CERVICAL OUTCOME MEASURES: TESTING FOR POSTURAL

STABILITY AND BALANCE

B. Kim Humphreys, DC, PhD

ABSTRACT

Background: Clinical tests assessing a correlation between structural pathology and cervical pain have been
unsuccessful, leading the way for the development of functionally based tests. The purpose of this narrative is to review
4 promising functional tests for the assessment of sensorimotor dysfunction in patients with neck pain. The Joint Position
Error/Head Repositioning Accuracy tests, and the Rod and Frame Test were reviewed.
Special Features: The SPNTT was developed to test proprioceptive mechanisms in the neck by applying torsion to
mainly mechanoreceptors in the cervical spine. The Joint Position Error and Head Repositioning Accuracy test
cervicocephalic kinesthesia or the ability to perceive both movement and position of the head in space related to the
trunk. The Rod and Frame Test assesses patients' perception of the vertical orientation of their head in 3-dimensional
space. All of these tests evaluate important mechanisms responsible for maintaining postural stability and balance and
are thought to be applicable for use in mechanical neck pain patients.
Summary: All of the reviewed tests show clinical promise because they are able to distinguish patients with neck
pain, particularly those with whiplash trauma and dizziness from asymptomatic controls. All of the tests assess
cervical sensorimotor dysfunction, although considerably more research is needed to more clearly establish the
psychometric properties for each test including minimal clinical important difference. Although these tests can be
used in routine clinical practice, they should be used in combination with other related tests. (J Manipulative Physiol
Ther 2008;31:540-546)
Key Indexing Terms: Posture; Musculoskeletal Equilibrium; Neck Pain; Outcome Assessment (Health Care); Spine;
Cervical Vertebrae

H
uman posture may be defined as the configuration
of the musculoskeletal (MSK) system in achieving
activities of daily living against the forces of
gravity. Consequently, balance can be defined as the ability
of the MSK system to maintain a stable posture. The head
and neck contain systems that are essential to the overall
maintenance of human posture and balance.
Reports by Treleaven,1 Morningstar et al,2 and Bolton3
provide manual therapists with an overview and up-to-date
review of the literature on the physiological systems that
maintain and control posture. From the body of current
research, it is clear that the visual, somatosensory, and
proprioceptive systems of the cervical spine are paramount
in controlling posture and balance against gravity.1-4
Formerly Special Assistant to the President, Canadian Memorial
Chiropractic College, Toronto, Canada. Presently Assistant Professor
for Chiropractic, Faculty of Medicine, Balgrist Hospital, University
of Zurich, Switzerland (e-mail: kim.humphreys@balgrist.ch).
Paper submitted April 4, 2008; in revised form August 2, 2008.
0161-4754/$34.00
Copyright 2008 by National University of Health Sciences.
doi:10.1016/j.jmpt.2008.08.007
Cues from the visual, vestibular, and cervical proprio-
ceptive systems are responsible for orientation of the head
with respect to the trunk in 3-dimensional space.1-5 Input
from the visual (oculomotor) system is important in postural
control because it allows the position of the head and trunk to
be fixated in space to balance the center of mass of the body
over the feet or base of support.2 Information from mainly
the vestibular system and mechanoreceptors in skin,
muscles, joints, ligaments, and tendons give us the ability
to know, at all times, the orientation of the head in relation
to the trunk and the surrounding environment.6-8 It is
now known that the cervical spine possesses a more refined
proprioceptive system than the lumbar spine.9 This is likely
due to the abundance of muscle spindles and mechanor-
eceptors subserving proprioception, particularly in the
suboccipital region of the cervical spine.1-3,10-12 These
cervical receptors have connections with the visual and
vestibular systems as well as the sympathetic nervous
system.1 They also are involved in the cervicocollic reflex,
the cervicoocular reflexes, and the tonic neck reflex, which
are important in regulating head, eye, and postural
stability.1-3,13 During movement of the cervical spine,
visual, vestibular, and proprioceptive signals change con-
tinuously due to changes in muscle length, visual scene, and
contour of the multiarticular surfaces of the vertebrae.5,14-16

540
Journal of Manipulative and Physiological Therapeutics
Volume 31, Number 7
Emerging evidence strongly suggests that neck pain and
particularly patients with chronic whiplash-associated dis-
orders (WADs) exhibit impairments in postural control.17
These include difficulty with standing balance, altered
control of eye movements, and altered kinesthetic sensi-
bility.17-21 Other signs and symptoms of postural control
dysfunction, particularly involving the somatosensory and
proprioceptive systems, are increased pain, headache,
vertigo/dizziness, nystagmus, ataxia, and visual/oculomotor
disturbances.5 Of these, cervicogenic dizziness or cervical
vertigo is thought to be relatively common, particularly in
patients with whiplash and patients who have had a
whiplash-associated trauma. Cervicogenic dizziness and
unsteadiness, although controversial, are thought to be due
to an alteration in sensory information from deep cervical
tissues and cervical proprioceptors as a result of trauma,
degenerative, inflammatory, or mechanical changes.21 Hum-
phreys et al22 reported that one third of 180 consecutive
patients with neck pain had problems with dizziness.
