Cervical joint position error

The cervical joint position error (JPE) assesses the ability to relocate the head to the natural head posture.^1,2 Disturbances in postural control frequently occur after whiplash, with impairments in head-neck awareness reported as one of the manifestations.³ The reliability and validity of this test has been established. Importantly, rehabilitation of joint position error (as part of a wider rehabilitation program) has resulted in improved health outcomes after whiplash.

How to

Set up

1. Mount a laser pointer onto a light headband.

2. Observe and mark the natural head position as indicated by the laser on a wall.

3. Ask the patient to close their eyes and actively move their head in a specified direction, then return to the starting position as accurately as possible.

4. Measure the average difference between the starting and end position in cms and then converted to degrees. Generally a distance of 90cm is used between the target and the laser to facilitate calculations of cm to degrees, using prefabricated targets.

5. Repeat at least 3 consistent trials in each direction and reposition the patients head manually to the starting position between trials.

When and why

• Assessment of JPE is recommended in most patients with whiplash because it is frequently impaired. Such patients may report they have a ‘wobbly head’ don’t feel like they know where they are is space or report disturbances in sensorimotor control such as dizziness or light-headedness.
• Deficits in sensorimotor control are more pronounced in patients with whiplash who complain of dizziness, unsteadiness or visual disturbances^.1
• Rehabilitation of cervical joint position error improves the impairment and may improve neck pain and dizziness.

Results

Errors of greater that 4.5 degrees suggest the cervical joint position error is impaired.¹

References

1. Kristjansson & Treleaven. Journal of Orthopaedic & Sports Physical Therapy 2009; 39:364-77.

2. Treleaven Manual Therapy 2009; 13:2-11.

3. Treleaven et al. Journal of Rehabilitation Medicine 2003; 35:36-43.

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Oculomotor disturbance

Tests to assess oculomotor disturbances include the smooth pursuit neck torsion test (SPNT).^1,2 The test is understood to assess eye movement disturbances due to altered cervical afferent input.² Disturbances in oculomotor control frequently occur after whiplash^2,3 and may be associated with poorer prognosis.⁴ Other tests assessing oculomotor disturbances include tests of gaze stability and eye-head coordination.

How to

Smooth pursuit neck torsion test (SPNT)

1. Sit the patient in a neutral position. 

2. Ask the patient to follow a pen or your finger with their eyes whilst keeping their head still. 

3. Move the pen at the patient’s natural focal length across their field of vision horizontally in a visual range of 40 degrees several times.  The speed of movement should be about 20 degrees per second (i.e. 4 seconds to go from one side to the other). 

4. Observe the pursuit of the eyes.

5. Repeat the test with the neck torsioned by rotating the trunk, keeping the head still. This is done so that input to the vestibular system is minimally affected. 

The test is positive if the control of the eye movement is worse in either left or right torsioned positions and or if the patient’s visual symptoms or dizziness are reproduced.  Eye movements should be smooth. Quick catch up movements (especially as the target crosses the midline) are considered abnormal. 

Gaze stability

1. Ask the patient to focus on a point in front of them and maintain focus while they rotate their head or move through flexion and extension.

Patients with whiplash are often unable to maintain focus or move their head as far, quickly or as smoothly as controls. Normal range of gaze stabilisation is approximately 40 degrees.

Eye head co-ordination

1. Ask the patient to move their eyes to a point then focus then move their head to the same point then focus.

2. Return to neutral, first with the eyes and then the head.

Patients with whiplash often cannot keep their head still while the eyes move.  They may also report dizziness or visual symptoms.  The test can be performed for points in rotation and flexion/ extension ranges.

When and why

• Indicated for patients with whiplash who report visual disturbances or complain of dizziness. Such complaints include blurred vision, reduced visual fields, photophobia and dizziness or unsteadiness.
• Assesses oculomotor disturbances in people with whiplash.  If impaired, rehabilitation of the same is associated with improved outcomes.

Results

• Look for increased saccadic movements especially as the patient crosses the midline and/or reproduction of symptoms in the torsion position compared to the neutral position as a positive test.

References

1. Tjell & Rosenhall. American Journal of Otolaryngology 1998; 19:76-81.  

2. Kristjansson & Treleaven. Journal of Orthopaedic & Sports Physical Therapy 2009; 39:364-77.

3. Treleaven et al. Journal of Rehabilitation Medicine 2005; 37:219-23.

4. Hildingsson & Toolanen. Acta Orthopaedica Scandinavica 1989; 60:513-6.

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Balance

Balance can be assessed using the tandem stance test and the step test.  These tests assess general postural stability.  Impairments in balance occur frequently after whiplash, in particular if the patient reports dizziness. 

How to

Tandem step test

Static balance – Tandem eyes closed balance

Have the participant stand with the dominant (kicking leg) behind in tandem stance, arms by their side.
Ensure the front foot heel is touching the back foot toe and feet are aligned
Time to 30 seconds with participant eyes closed, arm movement is permitted , test is ceased if patients steps  to secure balance. 

Step test

Have the participant stand one foot distance from 10cm block with shoes off
Instructions: “Your goal is to place your whole foot on and off the step as many times as you can in 15 seconds. Ensure your foot is flat on the block when you step and when you step back”
Count the number of times one foot is completely placed onto and off the block (back off the block is one full step)
Complete with left and the right
eyes closed, arm movement is permitted , test is ceased if patients steps  to secure balance.  

When and why

Patients with whiplash who disturbances in postural stability such as loss of balance, dizziness or un-cordination.  If impaired, rehabilitation of balance is recommended. 

References

1. Kristjansson & Treleaven. Journal of Orthopaedic & Sports Physical Therapy 2009; 39:364-77.

2. Treleaven Manual Therapy 2009; 13:2-11.

3. Treleaven et al. Journal of Rehabilitation Medicine 2003; 35:36-43.