ARTICLE IN PRESS

Manual Therapy 13 (2008) 2–11

www.elsevier.com/locate/math

Masterclass

Sensorimotor disturbances in neck disorders affecting postural

stability, head and eye movement control
Julia Treleaven
Neck Pain and Whiplash Research Unit, Division of Physiotherapy, University of Queensland, Brisbane, Qld 4072, Australia
Accepted 8 June 2007

Abstract

The receptors in the cervical spine have important connections to the vestibular and visual apparatus as well as several areas of the
central nervous system. Dysfunction of the cervical receptors in neck disorders can alter afferent input subsequently changing the
integration, timing and tuning of sensorimotor control. Measurable changes in cervical joint position sense, eye movement control
and postural stability and reports of dizziness and unsteadiness by patients with neck disorders can be related to such alterations to
sensorimotor control.
It is advocated that assessment and management of abnormal cervical somatosensory input and sensorimotor control in neck pain
patients is as important as considering lower limb proprioceptive retraining following an ankle or knee injury. Afferent information
from the cervical receptors can be altered via a number of mechanisms such as trauma, functional impairment of the receptors,
changes in muscle spindle sensitivity and the vast effects of pain at many levels of the nervous system. Recommendations for clinical
assessment and management of such sensorimotor control disturbances in neck disorders are presented based on the evidence
available to date.
r 2007 Elsevier Ltd. All rights reserved.

Keywords: Sensorimotor; Eye; Head; Postural stability; Cervical; Management

1. Introduction spindles per gram (Kulkarni et al., 2001; Boyd Clark

Sensorimotor control of stable upright posture and
head and eye movement relies on afferent information
from the vestibular, visual and proprioceptive systems,
which converge in several areas throughout the central
nervous system. The cervical spine has an important role
in providing the proprioceptive input and this is
reflected in the abundance of cervical mechanoreceptors
and their central and reflex connections to the vestib-
ular, visual and central nervous systems.
Muscle spindles in the cervical region are found in
high densities especially in the suboccipital region where
there are up to 200 muscle spindles per gram of muscle.
This number is considerable when compared to the first
lumbrical in the thumb where there are 16 muscle
Tel.: +617 3365 2275; fax: +617 3365 2775.
E-mail address: j.treleaven@shrs.uq.edu.au
et al., 2002; Liu et al., 2003). The cervical muscles,
especially the suboccipital muscles, relay information to
and receive information from the central nervous system
and there are specific connections between the cervical
receptors and the visual and vestibular apparatus and
the sympathetic nervous system (Selbie et al., 1993;
Bolton et al., 1998; Corneil et al., 2002; Hellstrom et al.,
2005). The cervical afferents are also involved in three
reflexes influencing head, eye and postural stability: the
cervico-collic reflex (CCR), the cervico-ocular reflex
(COR) and the tonic neck reflex (TNR). These reflexes
work in conjunction with other reflexes, which are
influenced by vestibular and visual input for coordinated
stability of the head, eyes and posture. The CCR
activates neck muscles in response to stretch to assist in
the maintenance of head position (Peterson, 2004). The
COR works with the vestibuloocular reflex and optoki-
netic reflex, acting on the extraocular muscles, to assist

