents including possible risks and benefits.
be compensated for or even ignored by the CNS by giving CNSNP were informed that an almost novel intervention
more weight to other sources of afferent inoformation from for the management of neck pain was going to be compared
seemingly intact visual and vestibular organs.23,24 This with a conventional one. It was explained that they were
might serve as an explanation for the intact postural control going to be randomly assigned to one of the treatment
reported in some investigations.25 Patients with chronic protocols. The assessor and data analyzer were blinded of
neck pain may rely heavily on their vestibular and/or visual the participants’ grouping.28
systems for postural control, potentially indicating an
extraordinary dependence on these sensory systems as a Sample size
compensatory mechanism. While a few studies have The determination of the requisite sample size was
investigated the effect of cervical proprioceptive training on calculated using G*Power software 3.19.2 considering the
clinical complaints of these patients, to the best of our mean and standard deviation of center of pressure (CoP)
knowledge, no study has yet examined whether addressing displacement range in the anterior-posterior direction,
cervical proprioception during the rehabilitation of CNP which served as one of the primary outcome measures
could benefit the relative reliance on various sources of during the pilot phase of this study. In order to achieve a
afferent inputs for postural control mechanisms. statistical power of 80% at an alpha level of 0.05, a sample
The objectives of the current study were thus to size of 30 individuals in each group was obtained.
investigate if 1) postural control of patients with CNP is Previous studies have also demonstrated this sample size
different from that asymptomatic participants under to be sufficient to attain acceptable levels of power in
different levels of availability of sensory afferents, 2) there postural control studies involving CoP variables.29
is difference between reliance of the postural control
system on the afferent signals from proprioceptive, visual Participants
and vestibular systems in CNP patients compared to CNSNP patients were selected from Rofeideh Rehabilitation
asymptomatic participants, and 3) adding neck Hospital outpatient clinic after being screened for inclusion
proprioceptive exercise to routine physiotherapy program criteria by a consulting.30 sixty patients with CNSNP and 30
will alter such possibly different weighting of sensory
afferents. asymptomatic subjects between 18- 55 years old were
recruited after being informed about the purpose and
content of the study and signed the informed consent form.
Materials and Methods Patients were randomized into two groups of proprioceptive
Study design (PT) and conventional physiotherapy treatment (CPT). The
The trial utilizes a controlled, randomized, and double- Intervention protocols were fully described in the
blind 2 × 2 factorial design and conforms to the CONSORT [appendix].
recommendations.26 The project was approved by the
ethical committee of the University of Social Welfare and
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Figure 1. Flow diagram of the trial protocol. CPT: Conventional Physical therapy; PT: Proprioceptive Training

Control group: The control group would receive groups failed to complete the intervention protocol. Extra
conventional physical therapy program exercise Cases were recruited to provide the pre-determined
program. They would also receive electrotherapy sample size. Brain tumor diagnosis, COVID-19 affection,
intervention during their clinic sessions. Each treatment moving the home place and family issues constituted
session would last around 60 minutes. The intervention drop-out reasons.
group would receive proprioceptive training in addition Exclusion criteria for both groups encompassed the
to the conventional program. Each treatment session following: any history of lower extremity or spine trauma
would last almost 120 minutes for this group. or surgery, recognized and observable spinal deformity,
The supervised proprioceptive exercises performed at neurological disorders, benign paroxysmal positional
clinic sessions included head relocating exercise vertigo, as confirmed by the Dix Hallpike test,37 inability
conducted under the guidance of a trained physical to extend the head for at least 60 degrees, and pregnancy.
therapist. In both groups, participants received Patients who had received physical therapy interventions
physiotherpy treatment three sessions per week for a for neck pain within three months preceding the study
total duration of 5 weeks. Patients were instructed to were also ineligible participation and were excluded.
perform their prescribed home exercises twice a day and
recorded exercise performance in their schedule sheet. Evaluation
CNSNP was defined as the persistent or recurring An experienced physiotherapist trained in the assessment
experience of pain in the area extending from the superior tools, performed evaluations during a week before and a
nuchal line to the first thoracic vertebrae with no week after intervention. The process began with the
identifiable specific pathoanatomic cause 31 lasting for at familiarization with the experimental protocol, which was
least 3 months.32,33 Patients with pain intensity scores then succeeded by taking basic anthropometric
between 3 to 7 (medium intensity) on the scored visual
analogue scale (VAS; 0-100mm) for an average of three measurements and recording demographic information
weeks prior to the study,34 Neck Disability Index (NDI) including age, sex and past medical history. CoP
scoring 20%-60% (moderate to severe disability)35 and displacement was measured under four different conditions
Tampa Scale for Kinesiophobia (TSK) score of more than which were determined based on the availability of various
10/100 were included.36 Three cases in each of the CNP sensory afferents. Patients completed the validated Persian
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version of NDI38 and TSK.39 Neck pain intensity was assessed open and head in neutral position; 3) upright standing with
by a 100-mm VAS anchored with ‘0: no pain at all’ and ’10: eyes open and 60◦ extension of the cervical spine aimed at
the worst imaginable pain’. manipulating the function of vestibular system;40-42 4)
standing upright with eyes closed and 60◦ extension of the
Postural control assessment protocol cervical spine. The inclination of the head as a due to cervical
All participants were dressed loose-fitting and instructed to extension was measured and controlled using the Bubble
stand barefoot on Synapsys® force platform, (SPS, inclinometer (12-1056, 360 Inclinometer) and was visually
SYNAPSIS, Marseille, France) with their arms hanging by monitored by the investigator during the test. Data was
their trunk. The position of the feet was standardized with collected at a sampling frequency of 100-Hz. The participants
the use of a tape marker on the force platform. The four completed three 45-second trials for each testing condition
testing conditions were commenced randomly [Table 1]: with 60-120 s of rest in between. The mean values of the
1) upright standing with eyes open, head in neutral position extracted variables each testing condition was repeated for
(the participants were instructed to focus on a target at their three trials under supervision of a trained physiotherapist
eye level located two meters away ; 2) upright standing on a who was blinded to the clinical characteristics of the
foam support surface which was 10 cm thick with the density participants.
of 20 kg/m3, designed similarly to the force plate with eyes

