Background
Study hypotheses
Methods/design
Trial design
Participants
Inclusion criteria
|
- Aged ≥18 years |
- Insidious neck pain for at least 3 months |
- Average neck pain intensity over the past week ≥30 mm (100 mm visual analogue scale) |
- Score ≥ 10/100 on the Neck Disability Index-Thai version (NDI-TH) [47] |
Exclusion criteria
|
- Previous history of neck and head trauma or surgery |
- Known or suspected vestibular pathology, vertigo or dizziness from ear or brain disorders, sensory nerve pathways (e.g. BPPV), or vascular disorders (e.g. migraine, hypertension) |
- Any musculoskeletal or neurological conditions that could affect balance |
- Inflammatory joint disease |
- Systemic conditions |
- Cognitive impairment |
- Taking four or more medications |
- Received physiotherapy treatment for their neck disorder in the past 12 months |
Procedure
Physiotherapist training and treatment fidelity
Intervention programs
Intervention | Description | Time (minutes) |
---|---|---|
Local neck treatment | Cervical mobilization | 10 |
Specific therapeutic exercises | 20 | |
Local treatment plus sensorimotor control exercises | Cervical mobilization | 10 |
Specific therapeutic exercises | 20 | |
Sensorimotor exercises | 15 | |
Local treatment plus balance exercises | Cervical mobilization | 10 |
Specific therapeutic exercises | 20 | |
Balance exercises | 15 | |
Local neck treatment plus sensorimotor control and balance exercises | Cervical mobilization | 10 |
Specific therapeutic exercises | 20 | |
Sensorimotor exercises | 15 | |
Balance exercises | 15 |
Modality | Description |
---|---|
Cervical mobilization [57] | Low-velocity passive mobilization techniques to the symptomatic cervical segments as determined by the physiotherapist’s clinical examination. Physiotherapists are free to select from what are termed passive accessory and physiological movement techniques as deemed relevant to the individual participant based on the initial and progressive reassessments. |
Cervical flexors | |
(i) Train craniocervical flexor (CCF) activation and holding capacity. Participants learn the correct movement and train to hold the contraction with and without feedback in progressively more difficult inner range positions. | |
(ii) Train the interaction of deep and superficial cervical flexors in movement patterning and functional tasks. | |
(iii) Train co-contraction of the deep cervical flexors and extensors. | |
(iv) Train strength and endurance of the cervical flexors. | |
Cervical extensors | |
(i) Train craniocervical extensors and rotators (head extension, head rotation < 40°) with the cervical spine in a neutral position. | |
(ii) Train cervical extension to bias the cervical extensors (extend cervical spine keeping the craniocervical region in a neutral position) | |
(iii) Train strength and endurance. | |
Axioscapular muscles | |
(i) Train scapular muscles in particular the upper/ middle/ lower trapezius and serratus anterior in both open and closed chain positions, with and without load and movement of the upper limb. | |
(ii) Train correct scapular posture. | |
Postural correction exercise | |
(i) Train a neutral spinal posture from first treatment. | |
(ii) Train scapulothoracic and cervical postures. Participants train to actively correct their posture and maintain for 10s. Practice is in sitting, standing (2-3 times an hour). | |
Cervical JPS. The participants practice moving their head to points in different directions initially with eyes open, using a laser pointer mounted onto a lightweight headband. This practice will involve relocating the head back to a neutral posture or to predetermined points in range. The exercise is progressed by closing the eyes and by changing directions and ranges of movement. | |
Cervical movement sense. The participants practice tracing horizontal and vertical lines on a chart on the wall focusing on accuracy and secondarily speed using a laser pointer mounted onto a lightweight headband for feedback on performance. Exercises are progressed by increasing speed and tracing more intricate patterns such as a figure of eight, zig-zag or an alphabet pattern. | |
Oculomotor control exercises | |
(i) Train eye follow. The participants follow a target moving from side to side and up and down while keeping their head still. | |