1356-689X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2007.06.003
 ARTICLE IN PRESS
J. Treleaven / Manual Therapy 13 (2008) 2–11
Cerebral cortex
Thalamus
Hypothalamus
Reticular formation
Spinothalamic
Spinocerebellar
Propriospinal Tracts
Ventral
Dorsal horn
Cervical
COR
CCR
OKR
Ocular
VOR
TNR
Lower limb
Fig. 1. Central and reflex connections associated with the cervical spine afferents.
clear vision with movement (Mergner et al., 1998).
The TNR is integrated with the vestibulospinal reflex
to achieve postural stability (Yamagata et al., 1991)
(Fig. 1).
The importance of the cervical central and reflex
connections can be realized from response to artificial
disturbances to the cervical afferents in asymptomatic
individuals. Sectioning of the cervical nerves or anaes-
thetic injections into the neck causes nystagmus,
disequilibrium and severe ataxia (DeJong and DeJong,
1977; Ishikawa et al., 1998). Vibration of neck muscles,
which is thought to stimulate muscle spindle afferents,
induces several disturbances in asymptomatic indivi-
duals including changes to eye and head position,
alterations to body sway and the velocity and direction
of gait and running (Lennerstrand et al., 1996; Bove
et al., 2002; Courtine et al., 2003). Similar effects have
been demonstrated by either simple isometric neck
muscle contractions or induced neck muscle fatigue
(Gosselin et al., 2004; Schmid and Schieppati, 2005;
Vuillerme et al., 2005). Such disturbances are thought to
result from a mismatch between abnormal information
from the cervical spine and normal information from the
vestibular and visual systems.
2. Disturbances in sensorimotor control in neck disorders
Considering the experimental evidence, it is not
surprising that disturbances in cervical joint position
sense (JPS) (Revel et al., 1991; Heikkila and Astrom,
3
Superior colliculous
Medial and lateral vestibular nucleii
Central cervical nucleus
Dorsal column nucleii
Cerebellum
SNS
VCR
Vestibular
VSR
1996; Treleaven et al., 2003), postural stability (Karlberg
et al., 1996; Sjostrom et al., 2003; Treleaven et al.,
2005a, b; Field et al., 2007) and oculomotor control,
such as altered smooth pursuit and saccadic eye move-
ment (Tjell et al., 2003; Treleaven et al., 2005a, b; Storaci
et al., 2006), can present in patients with neck disorders
of either an insidious or traumatic nature as a result of
cervical somatosensory dysfunction. An increased gain
of the cervico-ocular reflex has also been demonstrated
in patients with whiplash (Montfoort et al., 2006).
Altered smooth pursuit neck torsion control occurs in
neck pain subjects (both idiopathic and traumatic) but
not in those with vestibular disorders and central
nervous system dysfunction. Smooth pursuit neck
torsion control is a difference in eye movement control
when measured with the neck in torsioned (i.e., trunk
turned 451 but the head remains neutral compared to a
neutral head, neck and trunk position) and supports the
premise of neck afferent dysfunction as the cause of the
smooth pursuit eye movement disturbances (Tjell and
Rosenhall, 1998; Tjell et al., 2003; Treleaven et al.,
2005a, b).
Complaints of dizziness and or unsteadiness can also,
but not necessarily, occur in patients with chronic
cervical headache and persistent whiplash-associated
disorders (Treleaven et al., 2003; Jull et al., 2007). Some
neck pain patients also report visual complaints, loss of
balance and actual falls (Hulse and Holzl, 2000;
Treleaven et al., 2003). Cervical vertigo is considered a
principle cause when associated with a whiplash injury
(Wenngren et al., 2002; Treleaven et al., 2006) but other
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4 J. Treleaven / Manual Therapy 13 (2008) 2–11

