Effects of Cervical Proprioceptive Training in CMNP
Condition: Chronic Neck Pain
MeSH terms: Neck Pain
Study type: Interventional

Summary: 
      It is a randomized control trial will be conducted at Federal Government Polyclinic hospital
      on 44 chronic mechanical neck pain patients. Patients will be recruited in the study through
      non probability purposive sampling. Random allocation will be done through toss coin method
      into two groups; Conventional Physiotherapy Control group (n=22) and Proprioceptive training
      Experimental group (n=22). Research data will be collected through structural questionnaires.
      Tools will be used to collect data are NPRS, NDI, Goniometer (Cervical ROMs) and
      proprioception.
    

Detailed description: 
      Neck pain is a very common complaint. In the general population and musculoskeletal practice,
      it occurs second to low back pain in its frequency. Neck pain has a point prevalence of
      nearly 13% and lifetime prevalence of nearly 50%. Neck pain and disability are prevalent
      throughout the industrialized society. It is a common reason for visits in accidents and
      emergency departments. In Chiropractic treatment, Neck pain is the second most common
      complaint. It Is the result of fast, mechanical, stressful life, lack of mobility and poor
      posture. Some injury can also lead to neck pain. Sometimes neck pain lasts for a few days and
      itself goes away, but when it persists for a long time it results in greater problems. Neck
      pain is said to be more common in females than in males and in peaks at the middle age.
      Sedentary lifestyles are contributing to the prevalence of neck pain. Neck pain is one of the
      most debilitating musculoskeletal problems. Neck problems are a significant source of
      disability to patients, but they have not been studied in detail as low back pain problems.

      Neck pain can be categorized in many ways i.e. Duration(Acute, Sub acute, Chronic),
      Intensity, Severity, Type(Mechanical, Neuropathic etc.). Among them duration proves to be the
      best predictor of outcome. Short duration pain have better prognosis than long standing pain.
      Mechanical Neck Pain is defined as widespread cervical and/or shoulder pain possessing
      mechanical properties, such as symptoms aggravated by prolonged or abnormal neck posture,
      neck mobility and/or by palpation of the neck musculature Mechanical pain originates from the
      spine or by its supporting structures, such as muscles and ligaments. Pain arising from the
      facet joints eg, arthritis, diskogenic pain, and myofascial pain can be named as Mechanical
      pain. It is proposed to be associated with several anatomic structures, predominantly facet
      joints and uncovertebral(Luschka's joints). The risk factors for mechanical neck pain include
      abnormal posture, stress, substantial lifting and anxiety. Around 15% females and 10% males
      suffer from Chronic mechanical neck pain at any one time in life. Clinicians find it
      challenging to prevent a patient from entering into the chronic phase of their condition.

      The most mobile part of the vertebral column is the upper cervical spine. And it is at the
      expense of its mechanical stability. Neuromuscular control to the mobile cervical spine is
      provided by the highly developed proprioceptive system. Neck pain can lead to disturbed
      afferent input from the cervical region that may be a possible cause of symptoms such as
      dizziness, unsteadiness, and visual disturbances. Signs of altered postural stability,
      cervical proprioception, and head and eye movement control are also said to be the cause of
      disturbed afferent input.

      By an abundance of mechanoreceptors, the proprioceptive system of the cervical spine is very
      well developed especially from the muscle spindles in the deep segmental upper cervical
      muscles. Muscle spindle afferent are more important because they are the first ones to
      operate in proprioception. As compared to the lower cervical spine, the upper cervical spine
      has an abundance of muscle spindle receptors and greater contributions to reflex activity and
      connections to the visual and vestibular systems. It concludes that patients with the cause
      of upper cervical complaints in neck pain have a greater chance for balance and visual
      disturbances than those with complaints of lower cervical spine.

      The ability to maintain body orientation and posture in relation to the surrounding
      environment is a key process required for normal functions such as coordinated movements.
      Sensorimotor control of stable upright posture and head and eye movement depends on afferent
      information from the vestibular, visual and proprioceptive systems, which all together merge
      in several areas of the Central Nervous System. Proprioception is important for well-adapted
      sensorimotor control. Proprioception fulfills roles in feedback sensorimotor control and
      regulation of muscle stiffness, being specifically important for movement acuity, joint
      stability, coordination, and balance. For head-eye co-ordination and movement control,
      cervical proprioception is uniquely important. Musculoskeletal disorders due to pain,
      effusion, trauma, and fatigue alter the normal proprioceptive mechanism.

