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

Document Type : RESEARCH PAPER


1 1 Clinical Research Development Center of Rofeideh Rehabilitation Hospital, Tehran, Iran 2 Physiotherapy Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

2 KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, , Toronto, Canada

3 Department of Biostatistics and Epidemiology, Substance Abuse and Dependence Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

4 Physiotherapy Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran



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 
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


Main Subjects

  1. Hoy D, March L, Woolf A, et al. The global burden of neck pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014; 73(7):1309-1315. doi: 10.1136/annrheumdis-204431.
  2. Dabiri SR, Tehrani MR, Omidi-Kashani F, et al. The Responsiveness of Three Persian Outcome Measures Following Physiotherapy Intervention in Patients with Chronic Non-Specific Neck Pain. Arch Bone Jt Surg. 2023; 11(5):356.doi: 10.22038/ABJS.2023.68253.3227
  3. Ausloos M, Brugha TS, Collaborators G. Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018; 392(10159):1859-1922. doi: 10.1016/S0140-6736(18)32335-3.
  4. Bikbov MM, Kazakbaeva GM, Zainullin RM, et al. Prevalence of and factors associated with low Back pain, thoracic spine pain and neck pain in Bashkortostan, Russia: the Ural Eye and Medical Study. BMC Musculoskelet Disord. 2020; 21(1):64. doi: 10.1186/s12891-020-3080-4.
  5. Manchikanti L, Singh V, Datta S, Cohen SP, Hirsch JA. Comprehensive review of epidemiology, scope, and impact of spinal pain. Pain Physician. 2009; 12(4):E35-70. doi:10.36076/ppj.2009/12/E35.
  6. Côté P, Cassidy JD, Carroll LJ, Kristman V. The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain. 2004; 112(3):267-273.doi:10.1016/j.pain. 2004.09.004.
  7. de Zoete RM, Osmotherly PG, Rivett DA, Farrell SF, Snodgrass SJ. Sensorimotor control in individuals with idiopathic neck pain and healthy individuals: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2017; 98(6):1257-1271.doi: 10.1016/j.apmr.2016.09.121.
  8. Cheng C-H, Chien A, Hsu W-L, Yen L-W, Lin Y-H, Cheng H-YK. Changes of postural control and muscle activation pattern in response to external perturbations after neck flexor fatigue in young subjects with and without chronic neck pain. Gait Posture. 2015; 41(3):801-807.doi:10.1016/j.gaitpost.2015.02.007.
  9. Ruhe A, Fejer R, Walker B. Altered postural sway in patients suffering from non-specific neck pain and whiplash associated disorder-A systematic review of the literature. Chiropr Man Therap. 2011; 19(1):1-11.doi:1186/2045-709X-19-13.
  10. Stanton TR, Leake HB, Chalmers KJ, Moseley GL. Evidence of impaired proprioception in chronic, idiopathic neck pain: systematic review and meta-analysis. Phys Ther. 2016; 96(6):876-887.doi: 10.2522/ptj.20150241
  11. Oliveira AC, Silva AG. Neck muscle endurance and head posture: a comparison between adolescents with and without neck pain. Man Ther. 2016; 22:62-67. doi:10.1016/j.math.2015.10.002.
  12. Ghamkhar L, Kahlaee AH. Are ultrasonographic measures of cervical flexor muscles correlated with flexion endurance in chronic neck pain and asymptomatic participants? Am J Phys Med Rehabil. 2017; 96(12):874-880. 13.1097/PHM.0000000000000778.
  13. Cheng C-H, Wang J-L, Lin J-J, Wang S-F, Lin K-H. Position accuracy and electromyographic responses during head reposition in young adults with chronic neck pain. J Electromyogr Kinesiol.2010; 20(5):1014-1020. doi:10.1016/j.jelekin.2009.11.002.