Table 1. Description of Experimental Conditions

Condition Surface Eyes Head Position
1 Firm Open Neutral
2 Foam Open Neutral
3 Firm Open maximum extension
4 Firm Closed maximum extension

Data analysis reliability of CoP measurements. The homogeneity of the

All CoP signals were filtered using a 10-Hz low-pass, 2nd- variances was examined by Leven’s test. A two-way repeated
order Butterworth filter and then transformed into CoP- measures MANOVA was applied to compare CoP masseurs
driven variables using MATLAB-based routines (Mathworks, between and within the groups.43 the statistical analyses
Natick, MA, USA). Mean, standard deviation and 95% were performed using SPSS software (version 21; SPSS Inc,
confidence interval of CoP sway range and velocity in both Chicago, IL). Significance level was set at p < 0.05.
antero-posterior (AP range and velocity) and medio-lateral
(ML range and velocity) were calculated besides largest Results
lyapunov exponent (Lyp Exp). The groups were not different in any of the participant
characteristics (p>0.05) excepting age (p<0.01) [Table 2].
Statistical analysis The data was normally distributed for all dependent
The normality of the distribution of the data was checked variables so ANOVA was used to compare between and
using the Shapiro–Wilk Test. One-way ANOVA test was used within group diffrences. Since the age factor was different
to compare the groups for demographic variables. Gender between groups, it was considered as the covariate in the
distribution was compared between groups using Chi- ANOVA tests.
square test. Intra-class correlation coefficient (ICC) (2- way
random, absolute agreement model) was also used to asses

Table 2. Background characteristics of the participants in the CNSNP and control groups
Variables Group
CPT (n=30) PT (n=30) Control (n=30) p-value
Age (year) 42.97±10.01 43.60±9.83 33.37±10.73 0.00*
Weight (kg) 70.73±16.45 72.00±15.40 66.27±12.71 0.30
Height (cm) 165.57±9.28 166.07±9.67 167.33±7.38 0.72
Sex (female/ male) 1.30±0.46 1.33±0.47 1.40±0.49 0.71
Pain duration (month) 47.10±40.84 58.10±49.89 N/A 0.35
VAS (mm) 46.63±16.80 47.46±17.18 N/A 0.85
NDI (%) 13.43±5.74 16.17±9.89 N/A 0.19
Values are presented as mean ± SD
CNSNP: chronic non-specific neck pain; NDI: Neck Disability Index; VAS: visual analogue scale; N/A: not applicable
*Statistically significant
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Between group comparisons revealed higher CoP comparing asymptomatic participants while standing on
antroposterior (AP) range (P=0.02 and 0.01, respectively) the foam (condition 2) [Figure 2-5]. AP Lyp Exp was also
and AP (P=0.02 for both) and mediolateral (ML) velocity lower in these patients in condition 4 (P=0.02 and 0.03,
(P=0.03 for both) and lower AP Lyp Exp (P=0.02 and 0.01, respectively [Table 3, Figure 5].
respectively in the CPT and PT CNP group patients