Dizziness was found to be more common in females and
was associated with increasing levels of reported pain and
disability experienced over a longer period as well as a
history of whiplash trauma.22
Musculoskeletal conditions, particularly back and neck
pain, continue to be a major problem in society today, and
the problem is expected to increase over the next few
decades.23-25 To more effectively identify and manage neck
pain complaints, valid, reliable, and responsive clinical tests
are needed to make an accurate diagnosis of patients'
presenting problems. Because there does not appear to be a
relationship between structural pathology and cervical pain,
clinical tests have focused on functional assessment of the
cervical spine.26,27 In terms of postural stability and
balance, considerable research is still needed to provide
psychometrically sound diagnostic tests that are appropriate
for use in the routine clinical setting.
Therefore, the focus of this article will be a narrative
review of 4 specific sensorimotor tests involving the cervical
spine that show promise in the assessment of the visual
(oculomotor), somatosensory, and proprioceptive systems
that are important for postural stability and balance.
METHODS
Smooth Pursuit Neck Torsion Test
Description. The Smooth Pursuit Neck Torsion Test
(SPNTT) was first described by Tjell and Rosenhall.28
The SPNTT uses electrooculography to record the average
velocity of eye movement while subjects/patients follow a
moving target with the head in a neutral-looking, forward
position but the trunk turned (torsioned) to 45 to the left
and then the right. The theory behind the SPNTT suggests
that torsioning of the cervical spine stresses the MSK
structures in the neck, particularly mechanoreceptors/
proprioceptors.20,28 The SPNTT is thought to test the
Humphreys 541
Postural Stability and Balance
proprioceptive reflexes of the neck, the cervicocollic reflex,
and the cervico-ocular reflex. Abnormal results are thought
to be due to erroneous postural proprioceptive activity in
the cervical spine that is transmitted by these reflexes.28,29
The SPNTT is thought to be applicable for patients with
mechanical neck pain, patients with whiplash, and patients
with cervicogenic dizziness.28,29 As described by Treleaven
et al,19 the average velocity of eye movements was
measured by subtracting the corrective movements (sac-
cades) from the total excursion of the gaze. The patient/
subject is tested in the neutral, torsioned left and torsioned
right positions. The SPNTT difference is calculated by
comparing the neutral to the average velocities in the
torsioned positions. A more detailed description of the
methodology is found elsewhere.20,28,29
Review. Tjell and Rosenhall28 compared the SPNTT in
patients with whiplash compared with those with dizziness
from other diseases. A total of 75 patients with whiplash of
at least grade II, 50 of which had dizziness, were compared
to matched controls with dizziness of central origin,
Meniere disease and healthy participants. Tjell and
Rosenhall 28 found that patients with whiplash had
significantly reduced smooth pursuit gain, particularly in
those with complaints of dizziness compared with controls.
The sensitivity for those with WAD and dizziness was
90%, whereas the specificity was 91%. Sensitivity was
56% for those without dizziness. The authors concluded
that the SPNTT was a useful clinical test for cervicogenic
dizziness due to its high sensitivity and specificity.
Treleaven et al29 looked at the possible effects of
anxiety and neck pain on the results of the SPNTT for
patients with whiplash vs controls. The SPNTT was
administered to 100 participants with WAD (50 with
dizziness and 50 without) and 50 healthy controls. Their
results confirmed that patients with whiplash had sig-
nificantly reduced smooth pursuit gains compared with
healthy controls, whereas those with WAD and dizziness
were most affected. Self-report of anxiety and pain was
tested using the Neck Disability Index, a 10-cm Visual
Analogue Scale for pain, and the Dizziness Handicap
Inventory (short form) among other measures. These
scales did not influence the results of the SPNTT.
The authors conclude that the SPNTT is a useful clinical
test to detect eye movement disorders in patients with
WAD, particularly those who complain of dizziness, and
is likely due to dysfunction of cervical afferentation, that
is unaffected by patients' levels of self-reported anxiety
and pain.
Treleaven et al30 recently reported the results of a study
comparing the SPNTT and a number of other tests, which
will be reported later in 20 patients with persistent whiplash,
20 patients with acoustic neuroma, and 20 healthy controls.
