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Manual Therapy 13 (2008) 266–275

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Case Report

Sensorimotor disturbances in neck disorders affecting postural

stability, head and eye movement control—Part 2: Case studies
Julia Treleaven
Neck Pain and Whiplash Research Unit, Division of Physiotherapy, University of Queensland, Brisbane, Q1d 4072, Australia
Received 8 October 2007; accepted 8 November 2007

Abstract

Recent research highlights sensorimotor control disturbances in those with neck disorders. Assessment and management of the
symptoms of dizziness, altered cervical proprioception, eye and head co-ordination and disturbances to postural stability in those
with neck disorders are important and are presented in a companion article. In this paper, four case studies are presented to illustrate
the formulation and use of a tailored program designed to retrain balance, cervical proprioception and eye and head movement
control in those with neck disorders. This program should be used in conjunction with a multi-modal approach to the management
of neck disorders. Such a combined approach should address causes of abnormal cervical afferent input as well as the important
links between the cervical, vestibular and ocular systems and adaptive changes in the sensorimotor control system.
r 2007 Elsevier Ltd. All rights reserved.

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

1. Introduction and any adaptive changes in the sensorimotor control

In the preliminary article to this paper, the theoretical
framework for the assessment and management of
sensorimotor control disturbances affecting postural
stability, head and eye movement control in neck
disorders was presented. (Treleaven, 2007) Such dis-
turbances are thought to be resultant of abnormal
cervical afferent input and subsequent changes to the
integration, timing and tuning of sensorimotor control.
Recommendations for clinical assessment and manage-
ment of such sensorimotor control disturbances in neck
pain were presented based on the evidence available to
date (Treleaven, 2007). This highlighted the need for a
combined approach to address not only the possible
causes of abnormal cervical afferent input, such as pain,
inflammation, altered muscle spindle sensitivity and
functional impairment and morphological changes of
neck musculature, but to also consider the important
links between the cervical, vestibular and ocular systems
E-mail address: j.treleaven@shrs.uq.edu.au
system. Thus, local cervical treatment in conjunction
with tailored programs including cervical joint position
retraining, gaze stability and eye–head co-ordination
exercises as well as walking and balance training to
improve sensorimotor control in patients with neck
pain was recommended. The current paper presents a
series of case studies to specifically illustrate the
formulation and use of the tailored program designed
to retrain the sensory and motor aspects of sensorimotor
control in those with neck pain. The case studies also
highlight the assessment of sensorimotor control in neck
pain including investigation of the symptoms of dizzi-
ness and unsteadiness, cervical joint position error
(JPE), balance and oculomotor control and presents
considerations for other possible causes of such dis-
turbances. Particular emphasis is placed on the tailored
program in the case studies to illustrate its use, but this
should always be incorporated into a multi-modal
approach.
The tests used in the assessment of sensorimotor
control and the specifics of the tailored exercises are