Figure 2. *Significant Difference between Groups Figure 3. *Significant Difference between Groups
Comparison of the AP range before and after the Comparison of the AP velocity before and after the
interventions interventions
** Significant Difference between Groups 2&3 ** Significant Difference between Groups 2&3.
***Significant Difference between Groups 1&3.
***Significant Difference between Groups 1&3

Figure 4. *Significant Difference between Groups Figure 5. *Significant Difference between Groups
Comparison of the ML velocity before and after the Comparison of the AP LyExp before and after the
interventions interventions
** Significant Difference between Groups 2&3 ** Significant Difference between Groups 2&3
***Significant Difference between Groups 1&3 ***Significant Difference between Groups 1&3

Table 3. Between Groups Comparison of the posturographic variables under different standing task conditions before interventions in
participants with and without NSCNP
Variable Condition Group Mean Diff CI P-value
1 2 3
1 1.85±0.85 1.86±0.57 2.20±0.98 1-2 0.015 -0.432-0.402 0.944
1-3 0.348 -0.765-0.069 0.101
2-3 0.333 -0.750-0.084 0.116
2 4.09±0.85 3.98±0.91 3.18±1.29 1-2 0.289 -0.818-0.240 0.281
1-3 0.389 -0.918-0.140 0.024*
Range 2-3 0.100 -0.629-0.429 0.010*
(AP) 3 2.19±1.33 2.16±0.92 2.39±0.83 1-2 -0.028 -0.508-0.564 0.919
1-3 0.204 -0.740-0.332 0.147
2-3 0.231 -0.767-0.305 0.734
4 3.05±1.36 3.10±1.25 3.25±1.42 1-2 0.016 -0.704-0.673 0.964
1-3 0.199 -0.888-0.489 0.567
2-3 0.184 -0.872-0.505 0.597
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Table 3. Continued
1 1.59±0.51 1.81±0.63 1.72±0.91 1-2 0.220 -0.578-0.139 0.226
1-3 0.129 -0.487-0.229 0.477
2-3 -0.091 -0.267-0.449 0.615
2 3.00±0.84 3.12±0.74 3.03±1.33 1-2 0.113 -0.626-0.400 0.664
1-3 0.021 -0.534-0.492 0.935
2-3 -0.092 -0.421-0.605 0.724
Range 3 1.75±0.55 1.83±0.73 1.79±0.72 1-2 0.079 -0.422-0.265 0.650
(ML) 1-3 0.043 -0.387-0.300 0.803
2-3 -0.035 -0.308-0.379 0.838
4 2.25±0.86 2.48±1.08 2.09±0.88 1-2 0.228 -0.713-0.257 0.352
1-3 -0.162 -0.323-0.647 0.509
2-3 -0.390 -0.095-0.875 0.114
1 0.63±0.18 0.59±0.16 0.64±0.17 1-2 -0.038 -0.049-0.124 0.391
1-3 0.009 -0.095-0.078 0.841
2-3 0.046 -0.133-0.040 0.290
2 1.11±0.28 1.08±0.24 0.89±0.29 1-2 0.053 -0.190-0.083 0.440
1-3 -0.040 -0.097-0.177 0.022*
Velocity 2-3 -0.093 -0.043-0.230 0.023*
(AP) 3 0.72±0.28 0.67±0.20 0.70±0.16 1-2 -0.049 -0.063-0.161 0.385
1-3 -0.026 -0.086-0.138 0.647
2-3 0.023 -0.135-0.089 0.679
4 0.99±0.37 0.92±0.33 0.98±0.32 1-2 -0.069 -0.102-0.240 0.426
1-3 -0.014 -0.156-0.185 0.867
2-3 0.054 -0.225-0.117 0.530
1 0.56±0.16 0.52±0.16 0.53±0.11 1-2 -0.045 -0.030-0.119 0.236
1-3 -0.031 -0.044-0.105 0.415
2-3 0.014 -0.088-0.060 0.708
2 1.00±0.24 1.02±0.24 0.93±0.26 1-2 0.012 -0.136-0.112 0.849
1-3 -0.084 -0.041-0.208 0.033*
Velocity 2-3 -0.095 -0.029-0.220 0.031*
(ML) 3 0.58±0.17 0.55±0.18 0.53±0.15 1-2 -0.028 -0.055-0.111 0.506
1-3 -0.053 -0.031-0.136 0.214
2-3 -0.025 -0.059-0.108 0.560
4 0.73±0.23 0.68±0.22 0.65±0.18 1-2 -0.053 -0.055-0.161 0.330
1-3 -0.086 -0.022-0.194 0.116
2-3 -0.033 -0.075-0.141 0.546
1 0.08±0.02 0.08±0.02 0.07±0.01 1-2 0.012 -0.019-(-0.006) 0.125
1-3 0.005 -0.012-0.002 0.131
2-3 -0.007 0.001-0.014 0.320
2 0.07±0.01 0.07±0.02 0.08±0.01 1-2 0.004 -0.011-0.004 0.319
1-3 0.002 0.010-0.005 0.024*
Lyp Exp 2-3 0.001 -0.006-0.009 0.011*
(AP) 3 0.07±0.02 0.07±0.02 0.07±0.02 1-2 0.002 -0.010-0.006 0.684
1-3 0.005 -0.013-0.003 0.251
2-3 0.003 -0.011-0.005 0.456
4 0.07±0.02 0.07±0.02 0.08±0.02 1-2 -0.001 -0.008-0.011 0.755
1-3 -0.014 0.004-0.023 0.005*
2-3 0.012 0.003-0.021 0.013*
1 0.07±0.02 0.07±0.02 0.07±0.01 1-2 0.002 -0.012-0.008 0.678
1-3 -0.003 -0.007-0.012 0.602
2-3 -0.004 -0.005-0.014 0.350
2 0.08±0.01 0.08±0.02 0.08±0.02 1-2 0.002 -0.009-0.005 0.563
1-3 0.000 -0.007-0.006 0.909
2-3 -0.002 -0.005-0.008 0.643
Lyp Exp 3 0.07±0.03 0.07±0.02 0.07±0.02 1-2 0.005 -0.015-0.005 0.323
(Lat) 1-3 0.003 -0.013-0.007 0.545
2-3 -0.002 -0.008-0.012 0.700
4 0.07±0.02 0.08±0.02 0.07±0.02 1-2 0.005 -0.014-0.004 0.237
1-3 -0.001 -0.008-0.010 0.807
2-3 -0.006 -0.002-0.015 0.155
NSCNP: non-specific chronic neck pain. AP: anterior posterior; ML: mediolateral; SD: standard deviation
Values are presented as mean ± SD/*statistically significant/Condition 1: firm surface, open eyes, neutral head; Condition 2: foam surface, open eyes,
neutral head; Condition 3: firm surface, open eyes, head tilt; Condition 4: firm surface, closed eyes, head tilt
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After the intervention CoP AP range (P=0.02) and difference were found between these two groups after the
velocity (P=0.01) and AP Lyp Exp (P=0.03) remained intervention (P>0.05). CoP AP range (P=0.03) and
higher and lower, respectively in the CPT group velocity (P=0.04) became higher and AP Lyp Exp lower
comparing the control group participants under (P=0.03) in the CPT patients comparing those in the PT
condition 2 [Figure 2 and 3 and 5]. AP Lyp Exp was also group after the interventions under condition 2 [Table 4;
smaller under condition 4 in the CPT group comparing the Figure 2 and 3]. Neither pain intensity nor NDI were
control group AP Lyp Exp (P=0.02) [Table 4; Figure 5]. found statistically different between groups after the
This is while these outcome measures in the CNP patients inteventions (P>0.05).
receiving proprioception training approached those in
asymptomatic participants and no statistically significant

Table 4. Between Groups Comparison of the posturographic variables under different standing task conditions after interventions in NSCNP
Variable Condition Group Mean Diff CI P-value
1 2
1 1.76±0.52 1.62±0.48 0.139 -0.118-0.395 0.284