The purpose was to determine if the SPNTT and a battery of
tests could differentiate patients with persistent whiplash
from those with unilateral vestibular pathology associated
542 Humphreys
Postural Stability and Balance
Fig 1. Sitting position with laser mounted helmet and visual
occlusion for measuring JPE/Head Repositioning Error (JPE/HRA).
with acoustic neuroma and healthy controls. The results
showed that the SPNTT could differentiate the patients with
persistent whiplash from the other groups. The authors
suggest this add further evidence that the SPNTT is a test of
cervical afferent dysfunction and is a useful test for the
clinical setting.
Clinical Status. Now, it appears that the SPNTT is a valid
test for the cervical dysafferentation, particularly in
patients with whiplash complaining of cervicogenic
dizziness. However, there have not been enough studies,
particularly randomized controlled clinical trials, to
determine the other psychometric properties of reliability
and responsiveness (eg, effect size) or minimal clinical
important difference (MCID).
Conclusions. Although the SPNTT appears promising, more
research is needed to establish it as a valid, reliable, and
responsive functional test for the cervical spine.
Journal of Manipulative and Physiological Therapeutics
September 2008
Fig 2. Simple equipment for measuring JPE/Head Repositioning
Error (JPE/HRA) include laser pointer, helmet or head mounting,
goggles for visual occlusion, and marking pens for target.
Headphones for blocking noise are also recommended.
Joint Position Error and Head Repositioning Accuracy Tests
Description. Proprioception, including joint position sense,
is important in protecting spinal joints by regulating joint
stiffness in concert with the activation of mechanoreceptors
and muscle spindles.31 Abnormal Joint Position Error (JPE)
has been tested in patients with neck pain using 2 types of
tests: (a) ability to actively relocate the head to the neutral
position after it has been passively displaced and (b) ability
to actively relocate the head to the reference position within a
movement plane (Head Repositioning Accuracy [HRA]).32
Generally, the ability to reposition the head to a previous
reference position is called cervicocephalic kinesthetic
sensibility.31 For the clinician, the ability to relocate the
head to the neutral position can be done using simple
equipment: laser pointer with head mounting, paper target,
and glasses/goggles/blindfold to occlude vision and earmuffs
to occlude hearing5 (Figs 1 and 2). To test the ability to
reposition the head to a predetermined position within a
movement plane typically requires more sophisticated
equipment that can measure head displacement in 3-
dimensional space. Such systems include electromagnetic
tracking devices (3-Space Fastrak) or ultrasound-measuring
devices (Zebris) that are not currently practical for the
routine clinical practice setting.
Revel33 first developed the kinesthetic sensibility test or
the ability to reposition the head to neutral from a flexed,
extended, or rotated position, after discovering that patients
with neck pain were less accurate compared to healthy
controls. The test protocol requires the participant to be
seated 90 cm from a 40-cm-diameter target that has
concentric rings arranged 1 cm apart. Goggles/Glasses or
blindfold and earmuffs are used to occlude vision and
hearing. The participant sits in a comfortable position with a
laser pointer attached to a head mount. The head and laser
Journal of Manipulative and Physiological Therapeutics
Volume 31, Number 7
pointer are positioned to the center of the target (neutral), and
participants are asked to remember that position. The
examiner then passively moves the participant's head to the
left and holds the position for 2 seconds. The participant is
then asked to reposition their head to the neutral, starting
position. The examiner then records on the target the location
of the reposition and measures the difference between the
neutral and repositioned mark. Right rotation, flexion, and
extension are then tested. Three trials are used for each range
of motion.5,33
Review. As mentioned previously, Revel33 was the first to
show that patients with neck pain were significantly less
accurate than healthy controls in active repositioning of their
head from a neutral, starting position. Heikkila and Astrom34
investigated active head repositioning in 14 patients with
whiplash vs 34 healthy controls. They found that patients
with WAD were significantly more impaired than controls,
but that a 5-week rehabilitation program was able to
significantly improve HRA. Heikkila and Wenngren 35
confirmed that patients with WAD are less accurate in
HRA compared to controls and also showed significant
correlations between Smooth Pursuit Neck Torsion Test and
active cervical ROM and oculomotor functions and HRA.
This was the first time that oculomotor dysfunction was
associated with other sensorimotor impairments in patients
with neck pain. Rix and Bagust36 compared 11 patients with
nontraumatic neck pain with 11 asymptomatic controls
related to HRA. The results showed that patients with
nontraumatic neck pain did not show evidence of impaired
cervicocephalic kinesthetic sensibility (HRA) compared to
controls. This supports the evidence that JPE/HRA is likely
to be impaired in patients with WAD/trauma neck pain as
compared to those with mechanical neck pain.