1356-689X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2007.11.002
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J. Treleaven / Manual Therapy 13 (2008) 266–275
Table 1
Examples of exercises to improve sensorimotor control in neck
disorders
Activity Task
Improve cervical Relocate back to neutral, eyes closed, laser on
headband, check with eyes open
Joint position Relocate to pre-determined positions in range,
error (JPE) laser on headband, dots along wall eyes closed,
check eyes open
Practice tracing intricate patterns on the wall
with laser mounted on headband, eyes open
Improve balance Eyes open then closed, firm then soft surface
Different stances—comfortable, narrow,
tandem, single leg
Walking with head movements—rotation,
flexion and extension maintaining direction and
velocity of gait
Performing oculomotor or JPE exercises while
balance training
Improve oculomotor
Eye follow Eyes follow laser light moving backwards and
forwards across a wall while sitting in a neutral
neck position, then neck torsion (move laser
light with hand in lap)
Saccades Place numbered points at different points
around concentric circles, quickly move and
focus to randomized number
Gaze stability Maintain gaze as passively move trunk, neck
Maintain gaze as actively move trunk and neck
all directions
Change the focus point—few words, business
card
Fix gaze, close eyes, move head and open eyes
to check have maintained gaze (imaginary gaze)
Change the background of the target—plain,
stripes, checks
Eye–head co- Move eyes focus and then move head same
ordination direction and return to neutral
Move eyes one direction and head opposite
direction
Actively move head and eyes together
Move head and eyes together when peripheral
vision restricted
Move hand, arm, head and trunk following
with the eyes with or without vision restricted
outlined in Treleaven (2007); a summary of some of the
exercises is presented in Table 1. Other tests are outlined
in Jull et al. (2004). Brief descriptions of the ques-
tionnaires used are as follows.
 The Neck Disability Index is a 10-question assess-
ment tool, which records patient responses to
questions about neck pain and other symptoms, as
well as their effects on physical and social function.
The composite score indicates the degree of pain and
disability, with higher scores indicative of greater
disability (Vernon, 1996).
267
 The VAS provides a measure of pain intensity on a
scale where 0 is equivalent to no pain and 10
represents the worst pain imaginable. Higher scores
on VAS represent greater perceived pain.
 The General Health Questionnaire 28 (GHQ 28) is a
28-item measure of emotional distress in medical
settings, which is divided into four subscales: somatic
symptoms, anxiety/insomnia, social dysfunction and
severe depression. The total score can be used as a
measure of psychological distress. A score above 23 is
thought to be indicative of elevated psychological
distress (Goldberg, 1978).
 The Impact of Events Scale (IESR) is a questionnaire
that measures current stress related to a specific life
event, specifically the motor vehicle collision. Three
response sets are reported to be associated with
psychological reactions to stress: avoidance, intrusion
and hyperarousal (Weiss and Maramar, 1997).
 The Patient Specific Functional Scale (PSFS) is a
questionnaire used to quantify activity limitation
and measure functional outcome for patients. The
score ranges from 0 (unable to perform the activity)
to 10 (able to perform activity) at pre-injury level
(Westaway et al., 1998).
 The Dizziness Handicap Inventory short form
(DHIsf) is a 13-item questionnaire developed to
measure the self-perceived level of handicap asso-
ciated with the symptom of dizziness. The DHIsf is
scored between two statements; the first is scored 1
and the second is scored 0, with a possible maximum
score of 13, where 13 indicates no dizziness handicap
and 0 maximum handicap (Tesio et al., 1999).
2. Case studies
2.1. Case 1: acute whiplash injury complaining of
dizziness
2.1.1. Miss X, age 26 years, flight attendant
2.1.1.1. History. Miss X reported that she had been
involved in a motor vehicle collision 5 days prior. She
had been stopped on the highway in traffic and a car
behind her traveling at approximately 80 km/h was
unable to brake in time and rear-ended her car and
pushed it into the car in front. She felt immediate