AP Range 2 3.84±0.80 3.22±0.82 -0.206 -0.618-0.207 0.031*

3 1.98±0.80 1.86±0.52 0.115 -0.231-0.462 0.508

4 2.74±0.99 2.72±0.66 0.025 -0.410-0.459 0.909

1 1.61±0.46 1.50±0.42 0.108 -0.119-0.336 0.345

ML Range 2 3.00±0.83 2.81±0.62 0.151 -0.228-0.529 0.428

3 1.74±0.51 1.84±0.58 -0.104 -0.385-0.177 0.460

4 2.02±0.68 2.13±0.72 -0.108 -0.469-0.253 0.553

1 0.63±0.17 0.55±0.15 0.073 -0.007-0.154 0.074

AP Velocity 2 1.01±0.23 0.92±0.24 0.021 -0.098-0.140 0.043*

3 0.69±0.20 0.63±0.21 0.057 -0.046-0.160 0.724

4 0.95±0.29 0.87±0.28 0.079 -0.066-0.224 0.279

1 0.54±0.14 0.49±0.15 0.053 -0.022-0.127 0.162

ML Velocity 2 0.96±0.23 0.90±0.22 0.008 -0.105-0.122 0.882

3 0.57±0.14 0.55±0.15 0.038 -0.035-0.112 0.303

4 0.71±0.17 0.65±0.21 0.056 -0.039-0.151 0.245

1 0.07±0.02 0.08±0.02 -0.004 -0.011-0.003 0.270

Lyp Exp 2 0.07±0.01 0.08±0.02 0.004 0.014-0.006 0.033*

(AP)
3 0.07±0.02 0.08±0.02 -0.004 -0.014-0.005 0.361

4 0.07±0.02 0.08±0.02 0.003 0.013-0.006 0021. *

1 0.07±0.01 0.07±0.01 0.002 -0.006-0.010 0.552

Lyp Exp 2 0.09±0.01 0.08±0.01 0.004 -0.005-0.012 0.416

(Lat)
3 0.07±0.01 0.07±0.01 -0.007 -0.016-0.002 0.123

4 0.07±0.01 0.07±0.01 0.003 -0.005-0.011 0.470

NSCNP: non-specific chronic neck pain. AP: anterior posterior; ML: mediolateral; SD: standard deviation
Values are presented as mean ± SD/*statistically significant
Condition 1: firm surface, open eyes, neutral head; Condition 2: foam surface, open eyes, neutral head; Condition 3: firm surface, open eyes, head tilt;
Condition 4: firm surface, closed eyes, head tilt.
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Within group comparisons revealed that CoP AP range also decreased CoP AP range (P=0.03) and velocity
(P=0.01) and AP (P=0.01) and ML velocity (P=0.03) (P=0.01) under condition 2 in the CNP patients [Table 5].
significantly decreased under condition 2 in the PT group While VAS scores significantly decreased after
after receiving the intervention while AP Lyp Exp interventions in both CPT and PT groups (P<0.01 for
increase was statistically significant under both both), there was no statistically significant alteration in
conditions 2 (P=0.02) and 4 (P=0.03) in this group of NDI scores of either group (P>0.05)
patients. The conventional physiotherapy intervention

Table 5. Effect of the two intervention protocols on the posturographic variables under different standing task conditions in NSCNP

Variable Condition Group Pre- Post- Mean Diff CI P-value

Intervention Intervention

1 1 1.84±0.84 1.75±0.51 0.090 -0.138-0.318 0.427

2 1.86±0.56 1.61±0.47 0.243 -0.012-0.499 0.061
2 1 4.09±0.84 3.84±0.77 0.280 0.498-0.510 0.019*
2 3.98±0.90 3.22±0.81 0.363 0.407-0. 685 0.029*
3 1 2.18±1.32 1.97±0.79 0.212 -0.048-0.474 0.106
Range
2 2.15±0.91 1.85±0.51 0.300 0.013-0.587 0.071
(AP)
4 1 3.04±1.35 2.73±0.98 0.305 -0.007-0.618 0.055
2 3.06±1.24 2.71±0.66 0.345 -0.388-0.730 0.076

1 1 1.58±0.508 1.60±0.45 -0.179 -0.140-0.104 0.766

2 1.80±0.62 1.69±0.42 0.309 0.154-0.465 0.600
2 1 3.00±0.83 2.95±0.82 0.045 -0.168-0.259 0.669
2 3.11±0.73 2.80±0.61 0.308 0.082-0.534 0.109
3 1 1.74±0.54 1.73±0.50 0.009 -0.113-0.132 0.873
Range
2 1.82±0.72 1.84±0.58 -0.016 -0.209-0.177 0.866
(ML)
4 1 2.24±0.86 2.02±0.67 0.223 0.018-0.428 0.084
2 2.47±1.07 2.12±0.71 0.343 0.081-0.606 0.072
1 1 0.62±0.17 0.61±0.16 0.008 -0.406-0.576 0.727
2 0.58±0.15 0.54±0.14 0.044 -0.003-0.092 0.070
2 1 1.11±0.27 1.01±0.22 0.066 -0.011-0.144 0.033*
2 1.08±0.23 0.92±0.23 0.140 -0.058-0.222 0.002*
3 1 0.71±0.27 0.68±0.19 0.032 -0.031-0.097 0.304
2 0.67±0.20 0.63±0.20 0.040 -0.021-0.102 0.189
Velocity
(AP) 4 1 0.98±0.36 0.94±0.28 0.041 -0.062-0.145 0.419
2 0.92±0.32 0.86±0.27 0.052 -0.034-0.138 0.226