causes of dizziness and unsteadiness should be consid-
ered, such as damage to the vertebral artery, vestibular
receptors or central nervous system, elevated anxiety or
medication intake (Baloh and Halmagyi, 1996; Ernst
et al., 2005; Sturzenegger et al., 1994). Greater deficits in
tests of head and eye movement control and postural
stability have been measured in patients with neck
disorders of traumatic origin, in association with the
complaint of dizziness (Tjell et al., 2003; Treleaven et al.,
2003, 2005a, b), although these deficits can present in the
absence of dizziness as well as in patients with idiopathic
neck pain (Kristjansson et al., 2003; Tjell et al., 2003;
Field et al., 2007). Although the causes of the
disturbances are similar it has been shown that an
individual patient may present with dysfunction in either
one or several systems. For example, an individual
patient may have moderate disturbances to eye move-
ment control but not necessarily have the same degree
or any disturbance in cervical JPS or balance (Treleaven
et al., 2006).
It would appear that either decreased or increased
cervical somatosensory activity can result in distur-
bances of sensorimotor function (Hinoki and Niki,
1975; DeJong and DeJong, 1977). This occurs via a
number of mechanisms (Fig. 2). Cervical mechanor-
eceptor function could be altered as a result of direct
trauma to mechanoreceptors (Loescher et al., 1993;
Chen et al., 2006), functional impairment of muscles
such as increased fatigability (Falla, 2004) or degene-
rative changes in the muscles such as fibre transforma-
tion, fatty infiltration and muscle inhibition or atrophy
(Uhlig et al., 1995; McPartland et al., 1997; Kristjansson
et al., 2004; Elliott et al., 2006). In addition, the effects
of pain at many levels of the nervous system can change
muscle spindle sensitivity and alter the cortical repre-
sentation and modulation of cervical afferent input
(Le Pera et al., 2001; Thunberg et al., 2001; Flor, 2003).
Psychosocial stresses might also alter muscle spindle
activity via activation of the sympathetic nervous system
(Passatore and Roatta, 2006).
It is likely that several processes combine to cause an
immediate and sustained alteration in somatosensory
function originating from the cervical spine, which
influence the tuning and integration of input within
the sensorimotor control system. Secondary impairment
of vestibular system functioning might also occur
(Fischer et al., 1997) and this has implications for
management of such disturbances in neck disorders. The
majority of the research into sensorimotor control
disturbances has been undertaken in patients with
persistent neck pain, however there is evidence that
deficits could occur soon after the onset of pain (Sterling
et al., 2003) and may have an influence on prognosis
(Hildingsson et al., 1993). Thus, routine assessment of
head and eye movement control and postural stability in
neck disorders is recommended.
Evidence to date would suggest that management of
disturbed sensorimotor control due to cervical somato-
sensory dysfunction might need to address the primary
causes of the altered somatosensory activity as well as
secondary effects. Specific treatments to the neck such as
acupuncture, manual therapy and cranio-cervical flexion
training have improved cervical joint position error,
vertigo and/or standing balance in patients with neck
pain (Fattori et al., 1996; Heikkila et al., 2000; Reid and
Rivett, 2005; Palmgren et al., 2006; Jull et al., 2007).
Alternatively, programs that emphasize gaze stability,
eye/head co-ordination and cervical position sense
without local cervical spine treatment have resulted in
decreased medication intake, improved neck pain and
disability and cervical joint position sense (Revel et al.,
1994; Humphreys and Irgens, 2002; Jull et al., 2007).

CNS
Represenatation cortex
Somatic reorganisation

Visual Altered Vestibular

system Altered cervical afferent Altered system
reflexes reflexes
input

Altered mechano receptor

Altered muscle spindle activity

Trauma Pain
Ischaemia Stress-SNS activation
Inflammation
Altered neuromuscular control
Morphological changes

Fig. 2. Mechanisms of disturbances of cervical somatosensory input in neck disorders.

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J. Treleaven / Manual Therapy 13 (2008) 2–11 5

Improvements in balance and symptoms of dizziness

have also been observed following a vestibular or
oculomotor rehabilitation program in patients with
persistent whiplash (Hansson et al., 2006; Storaci
et al., 2006). Currently local treatment to the cervical
spine in conjunction with tailored programs for sensori-
motor control is recommended for patients with neck
disorders. The tailored sensorimotor program is similar
to that used in vestibular rehabilitation (Herdman,
2000). This combined approach will address the local
causes of abnormal cervical afferent input and consider
the important links between the cervical, vestibular and
ocular systems and any secondary adaptive changes in
the sensorimotor control system.