Sterling et al37 were the first to show that only patients
with moderate to severe whiplash showed greater JPE
compared to controls and that these errors occurred within
1 month of WAD injury and remained at 3 months. Sterling
et al,38 investigating the effect of psychological distress on
sensorimotor function in WAD II and III patients compared
to asymptomatic controls, confirmed that JPE was only
present in patients with moderate to severe WAD and that
psychological distress was independent of the sensorimotor
test results. Similarly, Tang et al,31 using an ultrasound-based
3-dimensional system for measuring HRA, identified that
increasing age has a profound effect on increasing errors in
head repositioning.
More recently, Owens et al,39 using normal student
volunteers, showed that a recent history of cervical extensor
muscle contraction could produce HRA errors similar to
reports of WAD patients. The authors suggest that this
supports the role of paraspinal muscles in sensorimotor
dysfunction, not necessarily related to trauma.
The most recent research by Treleaven et al30 has shown
that the JPE test is able to differentiate patients with
persistent whiplash from those with vestibular pathology due
Humphreys 543
Postural Stability and Balance
to acoustic neuroma or asymptomatic controls. However, as
identified by Swait et al,4 a minimum of 5 trials of JPE and
HRA tests are needed to ensure adequate test-retest
reliability and that JPE or HRA must be used in conjunction
with other tests (standing balance, SPNTT) to ensure validity
for sensorimotor dysfunction.17
Conclusions. Current research suggests that both the JPE
and HRA tests are appropriate for use in clinical practice as
tests of sensorimotor dysfunction of the cervical spine.
However, current evidence supports their use in patients
with moderate or severe whiplash, especially those
complaining of cervicogenic dizziness, and that they should
be used in conjunction with other tests such as the SPNTT
and standing balance tests. More research is needed to
assess the psychometric properties of JPE/HRA tests as well
as subgroups of patients with neck pain that may be
appropriate for testing. Currently, effect sizes and MCID
values are unknown.
The Rod and Frame Test
Description. The Rod and Frame Test (RFT) was originally
developed by Whitkin et al40 as a quantitative measure of
errors in the perception of vertically.41 Balance, maintenance
of posture, and motor coordination are common everyday
activities that require an accurate perception of the orienta-
tion of the head in 3-dimensional space.42 The vestibular
system, which provides information about the position of the
head relative to gravity; the visual system, which uses
external cues to identify the head position in relation to its
environment; and the cervical proprioceptive system, which
signals the position of the head with reference to the trunk,
are all important in determining spatial orientation.42
Dysfunction of any of these systems can cause a variety of
signs and symptoms such as spatial disorientation, dizziness,
vertigo, disequilibrium, and nausea.5,22,29-33 The RFT was
adopted from perceptual and psychological research. It is a
simple, noninvasive test that is able to assess a participants'
perception of vertical. Grod and Diakow43 have shown that
the RFT can differentiate patients with neck pain from
asymptomatic controls. The authors hypothesize that the
alteration in verticality perception is due to dysfunction in
the cervical spine proprioceptive system.
The RFT is made up of a luminescent vertical rod
surrounded by a square frame. The subject is required to
position an offset rod into the vertical position using a
joystick. Participants are placed in a dark room where the
only visual objects are the luminescent vertical rod and
square frame. The rod is 102 cm long and the frame is
107 cm2. The center of rotation of the rod is in the center of
the frame so that they both share a common midpoint. The
rod is rotated independently from the frame. Subjects are
seated 2.5 m from the Rod and Frame device. In the protocol
by Grod and Diakow,43 participants undergo 3 tests of 3
trials each. On the first test, only the rod is visible (the frame
544 Humphreys
Postural Stability and Balance
Fig 3. The CRFT include video eyeglasses, computer, and software.
Rod-and-frame images as shown on the computer screen are
visualized when the video eyeglasses are worn by the user.
is covered), whereas on tests 2 and 3, both the rod and frame
are visible. Initially, the rod is offset by 10 for the first test,
and the subject is asked using a joystick to position the rod to
the vertical. The difference between the true vertical and the
patient's perception of vertical is recorded. In the second test,
the frame is offset by 10 and the rod by 30. In the third test,
the rod is set at 30 and the frame at 0.43
More recently, Bagust 41 and Bagust et al 42 have
developed a Computerized RFT (CRFT) using video eye-
glasses (Olympus Eye-Trek FMD 200) connected to a
computer monitor to produce a more convenient alternative
to the large mechanical RFT device (Fig 3).