1 1 0.55±0.16 0.94±0.22 -0.387 -0.466-0.307 0.290

2 0.51±0.15 0.93±0.21 -0.423 -0.516-0.330 0.326
2 1 1.00±0.23 0.96±0.22 0.610 -0.001-0.120 0.046*
2 1.02±0.23 0.90±0.21 0.081 0.012-0.150 0.022*
Velocity
(ML) 3 1 0.57±0.16 0.56±0.13 0.008 -0.038-0.056 0.702
2 0.54±0.17 0.52±0.14 0.019 -0.024-0.063 0.382
4 1 0.72±0.23 0.70±0.16 0.024 -0.049-0.098 0.503
2 0.67±0.21 0.64±0.20 0.027 -0.022-0.076 0.271
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Table 5. Continued
1 1 0.05±0.01 0.06±0.01 -0.008 -0.015-(-0.002) 0.509
2 0.07±0.01 0.07±0.01 -0.000 -0.005-0.004 0.845
2 1 0.07±0.01 0.07±0.01 -0.000 -0.006-0.006 0.046*
2 0.07±0.01 0.08±0.02 -0.000 -0.009-0.009 0.012*
Lyp Exp 3 1 0.06±0.01 0.06±0.01 0.000 -0.007-0.008 0.930
(AP)
2 0.06±0.01 0.07±0.01 -0.002 -0.012-0.007 0.619
4 1 0.07±0.01 0.06±0.01 0.006 -0.000-0.014 0.076
2 0.07±0.02 0.07±0.01 0.002 -0.006-0.010 0.020*

1 1 0.06±0.02 0.06±0.01 -0.004 -0.013-0.003 0.268

2 0.06±0.01 0.06±0.01 -0.000 -0.007-0.007 0.937
2 1 0.07±0.00 0.08±0.01 -0.007 -0.014-0.000 0.061
2 0.07±0.01 0.08±0.01 -0.001 -0.008-0.004 0.611
Lyp Exp
(Lat) 3 1 0.06±0.02 0.06±0.01 -0.000 -0.009-0.009 0.930
2 0.06±0.02 0.06±0.01 -0.002 -0.010-0.005 0.524
4 1 0.06±0.01 0.06±0.01 -0.001 -0.007-0.005 0.716
2 0.07±0.02 0.06±0.01 0.007 -0.000-0.014 0.077
NSCNP: non-specific chronic neck pain. AP: anterior posterior; ML: mediolateral; SD: standard deviation
Values are presented as mean ± SD/*statistically significant
Condition 1: firm surface, open eyes, neutral head; Condition 2: foam surface, open eyes, neutral head; Condition 3: firm surface, open eyes, head tilt;
Condition 4: firm surface, closed eyes, head tilt

