Incorporating proprioceptive training into whiplash rehabilitation.
Proprioception is our ability to sense position, movement, special orientation, and acceleration of our body parts in space. This information is fed into the brain by several sensory systems: mechanorecptors within the neck musculature, visual input, and vestibular input. The proprioceptive input from the musculoskeletal system includes information from muscle spindles that is fine tuned by tendons’ golgi tendon organs, and ligamentous mechanoreceptors. If information from any of these systems is inaccurate, errors in head positioning may occur resulting in dizziness, postural instability, and eye movement dysfunction.
It has become clearer as we accumulate moderate to high quality evidence, that whiplash patients appear to have deficits in joint position sense. A study by Treleaven et al supports previous research that shows cervical joint position sense is poorer in whiplash patients that experience dizziness.1 The authors surmise that this is due to a lack of proprioceptive input.
Active joint position testing can be accomplished using a head mounted laser as described by Kirtjansson.2 Patients sit about 90 cm from the wall, are asked to move their head with eyes closed away from their resting position, and then move the head back to their initial resting position: angle of error= TAN-1[error distance/distance of patient from wall]. Errors > 4.5o suggest impairment in relocation accuracy of the head. This test has shown moderate intratest reliability (ICC=0.68).3
In search of recent research to find out if retraining joint position sense improves pain or function I came across a single blinded randomised controlled trial done on 47 patients with nonspecific chronic neck pain.4 24 individuals underwent proprioceptive training with a laser mounted to a helmet, 23 underwent endurance training with a pressure biofeedback device for ten treatments. Pain and function (VAS and NDI) were evaluated along with tests for joint position error and endurance after the fifth and tenth sessions and then 45 days after the last treatment. As one would expect, endurance improved in the endurance group and joint position error improved in the proprioceptive exercise group, and function improved in both groups significantly. Pain was reduced significantly in both groups with the proprioceptive group improving more. Perhaps there is a link between proprioception and pain – adequate proprioceptive feedback is necessary to get an adequate muscle contraction. While they didn’t use whiplash patients in this particular study and they didn’t evaluate dizziness which is common amongst whiplash patients, it wouldn’t be a stretch to apply this to a whiplash group since joint position error seems to figure prominently in that group.
Here, I take a patient through some laser guided head repositioning exercises.
- Treleavan J, Jull g, Sterling M.Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med. 2003; 35(1):36-43
- Kristjansson, E., & Treleaven, J. (2009). Sensorimotor function and dizziness in neck pain: implications for assessment and management. journal of orthopaedic & sports physical therapy, 39(5), 364-377.
- Roren, A., Mayoux-Benhamou, M. A., Fayad, F., Poiraudeau, S., Lantz, D., & Revel, M. (2009). Comparison of visual and ultrasound based techniques to measure head repositioning in healthy and neck-pain subjects. Manual therapy, 14(3), 270-277.
- Arami, J., Rezasoltani, A., Eghlidi, J., Ebrahimabadi, Z., & Ylinen, J. The applicability of proprioceptive and endurance measurement protocols to treat patients with chronic non-specific neck pain. Elective Medicine Journal, 2014;2(3), 227-230.
For more information on the test click the link: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1156