3. Clinical assessment of sensorimotor control

disturbances in neck disorders

Based on the evidence to date, the assessment of

sensorimotor control in the neck pain patient should
include: investigation of the symptom of dizziness and
unsteadiness and measurement of cervical joint position
error, postural stability and oculomotor control. The
clinician though should be aware of other possible
causes of the disturbances and interview the patient and
choose tests accordingly to determine the most likely
cause. With respect to dizziness, the description,
temporal pattern, associated symptoms and history of
the complaint of dizziness can be useful in assisting
differential diagnosis of cervicogenic dizziness. Other
symptoms such as visual complaints (blurred vision,
words jumping and unclear contours of objects) loss of
balance, actual falls, difficulty walking in the dark, on
stairs or negotiating doorways should be noted. The
Dizziness Handicap Inventory Short Form Question-
naire (Tesio et al., 1999) can be used to quantify the
functional impact of the dizziness. The physical exam-
ination may include measures of cervical joint position
sense, postural stability and oculomotor control as
indicated. In research, precise measurements are taken
of these features. However, they can be assessed
satisfactorily in the clinical situation albeit with lesser
precision.
3.1. Cervical joint position sense (JPS)
A simple measure for cervical JPS is the use of a small
laser pointer or torch mounted onto a lightweight
headband as used by Revel et al. (1991) (Fig. 3). The
patient is seated 90 cm from a wall and the starting point
projected by the laser is marked. The patient (blind-
folded or eyes closed) performs an active neck move-
ment and then returns as accurately as possible to the
starting position. The final laser position is measured
against the starting position in centimeters. This method
Fig. 3. Test of joint position sense using a laser pointer. A measure of
joint relocation error is gained from measuring the distance between
the return and starting positions.
provides a quantitative assessment tool as errors as little
as 3–41 (4–5 cm) can indicate a deficit in cervical JPS
(Revel et al., 1991; Treleaven et al., 2003). Errors are
measured following active return from cervical exten-
sion, flexion and rotation. Relocating to selected points
in range (Loudon et al., 1997) and accuracy in retracing
patterns (Kristjansson et al., 2004) can also be used to
assess cervical kinaesthesia. Jerky movements, searching
or overshooting the initial position, reproduction of
dizziness and/or a noticeable difference of cervical
movement patterns in the test with eyes closed may
also indicate impaired cervical kinaesthetic sense.
3.2. Oculomotor
Oculomotor assessment incorporates assessment of
gaze stability (the ability to maintain gaze while moving
the head), smooth pursuit (eye follow while keeping the
head still), saccadic eye movement (rapid eye move-
ments to change a point of fixation) and eye/head co-
ordination (maintaining gaze when both the eyes and
head are moving). The tests are usually performed with
the patient in a sitting position but can be tested initially
in supine lying if necessary. The starting position will
depend on the severity of the patient’s complaints and
overall physical findings.
3.2.1. Gaze stability
Gaze stability is assessed by asking the patient to keep
the eyes focused on a target while actively moving the
head into flexion, extension and rotation (Fig. 4).
Inability to maintain focus on the target, reduced or
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6 J. Treleaven / Manual Therapy 13 (2008) 2–11
awkward cervical motion or reproduction of symptoms
such as dizziness, blurring of vision or nausea are signs
of an abnormal response.
3.2.2. Eye follow
The patient keeps the head still while following a
moving target with the eyes as closely as possible. The
target is moved slowly side to side (201/s through a
visual angle of 401). The test is repeated with the head
still but with the trunk rotated up to 451 (Fig. 5). The
test is repeated on the opposite side. Any difference is
noted in smooth eye follow or symptom reproduction in
Fig. 4. Testing gaze stability during head rotation to the right.
Fig. 5. Eye follow keeping the head still is tested (a) with the neck in a neutral position and repeated (b) with the neck torsioned via trunk rotation.
The neck torsion is tested to both the left and right. A deterioration in eye follow in the neck torsion positions, when compared to the neutral position
suggests a cervical origin of deficits in eye movement control.
these neck torsion positions compared to the neutral
position. Often patients with neck disorders will be
unable to keep up with the target and demonstrate quick
catch up eye movements when the neck is in torsion
particularly when the target is crossing the midline.
Saccadic eye movements at the extremes of the visual
angle and with the change of movement direction are
not considered abnormal.
3.2.3. Saccadic eye movement
The patient follows and fixes their gaze on a target
that is quickly moved and then held still momentarily.
The target is moved in several different directions. The
patient’s ability to quickly move to the target and fixate
on it is noted.
3.2.4. Eye/head co-ordination
The patient moves the eyes and head in the same
direction to focus on a point, leading with the eyes first
to a target and then the head ensuring the eyes keep
focused on the target. This can be performed to the left,
right and up and down.
3.3. Postural stability
A modified sensory organization test is used to assess
postural stability. Visual and proprioceptive input from