Discussion sensory or mechanical, is needed to unveil postural control

The aim of the present study was to assess and compare impairments in chronic musculoskeletal conditions.25,45,48
how the postural control system responses to sensory Our results suggest that the vestibular system manipulation,
afferents deprivation or distortion in patients with CNSNP produced by head tilt, does not adequately disturb the
and asymptomatic individuals. Also, investigate the postural control system to elaborate possible impairments in
differences between reliance of the postural control system the presence of CNSNP. This may indicate that other sensory
on the afferent signals from proprioceptive, visual and afferents, namely visual and proprioceptive, are capabale of
vestibular systems in patients compared to asymptomatic compensating altered vestibular clues in this condition
participants were evaluated. Additionally, we investigated without affecting the output of the postural control system.
whether specific proprioceptive training for subjects with Anyhow, this finding shows that postural control in CNSNP
CNSNP would yield better outcomes compared to routine patients is no more reliant on vestibular afferents than
physiotherapy for improvement of postural control besides asymptomatic participants. The only differences were
pain and disability. observed under conditions 2 and 4 where mechanical and
When comparing three groups, notable differences were sensory postural perturbations were induced, respectively.
observed in CoP displacement in the sagittal plane and CoP Most previous studies agree that mechanical disturbance of
velocity in both the sagittal and frontal directions when the support surface will induce largest postural
standing on the foam. Both CNSNP group patients perturbations revealed by greatest magnitudes of CoP
demonstrated larger CoP excursions and higher velocities of alterations.49,50 Standing on the foam will perturb control of
CoP displacements in comparison with pain-free posture both mechanically by adversely affecting the efficacy
participants. The patients also revealed more locally stable of the ankle strategy and via disturbing the proprioceptive
CoP dynamics in the sagittal plane both while standing on the afferents provided by ankle mechanoreceptors.49,50 Under
foam and standing with eyes closed and the head tilted. This such a challenging condition, CNSNP patients seem to have
is while no differences were observed between CNSNP less control on the CoP displacements in the sagittal plane
patients and control group participants under less despite the exaggerated neural effort they demonstrate
challenging conditions of baseline and standing with eyes under this condition manifested by greater CoP velocity.51
open and the head tilted. This is in line with some previous studies showing greater
Many other studies also found the postural behavior of the amplitudes of CoP excursion and velocity under difficult
CNSNP comparable to asymptomatic participants under postural conditions.49,52 CoP velocity has been recognized as
simple and non-challenging conditions.44-47 It has been one the most reliable, informative, predictive and sensitive
claimed that adequate level of postural disturbance, either 53,54 CoP parameters for assessing postural control55,56
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THE ARCHIVES OF BONE AND JOINT SURGERY. ABJS.MUMS.AC.IR EFFECT OF CERVIVAL PROPRIOCEPTIVE TRAINING ON POSTURAL CONTROL
VOLUME 12. NUMBER 1. January 2024

characterizing postural control mechanisms in chronic ultimately lead to pain by non-optimal micro-traumatic
musculoskeletal conditions including CNSNP. It has also been movements. From a different perspective, pain and
suggested that CNSNP patients, due to their cervical proprioception might both be alleviated by a third factor.
proprioception impairments, overweigh their ankle Normal length regaining of shortened soft tissues containing
afferents for the control of posture. This may exaggerate their mechano and noci-receptors, increased blood circulation and
postural responses to foam standing condition which muscular activity regulation induced by physiotherapy
directly challenges ankle sensory-motor function in program may all be regarded as plausible candidates.
comparison with control group participants. A Smaller Lyp Although the conventional physiotherapy program
Exp in CNSNP patients under foam standing condition is including administration of physical modalities and
indicative of a more locally stable behavior of the postural execution of general neck exercises was found effective both
control system.57 it has been previously suggested that the in control of pain and improvement of postural control,
postural control system in chronic musculoskeletal patients receiving this program continued to demonstrate
conditions might assume a more conservative strategy in altered postural control mechanisms comparing
terms of increased local stability, confronting limitations asymptomatic participants. This is while the proprioception