Review. Using an uncomplicated mechanical neck pain
group (19 subjects; 11 women and 8 men) and 17
asymptomatic controls (7 women and 10 men), Grod and
Diakow43 administered the RFT according the protocol
described above. Using averages for the 3 trials, the authors
found significant differences between symptomatic and
asymptomatic controls for the 3 test situations. In particular,
no frame (test 1) vs frame offset 10, rod offset 30 (test 2),
and between test 1 and rod 30 and frame 0 (test 3) were
significantly different between groups. The authors con-
clude that the differences in results on the RFT may be due
to dysfunction of cervical spine afferents such as mechan-
oreceptors in muscle, joints, and ligaments in patients with
neck pain. Interacting with pain afferents, the cervical spine
mechanoreceptors may alter subjects' ability to perceive the
vertical resulting in disturbed spatial orientation. The
authors raise the question that it is not known how patients
with neck pain who are experiencing dizziness would
perform or whether results from other tests of spatial
orientation would correlate (ie, ability to accurately locate a
digit out of sight).43
Journal of Manipulative and Physiological Therapeutics
September 2008
Bagust41 developed and tested a CRFT with video
eyeglasses, a computer screen, and a rod-and-frame program
written using Visual Basic 5.0 software. Using a prepro-
gramed sequence of 28 presentations on 17 asymptomatic
volunteers, Bagust showed that the CRFT produced devia-
tions from the normal in the direction of the frame angle,
maximal at 10 and 20 frame tilt, similar to previously
reported studies using the mechanical RFT.44,45 Although a
variety of RFT tests have been used, Bagust concluded that
the 1 to 6 mean error values for the CRFT were within the
range found by previous studies for the mechanical RFT,45,46
indicating that the CRFT may be a more practical alternative
to the RFT for the clinical setting.
Using the CRFT, Bagust et al42 compared 71 patients
with neck pain (26 traumatic; 45 insidious) with 17
asymptomatic control participants using the Grod and
Diakow43 protocol. Symptomatic subjects were tested before
treatment. The results confirmed that symptomatic subjects
are significantly less accurate in perceiving the vertical
compared to asymptomatic controls. Bagust et al suggest that
the CRFT is a useful alternative to the mechanical RFT and
that an absolute error of 2.5 or N2.5 is needed before a
possible association between neck pain and verticality
perception can be made. They also suggest that because a
wide variation was found within the neck pain group, a
subgroup of patients with neck pain may be more associated
with poorer performance on the CRFT/RFT.41
Clinical Status. Currently, 2 small studies have shown that the
RFT may be able to differentiate symptomatic neck pain
patients from asymptomatics. Although the CRFT/RFT
shows promise as a test of cervical proprioceptive dysfunc-
tion, it has yet to be fully tested in terms of validity,
reliability, and responsiveness. Randomized controlled trials
are lacking, and as suggested by Bagust,33 a subgroup of
patients with neck pain who have significantly impaired
verticality perception has yet to be identified. One possibility
is that patients with WAD who experience cervicogenic
dizziness may be one such subgroup.
Conclusions. Used within the suggested range for absolute
error by Bagust,33 the CRFT/RFT may be a useful adjunct to
other cervical spine functional tests. However, more research
is needed to identify the psychometric properties of the
CRFT/RFT as well as possible associations between
oculomotor/vestibular and proprioceptive function.
CONCLUSIONS
The focus of this article was to provide a narrative
review of the current status of 4 promising functional tests
for the assessment of sensorimotor and proprioceptive
dysfunction in the cervical spine. During the past decade,
the SPNTT, the JPE/HRA tests, and the RFT have been
developed for use in patients with neck pain. All 4 tests
show promise in that they are able to distinguish between
neck pain and asymptomatic controls. However, all seem
Journal of Manipulative and Physiological Therapeutics
Volume 31, Number 7
Practical Applications
Structural pathology and clinical pain have not
shown to be related.
Functional outcome measures that test the sensor-
imotor and proprioceptive systems show greater
promise for neck pain.
Specific Neck Torsion Test, JPE, HRA, and RFT are
clinical tests that are promising for assessing
patients with neck pain and patients with whiplash.
best suited for assessment of patients with whiplash,
particularly those with cervicogenic dizziness, although
further subgroup analysis is needed. Future testing is also
needed to assess their validity in terms of the exact
sensorimotor and proprioceptive systems they are testing,
their test-retest reliability, measures of responsiveness (ie,
effect size), and MCID. New research will likely prompt the
development of a battery of specific tests that will enable
clinicians to better assess and manage the burden of
mechanical neck pain present in society today.
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