the lower limbs is altered as the tests progress (Shum-
way-Cook and Horak, 1986). Balance in comfortable
and narrow stance can be assessed with the patient
standing on a firm and then a soft surface such as a piece
of 10 cm dense foam. The tests should be performed
with both eyes open and closed. Inability to maintain
stance for 30 s, noticeably large increases in sway, slower
responses to correct sway or rigidity to prevent sway are
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J. Treleaven / Manual Therapy 13 (2008) 2–11
considered abnormal responses. It is thought that people
with neck disorders rely more on vision and other
somatosensory inputs for balance and thus deficits will
be greatest when these inputs (e.g., vision) are reduced.
For increasing challenge, the patient can be tested in
tandem and then single leg stance on a firm surface with
eyes open and closed. It is reasonable to expect that a
person under the age of 60 years can maintain stability
for up to 30 s in the comfortable and narrow stance tests.
Subjects under 45 years should also be able to complete
tandem and single leg stance tests. (Treleaven et al.,
2005a, b) Assessment of the ability to complete the 30 s
of the tandem stance can be a useful screening test
(Treleaven et al., 2005a, b; Field et al., 2007).
3.4. Additional tests
There is some evidence that the neck may directly
influence vestibular functioning (Fischer et al., 1997). In
addition, primary vestibular pathology is also possible
following a whiplash injury or in the middle aged/elderly
population. Thus, assessment of postural control
disturbances may need to address secondary vestibular
influences on postural control. While there is certainly
overlap between cervical and vestibular systems in a
number of the testing procedures already described,
additional tests to investigate vestibular function more
closely may be necessary in some neck pain patients,
especially those complaining of loss of balance and falls.
Factors such as ageing, pre-existing vestibular patho-
logy and medical conditions might increase the degree of
disturbances in those with neck disorders (Poole et al.,
2007). Additional tests might include tests of dynamic
balance and functional ambulation (Herdman, 2000;
Alpini et al., 2005), as well as testing of the vestibulo-
ocular reflex (Herdman, 2000). In cases where Benign
Paroxysmal Positional Vertigo is suspected the Hall-
pike-Dix manoeuvre should be included (Herdman,
2000). Referral for a more thorough investigation of the
vestibular or central nervous system may be warranted
in those where cervical causes of the disturbances cannot
be substantiated.
4. Management of sensorimotor control disturbances in
neck disorders
The findings of the assessment will direct and tailor
the most appropriate management of sensorimotor
control disturbances in the individual patient with a
neck disorder. It is suggested that management include
both local treatment to the neck to decrease pain and
improve neuromuscular function in combination with
tailored sensorimotor exercises to improve any deficits
in cervical JPS, oculomotor control and postural
stability. This addresses the causes of abnormal cervical
7
mechanoreceptor input as well as the effects resulting
from the potential conflict arising from abnormal
cervical afferent input and normal vestibular and ocular
input.
Exercises for each system should be performed two to
five times per day. Temporary reproduction of dizziness
is acceptable however exacerbation of neck pain or
headache is not acceptable. If this occurs the exercises
should be modified by decreasing the number of
repetitions or altering the patient position to a more
supported position such as supine lying. Progression of
each exercise set can be achieved by altering the
duration, repetitions and the degree of difficulty of the
task. Exercises can also be progressed by performing
activities such as an eye task or cervical JPS practice
while sitting on an unstable surface or while standing
with the feet in an unstable base of support for example,
heel toe stance, or while walking. Some examples follow.
4.1. Cervical joint position sense
The patient practices relocating the head back to the
natural head posture and to pre-determined positions
in range from the movement directions assessed to be
abnormal. The patient may practice first with the eyes
open and then with eyes closed, lining up their natural
head posture and target positions with points on the
wall to check their accuracy on return. The exercise can
be made more precise for home use with the use of a
pencil torch or laser attached to a headband. Higher
level skills training could include tracing intricate
patterns, such as a figure of 8 placed on the wall, with
the head using the head torch or laser for feedback.
4.2. Oculomotor exercises
The exercise level is set on the basis of the oculomotor
assessment. The degree of difficulty for oculomotor
exercises can be increased by increasing the speed of the
task, range of motion, changing the patient’s position
and the focus point or background (Fig. 6). Table 1
outlines how each of the various variables can be altered
to progress the exercises.
4.2.1. Eye follow with a stationary head
The patient eyes follow a target moving side to side
and up and down keeping the head still. For home use,
the patient could practice tracking a tennis ball tossed
sideways or up and down whilst keeping the head still.
4.2.2. Saccadic eye movements
Saccadic movements of a target are performed at
randomised eye positions. Progression can include
increasing the speed of the movements, position of
the patient and the visual background or focus point
(Table 1).
 ARTICLE IN PRESS
8 J. Treleaven / Manual Therapy 13 (2008) 2–11