bilateral neck pain and stiffness and visited her GP. She
had plain cervical X-rays that were unremarkable. Since
then her neck pain has persisted and intermittent
occipital headache is noted particularly if her neck pain
is exacerbated. She reported moderate restriction in her
range of cervical motion and several episodes of
dizziness and some blurred vision when her neck pain
is exacerbated. Dizziness was reported to last several
seconds. True vertigo or spinning was not reported.
Her symptoms were reportedly increased by neck
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movements and sustained neck positions and eased with dizziness, others difficult to assess at this stage, due
rest, heat and simple analgesic medications. She has not to poor cervical range of motion.
sought any other treatment to date. She is currently off  Eye follow neutral—some dizziness reproduced,
work. She also reported nervousness related to driving unable to assess torsion position due to lack of
as a passenger and has not tried to drive herself. She has range of motion.
also been having dreams and nightmares associated with  Gaze stability—poor with left cervical rotation and
the accident. She reported no past history of neck pain, flexion.
dizziness or blurred vision or headaches prior to the  Saccadic eye movements—poor for eye movements
motor vehicle collision. to the left and downwards.
 Eye–head co-ordination—unable to assess accu-
2.1.1.2. Questionnaire scores rately due to lack of cervical range of motion.
 Neck 30/100 Moderate disability
Disability 2.1.1.5. Initial management. A multi-modal interven-
Index tion may include pain-free manual therapy and exercise
therapy to improve neuromuscular control and cervical
 Current 4/10 Moderate neck pain range of motion and advice regarding pain relief,
pain VAS ergonomics and posture. Monitoring of the signs of
specific distress relating to the accident (elevated IESR
 GHQ 28 18/84 Below threshold score and reports of nightmares and dreams about
distress the accident) should be conducted over the next couple
 IESR 5/12 Moderate distress of visits and referral to a psychologist if symptoms
persist.
 Dizziness 8/13 Mild handicap A tailored program to assist with improvement of
Handicap sensorimotor control should also be integrated and
Inventory would include
(sf)
 Balance comfortable stance eyes open and closed—
 Patient Reading 5, Driving 6, up to 30-s attempts.
specific Sleeping 5  Eye follow in neutral—in supine lying.
functional  Gaze stability—using target of small dot or mark on
scale /10 the ceiling—flexion and rotation to the left per-
formed passively during treatment and actively in
supine lying.
2.1.1.3. Relevant physical examination findings
Add next visit/visits
 Global moderate restriction in cervical range of
motion.  Cervical JPE—left rotation relocation to neutral
 Symptomatic joint dysfunction (L) C 1/2 and 2/3 practice in supine lying if able to perform pain free.
motion segments (pain VAS 7/10), decreased pressure  Saccades—practicing quickly moving eyes to the left
pain thresholds over the left cervical spine. and downwards to fixate on a point.
 Neuromuscular control—poor neuromuscular con-
trol of the cervical and left shoulder girdle region.
 No evidence of nerve tissue mechanosensitivity, 2.1.1.6. Home program. Two times per day, five
neurological deficits or generalized hypersensitivity. repetitions per exercise. Stop any exercises if it exacer-
bates pain or headache. A slight exacerbation of
dizziness/blurred vision is allowable.
2.1.1.4. Assessment of sensorimotor control
2.1.1.7. Progress. Progression of the oculomotor ex-
 Balance—comfortable stance eyes closed repro- ercises can be achieved by altering the focus point,
duced dizziness and demonstrated marked increased background of the focus point, duration, repetitions,
sway. Higher-level balance tests not required at this range and speed of the activity as well as performing the
stage. above relocation, gaze stability and eye follow exercises
 Cervical JPE in sitting—global limited range of in sitting.
motion to 201 most movements—inaccurate return Once cervical range of motion improves reassessment
to neutral from rotation to left productive of of each task and other tests unable to assess initially
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should be performed and exercises tailored according to 2.2.1.2. Questionnaire scores.