induced by pain chronicity or motor insufficiencies. Such an specific exercise seemed successful help these patients
adaptation might protect the system at the expense of losing regain their normal postural control. Even if postural
motor flexibility needed to response to unexpected dynamics alterations are considered as compensatory
perturbations.58,59 The results found the same strategy to be beneficial adaptations assumed by the motor control system,
working under condition 4 where the subjects were deprived it seems that such proprioceptive exercises reduce the need
from both intact visual and vestibular afferents. This may for such adaptations. Eye-head-neck coordination exercises
indicate that in condition 3, vestibular manipulation had are specific proprioceptive trainings including head
been at least partially compensated by visual inputs, which relocation, maintaining gaze stability, eye tracking exercises
was not the strategy employed in condition 4 when eyes and coordinating movement between the eyes and the
were closed. head.17 Such exercise have been supposed to be effective in
After the interventions, the two CNSNP patient groups resolving the conflict arising from abnormal cervical
demonstrated a divergent behavior. Although both groups afferents and seemingly intact vestibulo-occular inputs.17
revealed improvements in their postural control under the Such conflicts have been claimed as sources of postural
foam standing condition in terms of reduced AP CoP range unsteadiness in CNSNP patients. Since the head hosts the
and velocity, the CPT group remained distinguished from the visual and vestibular sensory organs, improved head-neck
control group. This is while most of the differences between coordination may provide more reliable proprioceptive
the PT and the control group were resolved after the afferents from the mechanoreceptor-rich cervical region.68
interventions. This briefly demonstrates that addition of This may in turn lead to more accurate and precise motor
proprioception specific exercises may add to the benefits of commands to the cervical muscles ultimately removing the
the physiotherapay program in terms of postural control need for overactivity of the superficial cervical muscles as a
mechanisms. major source of muscular pain.17,69 Previous investigations
From a clinical point of view, our results are in line with have also introduced cervical proprioception deficit as a
previous reports further supporting the benefit of exercise predisposing factor to pain via poor motor control.10,70
therapy in the management of neck pain in patients with Impaired cervical proprioception and pain seem to form a
CNSNP.60-62 Consistent with previous studies,17,63,64 our vicious cycle in many of CNSNP cases.71
results showed that both groups improved in terms of pain An important point to be considered is that although
which confirms the pain-modulation properties of active addition of proprioceptive exercises significantly added to
neck exercises besides physical modalities utilized for pain the regulation of postural mechanisms in CNSNP patients
and inflammation control.65 Pain may adversely affect making them almost indistinguishable from control
proprioception at different levels. First it may reduce muscle participants, the pain intensity level in these patients was not
spindle sensitivity at the peripheral level. Second different from those receiving conventional physiotherapy.
proprioceptive afferents may lose sensory competition to Neck pain-related disability improvement was also not
pain at the spinal level.66,67 Pain may also occupy the central significant in any of the patient groups. It might be speculated
processing capacity needed for the perception and that clinical improvements lag those of postural control
processing of the proprioceptive afferents at the cortical and/or greater magnitudes of postural improvements are
level. Physical modalities and exercise therapies addressing needed to yield clinically significant alterations. The chronic
pain experienced in the cervical region may thus indirectly nature of pain and pain-related alterations in these cases may
improve proprioceptive functioning of the cervical spine at necessitate long enough modulations to reverse such
all these levels. On the other hand, altered proprioceptive alterations, making 5-week interventions inadequate to
functioning has been suggested as a possible mechanism for observe resolution of all levels of functional disability.
impaired postural control in CNSNP by adversely affecting
the fine control of movement meant to prevent microtrauma Conclusion
to cervical tissues during normal daily movement of the head Individuals with CNSNP exhibited larger and faster
and neck. In this scenario, impaired proprioception may postural oscillations during a more robust dynamics
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THE ARCHIVES OF BONE AND JOINT SURGERY. ABJS.MUMS.AC.IR EFFECT OF CERVIVAL PROPRIOCEPTIVE TRAINING ON POSTURAL CONTROL
VOLUME 12. NUMBER 1. January 2024