(ii) Train gaze stability exercises. The participants perform active movements, while fixing their gaze on the target. Progressions include increasing the target’s speed, changing the participant’s position and changing visual background and focus point. | |
(iii) Train eye head co-ordination exercises. The participants move their eyes and head in the same direction to focus on a target. Progressions include moving the eyes first then the head and moving eyes and head in opposite directions. | |
The training starts with static balance and progresses to dynamic balance and challenging gait. The exercises will be progressed by closing the eyes, altering the support surface (i.e. a soft surface), concurrent voluntary movements, or increasing speed. |
Exercise | Level | Details | Targeted repetitions |
---|---|---|---|
Cervical flexors | 1 | Re-education of CCF movement pattern | |
Supine, knees bent | |||
- Gentle and controlled nodding action facilitated with eye movement | 10 reps | ||
Holding capacity | |||
Supine, knees bent | |||
- Repeated and sustained CCF progressing from 22 to 30 mmHg | 10 s holds × 10 reps | ||
2 | Interaction between the deep/superficial cervical flexors | ||
Sitting | |||
- Controlled head movement through range of extension and return to neutral | 10 reps | ||
Co-contraction of the deep cervical flexors/extensors | |||
Sitting | |||
- Isometric cervical rotation facilitated with eye movement (left/right sides) | 5 s holds × 5 reps | ||
3 | Strength/endurance of the cervical flexors | ||
Sitting | |||
- Isometric CCF in a range of cervical extension | 10 s holds × 10 reps | ||
- Lifting the head off the wall (with the chair up to 30 cm away from the wall) | 10 s holds × 10 reps | ||
Supine | |||
- Lifting the head off a pillow (2, 1 then 0 pillows as per participant’s capacity) | 10 s holds × 10 reps | ||
Cervical extensors | 1 | Re-education of extension movement pattern | |
Prone on elbows/four-point kneeling positions | |||
- Craniocervical extension | 3 sets of 5 reps | ||
- Craniocervical rotation (< 40°) | 3 sets of 5 reps | ||
- Cervical extension while keeping the craniocervical region in a neutral position | 3 sets of 5 reps | ||
2 | Co-contraction of the deep cervical flexors/extensors | ||
Sitting | |||
- Isometric cervical rotation facilitated with eye movement (left/right sides) | 5 s holds × 5reps | ||
3 | Strength/endurance of the cervical extensors | ||
Prone on elbows/four-point kneeling positions | |||
- Isometric hold in range of cervical extension | 10 s holds × 10 reps | ||
- Addition of progressive load (light weights attached to head) as per patient’s capacity | |||
Axioacapular control | 1 | Re-education of scapular movement control | |
Side lying with arm elevated 140°/sitting | |||
- Passive repositioning of the scapular | 10 reps | ||
- Active repositioning of the scapular | 10 reps | ||
Holding capacity | |||
Side lying with arm elevated 140°/sitting | |||
- Active repositioning the scapular posture and isometric hold | 10 s holds × 10 reps | ||
2 | Axioscapular muscle control | ||
Sitting | |||
- Arm movement without load (external rotation/abduction/flexion < 30°) | 10 reps | ||
- Arm movement without load throughout range | 10 reps | ||
Prone on elbows/four-point kneeling position | |||
- Thoracic lift (serratus anterior) and isometric hold | 5 s holds × 5 reps | ||
3 | Strength/endurance of axioscapular muscles | ||
Sitting | |||
- Arm movement with load (external rotation/abduction/flexion < 30°) | 10 reps | ||
- Arm movement with load throughout the range | 10 reps | ||
Prone | |||
- Lift the shoulder off the bed and hold without arm load | 10 s holds × 10 reps | ||
- Lift the shoulder off the bed and hold with arm load | 10 s holds × 10 reps | ||
Postural correction | 1 | Correction of spinal posture | |
Sitting | |||
- Active upright sitting initiated with lumbo-pelvic movement | 10 s holds × 10 reps | ||
2 | Correction of spinal posture and scapular orientation | ||
Sitting | |||
- Actively positioning the scapular in a neutral posture while maintaining spinal posture | 10 s holds × 10 reps | ||
3 | Spinal and scapular correction plus occipital lift | ||
Sitting | |||