the findings.
 Neck 16/100 Mild disability
Disability
2.1.1.8. Commentary. This case illustrates that the Index Score
onset of sensorimotor disturbances can occur soon after
injury (Sterling et al., 2003a). Often a full assessment  Current pain 4/10 Moderate neck
cannot be conducted initially due to poor cervical range VAS pain
of motion, but should be introduced as soon as able and
reassessed as range of motion improves. Some of the  GHQ 28 4/84 Below threshold
exercises can begin immediately even though the patient distress
has a significant reduction in cervical range of motion.  Dizziness 13/13 No handicap
Eye and head exercises are initially encouraged in supine Handicap
to prevent neck pain and headache exacerbation. Inventory (sf)
Exercises can particularly exacerbate headache and
performing the exercises in a comfortable supported  Patient specific Reading 7,
position should eliminate this. Limiting how many functional Driving 7,
exercises are given for the home program as well as scale Sustained sitting 7
integrating the exercises into others such as while
performing range of motion exercises will also avoid
pain exacerbation and avoid an ‘‘overload’’ of exercises. 2.2.1.3. Relevant physical examination findings
This should assist with patient compliance with the
home program.  Moderate restriction in cervical range of motion
In this case, the description of the dizziness and the into right rotation and lateral flexion.
deficits in sensorimotor control support the cervical  Symptomatic joint dysfunction at the (R) C 2/3 and
spine as the primary cause of the disturbances rather 5/6 motion segment (pain VAS 3/10).
than a vestibular or an anxiety-related cause. The  Neuromuscular control—poor neuromuscular con-
patient does present with an elevated level of specific trol of the cervical and right shoulder girdle regions.
psychological distress relating to the accident but  No evidence of nerve tissue mechanosensitivity,
this is unlikely to be the primary cause of the neurological deficits or secondary hyperalgesia.
sensorimotor disturbances although it might contribute
to abnormal cervical afferent input, via sympathetic 2.2.1.4. Assessment of sensorimotor control
nervous system activation (Passatore and Roatta, 2006),
and should be closely monitored and addressed as it has  Balance—comfortable stance within normal limits.
also been shown to be a prognostic indicator for a Narrow stance eyes closed on foam—moderate
poorer outcome for whiplash-associated disorders and increased sway. Tandem stance eyes closed unable
unlikely to change over time without intervention to maintain 30 s, failed at 5 s.
(Sterling et al., 2003b).  Cervical JPE (o4.5 cm normal)—extension 1 cm,
rotation (L) 2.5 cm, rotation (R) 2 cm. All within
2.2. Case 2: chronic neck pain and headache— normal limits.
no reported dizziness  Eye follow with left neck torsion position difficult to
follow with increased saccades when compared to
2.2.1. Mrs. X, age 46 years, counselor neutral neck position and right neck torsion
2.2.1.1. History. Mrs. X reported bilateral neck pain position.
right side greater than left, stiffness and tightness in the  Gaze stability—flexion and rotation to the right
upper trapezius region as well as an occipital and frontal poor.
headache several times per week. Plain cervical X-rays  Eye–head co-ordination—normal.
demonstrate early degenerative changes in the cervical  Saccades—normal.
spine. She reported that her symptoms were increased by
neck movements, computer work, sitting talking to
clients when her neck was turned or in a rotated 2.2.1.5. Initial management. Management to address
position, driving and sustained neck positions and eased abnormal cervical afferent input—might include
with rest, heat and medications. She has not sought any manual therapy, exercises to improve neuromu-
other treatment to date. She works fulltime as a scular control and cervical range of motion and advice
counselor. She has had no past history of trauma or on pain relief, ergonomics and posture. A tailored
injury to the neck or head. program to assist with the improvement of sensorimotor
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Fig. 1. Following a laser light backwards and forwards across a wall
with the neck in relative left torsion in sitting. The patient moves the
laser light to provide the target to follow.
control should also be added and would include the
following:
 Balance—narrow stance eyes closed on foam,
tandem stance eyes open then closed—30-s at-
tempts.
 Eye follow with neck in left torsion in sitting, five
times. At home, the patient could move a laser light
or torch backwards and forwards across a wall to
provide the target to follow (Fig. 1).
 Gaze stability—sitting focus on dot or word—move
head into flexion and rotation to the right.
2.2.1.6. Home program. Two times per day, five
repetitions per exercise.
2.2.1.7. Progress
 Eye and head exercises in standing then in narrow,
tandem and single leg stance.
 Altering the focus point from a dot to some words
or a business card.
 Increasing speed or range of movements.
 Increasing duration or number of repetitions.
Fig. 2. Soft surface narrow stance practice.
 Adding a busy background to the focus point.
 Adding a soft surface to narrow stance tests (Fig. 2).
2.2.1.8. Commentary. This case illustrates the point
that in the absence of any complaints of dizziness or
unsteadiness, deficits in sensorimotor control can still
occur and will be an important addition to the manage-
ment of this patient. The patient reported difficulty when
sitting talking to clients when her head was in an awkward
position, which could be related to the neck itself but could
also be related to the eye movement disturbances.
Addition of the tailored program is likely to enhance the
management of this patient’s neck pain and headache.
2.3. Case 3: chronic whiplash, complaints of dizziness,
blurred vision and moderate to severe headaches
2.3.1. Ms. X, age 49, sales executive
Ms. X presented with ongoing constant neck pain
radiating to the right trapezius region and right arm