      Neck pain patients are said to have a poor awareness of their head and neck posture, and a
      few patients are reported to complain about "whopping head" which might be the cause of
      altered cervical position sense. The rehabilitation procedures in the field of
      musculoskeletal diseases aim to improve muscular force, joint mobility, and proprioceptive
      sensibility. Currently, only strength and mobility are evaluated in cervical spine
      rehabilitation programs, although a wealth of cephalic and neck receptors suggests a major
      emphasis on proprioceptive information in postural and dynamic functions of the head-neck
      system.

      A study by J Arami and colleagues (2014) on the "Applicability of proprioceptive and
      endurance measurement protocols to treat patient with chronic non-specific neck pain" was
      conducted. Chronic neck pain patients were divided into two groups, one of them received
      endurance training and the other group received proprioceptive training. This study suggested
      that endurance exercise was a more efficient method for improving endurance and
      Proprioceptive training was better in resolving joint position error and Pain. Both protocol
      appeared to be useful in treating patients with chronic non specific neck pain.

      Cervicogenic headache is getting common in young adults along with proprioception deficit in
      the cervical region. In this study, 30 participants of Cervicogenic headache were included.
      The control group received stretching exercises. The experimental group in addition to
      stretching received cervical stabilization exercises. Headache disability index and neck
      proprioception were evaluated before and after the treatment programs. At the end of 4rth
      week, Headache disability index scores and neck pain and proprioception error improved more
      in the experimental group. Hence the study concluded that Cervical stabilization exercises
      along with stretching are more effective in improving neck proprioception and Headache
      disability index than stretching alone.

      The presence of strong coupling between gaze orientation and muscle neck activity has been
      well documented in humans. This co-ordination between neck motor functions and eye strongly
      suggest that eye head coupling based rehabilitation program are more appropriate to improve
      neck proprioception and this afterwards aid in reducing pain. A comparison was done between
      two groups of neck pain patients one of them receiving the traditional physiotherapy protocol
      for chronic neck pain and the experimental group received an eye head coupling based
      rehabilitation program modified from Revel et al., in addition to the traditional protocol
      given to the other group. The results showed a significant reduction in scores of Neck Pain
      and Disability scale in both groups with a greater decrease in the experimental subjects.
    

Intervention name(s): conventional physiotherapy; Cervical proprioceptive training
Intervention type(s): Other; Other
Intervention description(s): TENS for 15 minutes on Constant Mode according to patient comfort.
Infrared for 15 minutes.
Isometric exercises: Isometric neck flexion, extension, side bending exercises were given. 3 sets of 10 repetitions each were given. And resistance was given for 6-8 seconds for each movement.
Stretching exercises: Passive stretching for Sternocleidomastoid, short sub occipital muscles, Trapezius & Scalene, Pectoralis Major was given. 3 sets of 10 reps were given and each stretch was maintained for 10 seconds.
Home Plan: self stretches and isometrics.
Postural Education: posture correction in daily life activities in sitting, walking, lying.; TENS for 15 minutes on Constant Mode according to patient comfort.
Infrared for 15 minutes.
Isometric exercises: Isometric neck flexion, extension, side bending exercises were given. 3 sets of 10 repetitions each were given. And resistance was given for 6-8 seconds for each movement.
Stretching exercises: Passive stretching for Sternocleidomastoid, short sub occipital muscles, Trapezius & Scalene, Pectoralis Major was given. 3 sets of 10 reps were given and each stretch was maintained for 10 seconds.
Home Plan: self stretches and isometrics.
Postural Education: posture correction in daily life activities in sitting, walking, lying.
The patients wearing a cap with a laser pointer attached to it were seated three feet away from the target A, B and C. Start Chart A with a 3 cm, chart B 2cm and chart C 1cm narrow pathway were presented to the patients. The time taken by the patient to complete the pathway without any error was noted.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Random allocation will be done through toss coin method into two groups; Conventional Physiotherapy Control group (n=22) and Proprioceptive training Experimental group (n=22).
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: chronin non traumatic neck pain; Joint position error; Cervical Proprioception; NDI