14.              Revel M, Andre-Deshays C, Minguet M. Cervicocephalic kinesthetic sensibility in patients with cervical pain. Arch Phys Med Rehabil. 1991; 72(5):288-291.doi: 10.5555/uri: pii: 


  1. Strimpakos N. The assessment of the cervical spine. Part 1: Range of motion and proprioception. J Bodyw Mov Ther. 2011; 15(1):114-124.doi:10.1016/j.jbmt.2009.06.003.
  2. Nugraha MHS, Negara AAGAP, Antari NKAJ, Dewi AANTN. The Effectiveness of Proprioceptive Neuromuscular Facilitation in Mechanical Neck Pain: A Systematic Review. Sport and Fitness Journal. 2021; 9(2):103-108.doi:10.24843/spj.2021.v09.i02.p02.
  3. Revel M, Minguet M, Gergoy P, Vaillant J, Manuel JL. Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. Arch Phys Med Rehabil. 1994; 75(8):895-899.doi:10.1016/0003-9993 (94)90115-5.
  4. Tsiringakis G, Dimitriadis Z, Triantafylloy E, McLean S. Motor control training of deep neck flexors with pressure biofeedback improves pain and disability in patients with neck pain: a systematic review and meta-analysis. Musculoskelet Sci Pract. 2020; 50:102220. doi:10.1016/j.msksp.2020.102220.
  5. Palmgren PJ, Andreasson D, Eriksson M, Hägglund A. Cervicocephalic kinesthetic sensibility and postural balance in patients with nontraumatic chronic neck pain–a pilot study. Chiropr Osteopat. 2009; 17(1):1-10.doi:10.1186/1746-1340-17-6.
  6. Teng C-C, Chai H, Lai D-M, Wang S-F. Cervicocephalic kinesthetic sensibility in young and middle-aged adults with or without a history of mild neck pain. Man Ther. 2007; 12(1):22-28. doi: 10.1016/j.math.2006.02.003.
  7. Armstrong B, McNair P, Taylor D. Head and neck position sense. Sports Med. 2008; 38(2):101-117. doi: 10.2165/00007256-200838020-00002.
  8. Treleaven J. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Man Ther. 2008; 13(1):2-11.doi:10.1016/j.math.2007.06.003.
  9. Bays PM, Wolpert DM. Computational principles of sensorimotor control that minimize uncertainty and variability. J Physiol.2007; 578(2):387-396.doi: 10.1113/jphysiol.2006.120121.
  10. Beinert K, Keller M, Taube W. Neck muscle vibration can improve sensorimotor function in patients with neck pain. Spine J. 2015; 15(3):514-521. doi: 10.1016/j.spinee.2014.10.013.
  11. Alizadeh A, Jafarpisheh AS, Mohammadi M, Kahlaee AH. Visual, Vestibular, and Proprioceptive Dependency of the Control of Posture in Chronic Neck Pain Patients. Motor Control. 2022; 26(3):362-377. doi:10.1123/mc.2021-0008.
  12. Junqueira DR, Zorzela L, Golder S, et al. CONSORT Harms 2022 statement, explanation, and elaboration: updated guideline for the reporting of harms in randomised trials. BMJ. 2023; 381. doi: 10.1136/bmj-2022-073725.
  13. Dallal GE. Randomization. Com. Available at: Accessed August 16, 2008.
  14. Chess LE, Gagnier J. Risk of bias of randomized controlled trials published in orthopaedic journals. BMC Med Res Methodol. 2013; 13(1):1-10.doi:10.1186/1471-2288-13-76.
  15. Chow SC, Shao J, Wang H, Lokhnygina Y. Sample size calculations in clinical research. CRC press; 2017 Aug 15.doi:10.1201/9781315183084.
  16. Guzman J, Hurwitz EL, Carroll LJ, et al. A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther.2009; 32(2):S17-S28. doi:10.1097/BRS.0b013e3181643efb.
  17. AS FR. Regional musculoskeletal conditions: neck pain. Best Pract Res Clin Rheumatol.2003; 17(1):57-70. doi: 0.1016/S1521-6942(02)00097-9.
  18. Merskey H, Bogduk N. Classification of chronic pain, IASP Task Force on Taxonomy. Seattle: IASP press; 1994.doi:10.4236/ojn.2016.69075.
  19. Ezzati K, Ravarian B, Saberi A, Salari A, Reyhanian Z, Khakpour M. Prevalence of cervical myofascial pain syndrome and its correlation with the severity of pain and disability in patients with chronic non-specific neck pain. Arch Bone Jt Surg. 2021; 9(2):230.doi: 10.22038/abjs.2020.48697.2415.
  20. Crichton N. Visual analogue scale (VAS). J Clin Nurs. 2001; 10(5):706-6.
  21. Howell ER. The association between neck pain, the Neck Disability Index and cervical ranges of motion: a narrative review. J Can Chiropr Assoc. 2011; 55(3):211.doi: 0008-3194/2011/211–221.
  22. Miller RP, Kori SH, Todd DD. The Tampa Scale: a measure of kinisophobia. The Clinical journal of pain. 1991; 7(1):51.doi:10.1080/09638288.2022.2090624.
  23. Halker RB, Barrs DM, Wellik KE, Wingerchuk DM, Demaerschalk BM. Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic. Neurologist. 2008; 14(3):201-204. doi:10.1097/NRL.0b013e31816f2820.
  24. Mousavi SJ, Parnianpour M, Montazeri A, et al. Translation and validation study of the Iranian versions of the Neck Disability Index and the Neck Pain and Disability Scale. Spine. 2007; 32(26):E825-E831.doi:10.1097/BRS.0b013e31815ce6dd.
  25. Askary-Ashtiani A, Ebrahimi-Takamejani I, Torkaman G, Amiri M, Mousavi SJ. Reliability and validity of the persian versions of the fear avoidance beliefs questionnaire and tampa scale of kinesiophobia in patients with neck pain. Spine. 2014; 39(18):E1095-E1102.
  26. Adamo DE, Pociask FD, Goldberg A. The contribution of head position, standing surface and vision to postural control in young adults. J Vestib Res. 2013; 23(1):33-40.doi:10.3233/VES-130473.
  27. Hansson EE, Beckman A, Håkansson A. Effect of vision, proprioception, and the position of the vestibular organ on postural sway. Acta Otolaryngol.2010; 130(12):1358-1363. doi:10.3109/00016489.2010.498024.
  28. Jackson RT, Epstein CM. Effect of head extension on equilibrium in normal subjects. Ann Otol Rhinol Laryngol. 1991; 100(1):63 67.doi:10.1177/000348949110000110.
  29. Cohen J. Statistical power analysis for the behavioral sciences.Routledge; 2013. doi: 10.4324/9780203771587.