- Actively lengthen the back of the neck while maintaining spinal and scapular posture | 10 s holds × 10 reps | ||
Cervical joint position sense | 1 | Relocation with laser feedback | |
Sitting | |||
- Head relocating to neutral position with eyes opened (vertical/horizontal) | 5 reps × 3 sets | ||
- Head relocating to predetermined position in range with eyes opened (vertical/horizontal) | 5 reps × 3 sets | ||
2 | Relocation with laser feedback | ||
Sitting | |||
- Head relocating to neutral position with eyes opened (diagonal) | 5 reps × 3 sets | ||
- Head relocating to predetermined position in range with eyes opened (diagonal) | 5 reps × 3 sets | ||
- Head relocating to specific targets with eyes opened (all directions) | 5 reps × 3 sets | ||
3 | Relocation with laser feedback | ||
Sitting | |||
- Head relocating to neutral position with eyes closed (all directions) | 5 reps × 3 sets | ||
- Head relocating to predetermined position in range with eyes closed (all directions) | 5 reps × 3 sets | ||
Cervical movement sense | 1 | Movement sense training with laser feedback | |
Sitting | |||
- Tracing a line (vertical/horizontal) | 5 reps × 3 sets | ||
2 | Movement sense training with laser feedback | ||
Sitting position | |||
- Tracing an intricate pattern at a slow speed (a figure of eight/zig-zag/alphabet) | 5 reps × 3 sets | ||
3 | Movement sense training with laser feedback | ||
Sitting position | |||
- Tracing an intricate pattern at a fast speed (a figure of eight/zig-zag/alphabet) | 5 reps × 3 sets | ||
Oculomotor control | 1 | Eye follow, gaze stability and eye-head coordination | |
Sitting | |||
- Eyes following a target with slow speed while keeping the head still (vertical/horizontal) | 5 reps × 3 sets | ||
- Head moving while fixing eyes on a single spot (vertical/horizontal) | 5 reps × 3 sets | ||
- Eyes and head moving together to the same direction (vertical/horizontal) | 5 reps × 3 sets | ||
2 | Eye follow, gaze stability and eye-head coordination | ||
Sitting | |||
- Eyes following a target with fast speed while keeping the head still (vertical/horizontal) | 5 reps × 3 sets | ||
- Head moving while fixing eyes on complex targets (vertical/horizontal) | 5 reps × 3 sets | ||
- Moving the eyes first then the head to the same direction | 5 reps × 3 sets | ||
3 | Eye follow, gaze stability and eye-head coordination | ||
Sitting | |||
- Eyes following a target with neck in 45° torsion (vertical/horizontal) | 5 reps × 3 sets | ||
- Head moving while fixing eyes on a word target with complex backgrounds (vertical/horizontal) | 5 reps × 3 sets | ||
- Eyes and head moving to the opposite direction (vertical/horizontal) | 5 reps × 3 sets | ||
Balance control | 1 | Static balance | |
Standing | |||
- Narrow stance (firm/soft surfaces with eyes open/closed) | 30 s holds × 10 reps | ||
- Tandem stance (firm/soft surfaces with eyes open/closed) | 30 s holds × 10 reps | ||
2 | Dynamic balance and gait | ||
Standing | |||
- Throwing/catching a ball while tandem stance (firm/soft surfaces) | 30 s holds × 10 reps | ||
Walking | |||
- Normal walking with fast speed (forward/backward, side way) | 10 reps | ||
- Tandem walking (forward/backward) | 10 reps | ||
3 | Dynamic balance and gait with head movement | ||
Standing | |||
- Throwing/catching a ball while single leg standing (firm/soft surfaces) | 30 s holds × 10 reps | ||
Walking | |||
- Normal walking (forward/backward, side way) with head movement (left/right, up/down) | 10 reps | ||
- Tandem walking (forward/backward) with head movement (left/right, up/down) | 10 reps |
Outcome measures (Table 5)
Primary outcomes
Primary outcome measures | Data collection instruments |
Postural stability | A swaymeter |
- Sway displacement | |
- Sway area | |
Cervical joint position error | A laser-pointer attached to a lightweight headband |
Secondary outcome measures | |
Gait speed | 10-m walk test |
Dizziness intensity | VAS (0-100 mm) |
Neck pain intensity | VAS (0-100 mm) |
Neck disability | NDI-TH (0-100) |
Pain extent and location | iPad and custom software |
Cervical range of motion | A CROM instrument |
Functional ability status | PFSF (scale range 0-10) |
Health-related quality of life | Thai SF-36 (scale range 0-100) |
Global perceived benefit of treatment | A seven-point ordinal Likert scale (1-7) |