pain associated with frequent headaches, pain and
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vertigo following a motor vehicle collision 6 months control of the cervical and right shoulder girdle
ago. She has episodes of nausea and non-spinning regions complicated by muscle protection of nerve
vertigo with a constant feeling of unsteadiness worsened tissue mechanosensitivity.
by increased neck pain and headaches. She also reported  Decreased mechanical pain thresholds for the
episodes of blurred vision, occasional tinnitus, fullness cervical spine.
in the right ear and right ear pain. Her ear pain is  Decreased mechanical pain thresholds for upper and
associated with the neck pain and working, particularly lower limb sites and increased cold pain thresholds
reading and looking down. She has only had one over the cervical spine indicative of generalized
episode of vomiting associated with the vertigo 2 days hypersensitivity and altered central nervous system
post the accident. She has not had any episodes of true pain processing.
‘‘spinning’’ vertigo. She also reported difficulty with  Nerve tissue mechanosensitivity in the right upper
bumping into doorways, veering to the right when limb and upper cervical region demonstrated on the
walking, blurred vision with reading and words moving brachial plexus provocation test and passive neck
around the page at times. She has no prior history of flexion test.
neck pain, headaches, dizziness or ear complaints. She is
currently taking daily Celebrex and Panadol and 2.3.1.3. Assessment of sensorimotor control
Panadeine forte to control her headaches several times
per week. Ms. X has sought opinions from her general  Hallpike dix test (Herdman, 1997)—negative—
practitioner and a neurologist. She attended physiother- no nystagmus reproduced.
apy and acupuncture initially following the accident but  Cervical JPE in sitting (o4.5 cm normal)—marked
found that this tended to exacerbate her symptoms at increase in JPE from rotation to the left. Extension
times. CT and MRI scans of her head and cervical spine 3 cm, rotation (L) 12.5 cm, rotation (R) 2 cm.
have been performed. A slight disk bulge at C5/6 was Extension also causes exacerbation of nausea and
the only reported abnormal finding. dizziness.
 Eye follow in sitting—markedly abnormal with neck
2.3.1.1. Questionnaire scores torsion to the left and right, indicating disturbances
to cervical afferent input is influencing eye move-
 Neck 56/100 Moderate/severe
ment control. This also reproduced vertigo, blurred
Disability pain and
vision and headache particularly with neck torsion
Index Score disability
to the left.
 Current pain 7/10 Moderate pain
 Gaze stability in sitting—decreased with rotation to
the right and flexion. This reproduced dizziness,
VAS
blurred vision and nausea.
 GHQ 28 17/84 Below threshold
 Eye–head co-ordination in sitting—decreased on the
right side. This reproduced dizziness, blurred vision
score
and nausea.
 Impact of 2.83/12 Below threshold
 Saccades in sitting—abnormal for eye movement to
events revised score
the right and downwards.
score
 Standing balance—evidence of increased sway on
most tests of comfortable and narrow stance
 Dizziness 7 Mild/moderate
particularly on tests with the eyes closed. Ms. X
Handicap handicap
was unable to perform tandem stance with eyes
Inventory (sf)
closed. Eyes closed tasks also increased headache
and vertigo.
 Patient specific /10 Fast walk 0,
functional Cleaning 2,
2.3.1.4. Initial management. Management to address
scale Reading 4
abnormal cervical afferent input—in light of the signs of
generalized hypersensitivity and nerve tissue sensitivity,
management should be non-pain provocative. A review
2.3.1.2. Relevant physical examination findings of pain management options by her general practitioner
should be performed to ensure adequate pain control.
 Moderate global range of cervical movement Physiotherapy might include non-pain provocative
deficits. manual therapy, techniques to improve nerve tissue
 Symptomatic joint dysfunction at the (R) C1/2, 2/3 sensitivity, exercises to improve neuromuscular control
and C4/5 motion segments (pain VAS 5/10). and cervical range of motion and ergonomic and
 Neuromuscular control—poor neuromuscular postural advice. A tailored program to assist with the
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272 J. Treleaven / Manual Therapy 13 (2008) 266–275
improvement of sensorimotor control should also be
added and will be important to address the symptoms of
unsteadiness, vertigo, blurred vision and ear symptoms
and would include the following:
 Balance comfortable and narrow stance eyes open
and closed—30-s attempts.
 Cervical JPE relocation back to neutral following
rotation to the left in supine lying—comfortable
movement only.
 Gaze stability—rotation to the right and flexion
active and passive movement in supine lying.
 Leave eye–head co-ordination, saccades and eye
follow neck right torsion exercises until reassess any
effect of the above exercises on pain exacerbation.
2.3.1.5. Home program
 Two times per day, three repetitions each exercise.
 No increased pain during exercises.
 Stop if exacerbates pain or headache.
 Some dizziness and nausea is acceptable but should
not last longer than a couple of minutes.
2.3.1.6. Progress
 Carefully and slowly so not to exacerbate pain or
headache.
 Passive trunk movement into left rotation in sitting
or standing during treatment might also be helpful
for gaze stability (Fig. 3).
 Add saccades, eye–head co-ordination and eye
follow exercises one at a time.
 Add cervical JPE extension supine.
 Increasing number of repetitions of each exercise.
 Eye and head exercises in sitting then standing.
Fig. 3. Passive trunk movement into left rotation in standing to
improve gaze stability.
 Altering the focus point from a dot to some words
or a business card.
 Increasing speed or range of movements.
 Adding a busy background to the focus point.
 Restricting the peripheral vision.
 Balance—add soft surfaces, practice eyes open and
closed in tandem and single leg stance, eye and head