comparing asymptomatic participants under challenging Acknowledgement

standing conditions. But this did not make them more The authors would like to appreciate the support received
reliant on their visual or vestibular system function. from the Clinical Research Development Center of the
Although addition of proprioception exercises to Rofeideh Rehabilitation Hospital.
conventional physiotherapy made postural mechanisms of
these patients comparable to that in asymptomatic Conflict of interest: None
participants, possibly the short duration of the
intervention regimen did not suffice to add to pain and Funding: None
disability improvements in this group of patients
comparing to those not performing these exercises. Our Leila Goudarzi PhD 1,2
findings contradicted the hypothesis that impaired neck Hamed Ghomashchi PhD 3
proprioception in the presence of CNSNP is compensated Mohsen Vahedi PhD 4
by overweighting other sources of sensory afferents, i.e.,
visual and vestibular. Vestibular system manipulation, Amir Hossien Kahlaee, PhD 2
produced by head tilt in postural outcomes in the PT group 1 Clinical Research Development Center of Rofeideh
may confirm proprioception deficit as a contributing factor Rehabilitation Hospital, Tehran, Iran
to CNSNP. But it seems that postural adjustments are 2 Physiotherapy Department, University of Social Welfare
provided by compensations within the proprioceptive and Rehabilitation Sciences, Tehran, Iran
system in terms of reweighting propriceptive afferents
from different body regions. Further investigations on the 3 KITE Research Institute, Toronto Rehabilitation Institute,
extent to which the postural control system relies on University Health Network, , Toronto, Canada
proprioceptive inputs from various body regions may 4 Department of Biostatistics and Epidemiology, Substance
further elaborate the mechanism underlying postural Abuse and Dependence Research Center, University of Social
impairment in CNSNP patients. Welfare and Rehabilitation Sciences, Tehran, Iran

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THE ARCHIVES OF BONE AND JOINT SURGERY. ABJS.MUMS.AC.IR EFFECT OF CERVIVAL PROPRIOCEPTIVE TRAINING ON POSTURAL CONTROL
VOLUME 12. NUMBER 1. January 2024