44.              de Zoete RM, Osmotherly PG, Rivett DA, Snodgrass SJ. No differences between individuals with chronic idiopathic neck pain and asymptomatic individuals on 7 cervical sensorimotor control tests: a cross-sectional study. J Orthop Sports Phys Ther. 2020; 50(1):33-43. 


  1. Quek J, Treleaven J, Clark RA, Brauer SG. An exploratory study examining factors underpinning postural instability in older adults with idiopathic neck pain. Gait Posture. 2018; 60:93-98. doi:10.1016/j.gaitpost.2017.11.016.
  2. Silva AG, Cruz AL. Standing balance in patients with whiplash-associated neck pain and idiopathic neck pain when compared with asymptomatic participants: a systematic review. Physiother Theory Pract. 2013; 29(1):1-18.doi:10.3109/09593985.2012.677111.
  3. Wannaprom N, Treleaven J, Jull G, Uthaikhup S. Neck muscle vibration produces diverse responses in balance and gait speed between individuals with and without neck pain. Musculoskelet Sci Pract. 2018;35:25-29.doi:10.1016/j.msksp.2018.02.001.
  4. Quek J, Brauer S, Clark R, Treleaven J. New insights into neck-pain-related postural control using measures of signal frequency and complexity in older adults. Gait Posture. 2014; 39(4):1069-1073. doi:10.1016/j.gaitpost.2014.01.009.
  5. Patel M, Fransson P-A, Lush D, Gomez S. The effect of foam surface properties on postural stability assessment while standing. Gait & posture. 2008; 28(4):649-656.doi:10.1016/j.gaitpost.2008.04.018.
  6. Gill J, Allum J, Carpenter M, et al. Trunk sway measures of postural stability during clinical balance tests: effects of age. J Gerontol A Biol Sci Med Sci.2001; 56(7):M438-M447.doi:10.1093/gerona/56.7.m438.
  7. Shumway-Cook A, Woollacott MH. Motor control: theory and practical applications. 2st ed . Lippincott Williams & Wilkins, Philadelphia, cop; 2001.
  8. Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther. 2009; 39(5):364-377.doi:10.2519/jospt.2009.2834.
  9. Jeka J, Kiemel T, Creath R, Horak F, Peterka R. Controlling human upright posture: velocity information is more accurate than position or acceleration. J Neurophysiol. 2004; 92(4):2368-2379.doi:10.1152/jn.00983.2003.
  10. Rand TJ, Ambati VNP, Mukherjee M. Persistence in postural dynamics is dependent on constraints of vision, postural orientation, and the temporal structure of support surface translations. Exp Brain Res. 2019;237:601-610.doi:10.1007/s00221-018-5444-7.
  11. Lemay J-F, Gagnon D, Duclos C, Grangeon M, Gauthier C, Nadeau S. Influence of visual inputs on quasi-static standing postural steadiness in individuals with spinal cord injury. Gait Posture. 2013; 38(2):357-360.doi:10.1016/j.gaitpost.2012.11.029.
  12. Era P, Sainio P, Koskinen S, Haavisto P, Vaara M, Aromaa A. Postural balance in a random sample of 7,979 subjects aged 30 years and over. Gerontology. 2006; 52(4):204-213.doi:10.1159/000093652.
  13. Kędziorek J, Błażkiewicz M. Nonlinear measures to evaluate upright postural stability: A systematic review. Entropy (Basel). 2020; 22(12):1357.doi:10.3390/e22121357.