exercises in comfortable then in narrow stance,
walking with head turns maintaining direction and
velocity of gait.
2.3.1.7. Commentary. This case illustrates the complex
patient issues of generalized hypersensitivity, nerve
tissue mechanosensitivity, poor neuromuscular control,
cervical joint dysfunction and altered sensorimotor
control in those with persistent whiplash associated
disorders. Such a combination of problems is likely to
compound abnormal cervical afferent from a variety of
sources. In this case, it is essential that any management
be non-pain provocative and care with the progression
of the exercises will be very important to avoid pain
exacerbation. Adequate medication to provide effective
pain management will be important.
The moderate postural control deficits are likely
resultant of abnormal cervical afferent input to the
postural control system. Her description of the dizziness
would fit a cervical cause of the dizziness. Subjective ear
complaints such as these can also be associated with
cervical disorders. However, secondary vestibular im-
pairment or concomitant vestibular pathology may be
present and to date she has not had any investigations
associated with this (apart from the negative Hallpike
Dix which can exclude benign paroxysmal positional
vertigo (BPPV) as a possible cause). Thus she should be
monitored carefully and if her symptoms of vertigo, ear
complaints and blurred vision do not improve in line
with improvements to the cervical physical function,
review by an ENT specialist or vestibular rehabilitation
physiotherapist would be appropriate.
2.4. Case 4: chronic dizziness, unsteadiness and nausea
associated with symptoms of neck stiffness and headache
2.4.1. Mr. X, age 60 years, self-employed company
director
2.4.1.1. History. Mr. X reported a history of persistent
bilateral orbital pain, tiredness and heaviness of the eyes
associated with neck stiffness and discomfort following
an accident 2 years ago where he walked into a plate
glass door. He reported immediate headache, which
settled. Ten days afterwards, he drove for 6 h and after
falling asleep in an awkward neck position in the motel,
he awoke with dizziness (not true vertigo) and had
difficulty standing and walking. This settled with
stematil after approximately 4 days. Incidentally, he
had also been receiving treatment (antibiotics) for an ear
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infection a few days prior to this. Since then he has had
several episodes (lasting approximately 1 week) of mild
to moderate dizziness and unsteadiness and or nausea
preceded with activities involving sustained neck exten-
sion or flexion. He also reported intermittent difficulty
with visual conflict in shopping center aisles and
bumping into objects. Symptoms were reported to be
temporarily relieved by local cervical physiotherapy and
chiropractic treatment, applying ice packs to the eyes
and rest. Mr. X reported that he has not had any other
symptoms suggestive of VBI or migraine. He also
reported no incidents of true vertigo. Mr. X has
consulted several specialists in an attempt to try to
determine the cause of his symptoms including an ENT
specialist, neurologist, maxillofacial surgeon, optome-
trist and a physician. He has had two unremarkable
brain CT scans, one with IV contrast injection. Normal
audiometry testing and a negative Hallpike Dix test for
benign BPPV were also reported.
In the last 6 months, Mr. X has been attending both
physiotherapy and chiropractic treatment once every
week to 2 weeks. He reported that both these treatments
focusing on his upper cervical spine temporarily relieve
his eye pain, neck discomfort and unsteadiness; how-
ever, he feels his overall condition remains the same.
Physiotherapy has been focusing on manual therapy,
and more recently deep cervical flexor rehabilitation.
Mr. X reported that he has not been vigilant with his
home exercise program. Twenty-five years ago, he was
hit on the top of the skull by a roller door, resulting in a
loss of consciousness. He reported no neck pain or
headaches as a result of this accident.
2.4.1.2. Questionnaire scores
 Neck 20/100 Mild disability
Disability
Index Score
 Current pain 0.5/10 Mild neck pain
VAS
 GHQ 28 17/84 Below threshold
distress
 Impact of 3.08/12 Mild distress
events revised
score
2.4.1.3. Relevant physical examination findings
 Moderate restriction in upper cervical range of
motion.
 Symptomatic joint dysfunction: (R) C 1/2, 2/3 and
3/4 motion segments (pain VAS 3/10).
 Poor neuromuscular control of the cervical spine,
scapular control non-remarkable.
 No evidence of nerve tissue mechanosensitivity,
neurological deficits or generalized hypersensitivity.
2.4.1.4. Assessment of sensorimotor control
 Cervical JPE (o4.5 cm normal)—increased for
return from rotation to the left, right and extension.
Extension 10.5 cm, rotation (L) 8.6 cm, rotation (R)
5.2 cm.
 Eye follow—abnormal (increased catch up saccades)
when tested with neck torsion to the right and left
when compared to the neutral neck position.
 Gaze stability—poor and blurred vision when the
head moves into flexion and extension.
 Eye–head co-ordination—within normal limits.
 Saccadic eye movements into flexion and exten-
sion—blurred vision and dizziness reproduced.
 Standing balance—increase sway was noted on all
tests in narrow stance.
2.4.1.5. Initial management. Management to address
abnormal afferent input should continue especially
exercises to improve cervical neuromuscular control
and compliance with the home program will be vital.
Cervical range of motion and ergonomic and postural
advice to avoid unnecessary stresses placed on the upper
cervical region will also be important. However, most
importantly, a tailored program to assist with the
improvement of sensorimotor control should also be
added and would include the following:
 Balance—narrow stance tasks 30 s eyes open and
closed.
 Cervical JPE retraining in sitting into extension and
rotation left and right.
 Gaze stability in sitting into flexion and extension.
Add next visit/visits

