POSTURAL CONTROL IN PEOPLE WITH OSTEOARTHRITIS

OF THE CERVICAL SPINE

Pierre Boucher, DC, PhD, a Martin Descarreaux, DC, PhD, a and Martin C. Normand, DC, PhD a

ABSTRACT

Objective: This study examines whether there is a relationship between clinical correlates of osteoarthritic changes of
the cervical spine and changes in postural stability.
Methods: This was a control group study with repeated measures. Twenty-three patients were recruited from the
chiropractic University Clinic to participate in this study. The presence and severity of osteoarthritic changes of the
cervical spine were determined radiologically. Balance control was evaluated by testing subjects' postural stability on a
force platform with and without vision. A general clinical assessment of the neuromusculoskeletal system was performed
to screen for any physical condition that could affect postural stability. Participants' characteristics were compared
between each group using a 1-way analysis of variance for independent samples, and postural stability variables were
submitted to a 2-way repeated measures analysis of variance.
Results: Subjects with signs of osteoarthritis of the cervical spine showed an increased range of sway, a faster sway
speed, and a greater excursion than control subjects. They also showed a larger degree of lower limb neuropathy than
control subjects.
Conclusion: The postural instability shown by the osteoarthritic group may be due to the effects of the lower limb
peripheral neuropathy alone or due to a combination of both cervical degenerative changes and peripheral changes.
Further research is needed to clearly isolate the effects of the degeneration of the cervical spine on postural control.
(J Manipulative Physiol Ther 2008;31:184-190)
Key Indexing Terms: Posture; Osteoarthritis; Musculoskeletal Equilibrium; Peripheral Nervous System Disease; Aging

P
ostural stability is achieved, in part, through spatial
and temporal integration of proprioceptive, visual,
and vestibular information, producing the perception
of our body's orientation in space and how external objects
are located relative to us. Diminished sensory functions and
slowing of sensorimotor processing occur with normal
aging.1 Besides, older people are at higher risk of developing
multiple impairments affecting different components of the
nervous system such as sensory loss, weakness, orthopedic
constraints, and cognitive impairments.2,3
More specifically, pathology in peripheral systems can
affect the sensory components of postural control, including
the accurate detection of head and body position and motion.2
A change in the quantity and the quality of peripheral sensory
information may deprive the central nervous system of
important information and compromise postural stability.4
a
Professor, Dpartement de Chiropratique, Universit du
Qubec Trois-Rivires, Canada.
Submit requests for reprints to: Pierre Boucher, DC, PhD,
Dpartement de Chiropratique, Universit du Qubec Trois-
Rivires, 3351 boul. des Forges, CP 500, Trois-Rivires, QC,
Canada G9A 5H7 (e-mail: pierre.b.boucher@uqtr.ca).
Paper submitted June 28, 2007; in revised form October 18,
2007; accepted October 18, 2007.
0161-4754/$34.00
Copyright 2008 by National University of Health Sciences.
doi:10.1016/j.jmpt.2008.02.008
An experiment conducted by de Jong et al,4 where animals
and man were injected with local anesthetics into the deep
tissues of the neck, clearly illustrates the role of neck
afferents. After the injection with local anesthetics, vertigo,
ataxia, and nystagmus were observed in animals and human
subjects. The authors of this study suggested that ataxia,
dizziness, and vertigo could arise from disorders affecting
the afferent flow of impulses from deep tissues of the neck.
Besides, loss of proprioceptors in cervical joints,5 osteoar-
thritis of the cervical spine,6-12 and neck motion limit-
ation13,14 are frequently mentioned as factors contributing
to loss of balance and falls in the elderly.
Among the factors mentioned above, osteoarthritis is of
particular interest because it is the most frequent articular
disease.15 It affects the integrity of cartilage and produces
modifications in other tissues such as synovial membrane
inflammation, thickening of articular capsules, and periarti-
cular amyotrophy.15 These modifications may also alter the
neurophysiologic properties of cervical joint receptors,
which exert powerful tonic reflexogenic influences on the
motoneuron pools of the cervical and limb musculature, on
the external ocular muscles, as well as contribute signifi-
cantly to postural and kinesthetic sensations.16,17 Cervical
facet joint capsules contain a significant density and
distribution of different mechanoreceptors,18 and some
authors have suggested that the intrinsic suboccipital
muscles might also play an important role in signaling the