Focus on
Focus
these words

Focus on
Focus
these words

Focus on
Focus
these words

Fig. 6. Progression of eye exercises by altering either the focus point or the background of the focus point.

Table 1
Various methods of progression of the oculomotor exercises

Variable Start Progress Further progression

Target Single spot Word Business card

Background to target Plain Stripes Checker board
Patient position Supine—sitting Standing—vary stance Walking
Neck position Neutral Torsion 301 Torsion 451
Speed Slow Medium Fast
Vision Unrestricted Restricted peripheral Restricted peripheral
Range of motion Small Medium Large
Duration of exercise 30 s 1–2 min 5 min
Frequency of exercise 2  day 3  day 5  day

4.2.3. Gaze stability
Training may commence with the clinician perform-
ing slow passive neck movements or the patient
performing active neck movements, while they fixate
their gaze on a point on the ceiling. The clinician can
also passively move the trunk while the patient
maintains gaze on a target. The patient can be asked
to fix their gaze on a point, close their eyes and perform
a neck movement and open their eyes after the head
movement to check for stable gaze on the target. Any
task may be progressed by restricting peripheral vision,
using a pair of swimming goggles that have been
blackened out except for a small area in the center of
each side.
4.2.4. Eye/head co-ordination
The exercises commence with rotating the eyes and
head to the same side, in both left and right and up
and down directions. As a progression, the eyes are
moved first, then the head, but the patient continues
to maintain focus on two targets which can be
positioned horizontally or vertically. Further progres-
sion could include the patient performing active
neck rotation to follow a slow moving target while
their peripheral vision is restricted. The patient
can also practice rotating the eyes and head to
the opposite side in both directions. For home
practice, the patient could hold a target in front of
them and move the target and their head in opposite
directions.
The patient should also practice moving the eyes,
head, neck and arm following their thumb or moving
the eyes, head, neck and trunk to look as far behind as
possible. Active movements of the head to follow a
moving target can be performed both with unrestricted
and peripheral restricted movement.
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J. Treleaven / Manual Therapy 13 (2008) 2–11
Fig. 7. Home practice of tandem stance balance exercise.
4.3. Postural stability
The starting level for balance retraining will depend
on which tests the patient failed or had difficulty with in
the clinical assessment. This could be comfortable,
narrow, tandem or single leg stance. The conditions
for training progress from eyes open, eyes closed to
different supporting surfaces. Patients practice the
exercise at home perhaps in a corner area, such that
they are able to regain balance easily if necessary
(Fig. 7). They gradually increase the time of maintaining
stability to reach 30 s. Challenges to the system can be
increased with the addition of relocation practice or
oculomotor exercises to the balance exercise. Walking
forwards, backwards and sideways while actively mov-
ing the head into different directions, maintaining
direction and velocity of gait, also challenge cervical
afferent input for balance mechanisms.
5. Conclusion
Given the importance of the neck for postural
stability, head and eye movement control, as well as
the nature of the changes in sensorimotor control seen in
those with neck disorders, assessment and management
of such disturbances should form an important part of
the multimodal approach to neck disorders. This should
include addressing the causes of the altered cervical
somatosensory input such as improving neuromuscular
function and decreasing pain and inflammation as well
9
as a tailored sensorimotor exercise program to improve
identified deficits in postural stability and head and eye
movement control. The recommended clinical assess-
ment and management is based on the available
evidence to date, however this is an emerging area and
more extensive research is needed to refine and identify
methods for assessment and determine the optimal
strategies for management of such disturbances in
patients with neck disorders.
There will be a case study published online to support
this Masterclass at a later date.
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