  14. Brumagne S, Cordo P, Verschueren S. Proprioceptive weighting changes in persons with low back pain and elderly persons during upright standing. Neurosci Lett. 2004; 366(1):63-66. doi:10.1016/j.neulet.2004.05.013.
  15. Brumagne S, Janssens L, Knapen S, Claeys K, Suuden-Johanson E. Persons with recurrent low back pain exhibit a rigid postural control strategy. Eur Spine J. 2008; 17:1177-1184. doi: 10.1007/s00586-008-0709-7.
  16. Letafatkar A, Rabiei P, Alamooti G, Bertozzi L, Farivar N, Afshari M. Effect of therapeutic exercise routine on pain, disability, posture, and health status in dentists with chronic neck pain: a randomized controlled trial. Int Arch Occup Environ Health. 2020; 93:281-290. doi: 10.1007/s00420-019-01480-x.
  17. Louw S, Makwela S, Manas L, Meyer L, Terblanche D, Brink Y. Effectiveness of exercise in office workers with neck pain: A systematic review and meta-analysis. S Afr J Physiother. 2017; 73(1).doi:10.1055/s-0043-1770072.
  18. Price J, Rushton A, Tyros I, Tyros V, Heneghan NR. Effectiveness and optimal dosage of exercise training for chronic non-specific neck pain: A systematic review with a narrative synthesis. PLoS One. 2020; 15(6):e0234511.doi:10.1371/journal.pone.0234511.
  19. Humphreys B, Irgens P. The effect of a rehabilitation exercise program on head repositioning accuracy and reported levels of pain in chronic neck pain subjects. Journal of Whiplash & Related Disorders. 2002; 1(1):99-112.doi:10.3109/J180v01n01_09.
  20. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. J Orthop Res. 2007; 25(3):404-412. doi:10.1002/jor.20220.
  21. O’Leary S, Falla D, Hodges PW, Jull G, Vicenzino B. Specific therapeutic exercise of the neck induces immediate local hypoalgesia. J Pain. 2007; 8(11):832-839. doi:10.1016/j.jpain.2007.05.014.
  22. Capra NF, Hisley CK, Masri RM. The influence of pain on masseter spindle afferent discharge. Arch Oral Biol. 2007; 52(4):387-390.doi:10.1016/j.archoralbio.2006.10.011.
  23. Flor H. Cortical reorganisation and chronic pain: implications for rehabilitation. J Rehabil Med. 2003; 41(41):66-72.doi:10.1080/16501960310010179.
  24. Pérez-Cabezas V, Ruiz-Molinero C, Jimenez-Rejano JJ, Chamorro-Moriana G, Gonzalez-Medina G, Chillon-Martinez R. Effectiveness of an eye-cervical Re-education program in chronic neck pain: a randomized clinical trial. Evid Based Complement Alternat Med. 2020:2020:2760413. doi:10.1155/2020/2760413.
  25. Petersen CM, Zimmermann CL, Tang R. Proprioception interventions to improve cervical position sense in cervical pathology. International Journal of Therapy and Rehabilitation. 2013; 20(3):154-63.
  26. Peng B, Yang L, Li Y, Liu T, Liu Y. Cervical proprioception impairment in neck pain-pathophysiology, clinical evaluation, and management: a narrative review. Pain Ther.2021;10:143-164.doi:10.1007/s40122-020-00230-z.

71.              Lee CH, Chen CC. Role of proprioceptors in chronic musculoskeletal pain. Exp Physiol. 2023.doi:10.1113/EP090989.