 Dizziness 4/13 Moderate  Eye follow—with neck torsion to the left and right.
Handicap handicap  Saccadic eye movements into flexion and extension.
Inventory (sf)
2.4.1.6. Home program
 Patient specific Reading 4,
functional Driving 4,  Two to three times per day, five repetitions each
scale Watching TV exercise;
4/10  stop if exacerbates pain or headache and
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274 J. Treleaven / Manual Therapy 13 (2008) 266–275

 some dizziness and nausea is acceptable but should

not last longer than a couple of minutes.

2.4.1.7. Progression

 Cervical joint position retraining to different points

in range of neck motion, tracing patterns with laser
light on head (Fig. 4).
 Balance—add soft surfaces, eye and head exercises
in comfortable then in narrow stance, walking with
head turns maintaining direction and velocity of
gait.
 Altering the focus point from a dot to some words
or a business card and or adding a busy background
to the focus point (Fig. 5).
 Increasing speed or range of movements.
Fig. 5. Gaze stability exercises with a business card as the focus point
 Increasing number of repetitions.
and a busy striped background.
 Restricting peripheral vision performing active head
and eye movements (Fig. 6).

2.4.1.8. Commentary. In this case, there was evidence

of altered neuromotor control of the cervical spine,
painful upper cervical segmental joint dysfunction
in conjunction with moderate sensorimotor control
disturbances relating to cervical JPE, neck-influenced
eye follow, gaze stability, saccadic eye movement
and balance. It is likely that the causes of his symp-
toms are due to abnormal afferent input from the
cervical spine and has been improved temporarily
with management addressing his cervical spine. It is
unlikely that the vestibular system is the primary
cause of the complaints but it is possible that some

Fig. 6. Restricting peripheral vision while performing active head and

eye movements.

hypofunction of the vestibular system is present

Fig. 4. Cervical joint position retraining tracing a pattern with a laser
light mounted onto the head.
due to the patient’s age, past history of the vesti-
bular neuritis and secondary adaptations due to
influence from the cervical spine. Mild head injury is
also possible.
Mr. X has attended both physiotherapy and chir-
opractic in the past with only temporary results. More
compliance with the home exercise program to improve
cervical neuromuscular control will be important as this
has shown to improve cervical JPE (Jull et al., 2007).
However, in this case, it would seem that the introduc-
tion of the tailored program designed to improve
sensorimotor control will be of most significance to
assist in the long term.
 ARTICLE IN PRESS
J. Treleaven / Manual Therapy 13 (2008) 266–275
3. Integration of exercises
A number of the above exercises can also be easily
integrated into the overall multi-modal physiotherapy
management and home exercise program which can
assist in patient compliance, for example, gaze stability
while performing range of motion exercises, gaze
stability while performing manual therapy techniques,
e.g. PIVVMS, use of eye movement (eye–head co-
ordination) to facilitate craniocervical flexion (CCFT)
or cervical range of motion exercises, targeting specific
pressures with the eyes closed during CCFT retraining,
gaze stability and eye–head co-ordination exercises
while performing neck extensor exercises in four-point
kneeling (Jull et al., 2004), and adding oculomotor and
joint relocation exercises while standing in various
positions and when walking.
4. Summary
The four case studies presented highlight the im-
portance of assessment and management of sensorimo-
tor control disturbances in those with neck disorders.
Multi-modal management for the cervical spine is
advocated and as part of this, the formulation and use
of a tailored program designed to retrain balance,
cervical proprioception and eye and head movement
control in those with neck disorders has been specifically
considered.
275
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