184
Journal of Manipulative and Physiological Therapeutics
Volume 31, Number 3
cervical proprioceptive information involved in the con-
scious perception of equilibrium, position, and spatial
orientation when vision is occluded.19-21 It has also been
suggested that atrophy and fatty infiltration in the deep
suboccipital muscles may lead to diminished or altered
proprioceptive input to higher centers22,23 as evidenced by a
reduced standing balance performance.24
Pain may also be associated with osteoarthritis. Many
authors have investigated the effect of pain in cervical con-
ditions to detect disturbances in sensorimotor control. Recent
data indicate that cervical joint positioning error, balance, and
eye movement control can all be altered by posttraumatic
cervical pain.25-27 However, although the cervical region
plays an important role in the postural control mechanisms,
few studies have investigated the potential effect of cervical
spine degenerative changes on postural control.
Therefore, the aim of this study was to quantify postural
balance in patients with osteoarthritis and age-matched
healthy control subjects. Because osteoarthritis prevalence
increases dramatically with age, with a greater incidence in
subjects between 40 and 50 years,28 postural balance was
also evaluated in a group of young healthy subjects to
evaluate the potential aging and cervical osteoarthritis
interaction. We hypothesized that a group of patients with
cervical osteoarthritis will exhibit poorer postural balance
when compared with both a group of aged-matched and
young control subjects without osteoarthritis.
METHODS
Experimental Design
The following experimental design was used: control
group studies with repeated measures.
Subjects
Three groups of patients (n = 23) were formed for this
experiment: (1) patients with moderate to severe radiologic
signs of osteoarthritis of the cervical spine (clinical/high
OA), (2) patients with none to mild radiologic signs of
osteoarthritis of the cervical spine (age-matched low OA
control group), and (3) young subjects without any sign of
osteoarthritis of the cervical spine (healthy young controls).
Direct recruitment and snowball sampling were used to
recruit the patients.29 Subjects of groups 1 and 2 were
recruited from the pool of presenting new patients of the
outpatient clinic at the Universit du Qubec Trois-
Rivires, Canada, who were referred to the radiology
department for cervical spine radiographs as part of their
clinical examination. Subjects of group 3 were all patients at
the University Clinic at the time of the experiment and were
recruited from the chiropractic student body at Universit du
Qubec Trois-Rivires. Two fifth year chiropractic interns
were in charge of evaluating the subjects and collecting the
data. The principal investigator (PB) reviewed all files to
Boucher et al 185
Postural Control and Osteoarthritis
Table 1. Inclusion and exclusion criteria
Inclusion criteria
To be an adult patient of the chiropractic University Clinic
To have received a radiologic examination of the cervical spine during
the last 18 months
To have radiologic evidence of osteoarthritis of the cervical spine
(experimental group)
Exclusion criteria
Signs and/or symptoms of motor or sensory dysfunctions
History of chronic alcohol or drug consumption
Consumption of prescription drugs affecting the nervous system
Exposure to toxic substances
History of any medical condition susceptible to affect postural stability
ensure that the protocol was properly followed and
authorized the recruitment of each subject in this study.
Before proceeding to the patients' selection, interns met
with a specialist in chiropractic radiology who reviewed
the patients' radiographs and classified the degree of
articular degeneration according to the criteria described by
Petersen et al.30
Patient Recruitment According to Experimental Groups
Group 1 (clinical/high OA). The clinical records of new
patients showing moderate to severe radiologic signs of
osteoarthritis of the cervical spine were analyzed to exclude
those who could not meet the inclusion-exclusion criteria
(Table 1). After this screening procedure, subjects meeting
the criteria were contacted by telephone and invited to
participate in the study. Six males and 3 females (mean age,
64 years) were recruited.
Group 2 (age-matched low OA control group). The clinical records
of new patients showing none to mild radiologic signs of
osteoarthritis of the cervical spine were analyzed. Those who
could match age and sex of the subjects of group 1 and met
the inclusion-exclusion criteria were contacted by telephone
and invited to participate in the study. Three males and 4
females (mean age, 59.3 years) were recruited.
Group 3 (healthy young controls). After the formation of groups
1 and 2, 3 male and 4 female chiropractic students (mean
age, 24.4 years) who were under chiropractic care and had
radiographs of their cervical spine as part of their clinical
examination were recruited.
Examination Protocol
The purpose of the clinical examination was to detect any
condition that could affect postural stability. All tests were
performed according to the University Clinic standards.
Subjects who agreed to participate in the experiment were
invited to a first interview during which they were informed
about both the goal of the experiment and its protocol. All
subjects gave informed consent according to the university
ethics committee. Two fifth year chiropractic interns were in
186 Boucher et al
Postural Control and Osteoarthritis
Table 2. Participants' demographic data and clinical examination
scores
Group 1 Group 2 Group 3
Age (y) 64.0 (7.6) 59.3 (5.9) 24.2 (2.2)
Sex 6 men, 3 women 3 men, 3 women 3 men, 4 women
Valk score 6.2 (3.1) 0.6 (1.5) 0 (0)
NDI score (%) 25.8 (28.1) 10.6 (14.6) 1.1 (2.0)
Pain 21.1 (24.9) 16.3 (29.4) 1.1 (3.0)
(VAS, 100 mm)
MMSE 28.1 (1.4) 29.7 (0.8) 29.7 (0.8)
VAS, Visual analog scale.
charge of evaluating the subjects and collecting the data. The
principal investigator (PB) reviewed all files to ensure that
the protocol was properly followed and authorized the
recruitment of each subject in this study.
Interns then reviewed the patients' clinical record for past
or present conditions that could affect neuropsychologic or
postural performance. Data were collected to gather
information on (1) general health status. (2) medication
consumption, (3) daily activities, (4) integrity of the
neuromusculoskeletal system, and (5) any other aspect that
could affect postural stability.
Patients were then asked to complete 3 self-administered
questionnaires. To measure disability in activities of daily
living as a result of neck pain, patients completed a validated
French version of the Neck Disability Index (NDI).31 This
questionnaire was used for the 3 groups to control for any
significant disabilities that could impair postural control.
Pain severity was recorded on an analog 10-cm scale labeled
no pain at 0 cm and worst pain possible at 10 cm. Mental
status was measured with a validated French version of
Folstein's Mini-Mental State Examination (MMSE).32 A
clinical assessment was performed to screen for any physical
condition that could affect postural stability. Those examina-
tions include the following: examination of the spine
(palpation, range of motion); postural stability and walking
(Romberg, normal walking, heel to toe, on the heels, on the
toes); eye examination (ophthalmoscopic, visual acuity,
visual fields); autonomic nervous system (pupillary reflexes,
arterial pressure standing and lying); carotid artery ausculta-
tion; and lower extremities examination (pulse and neuro-
logic examination according to Valk et al33).
The neurologic examination designed by Valk et al33 is
used to quantify the level of lower extremity neuropathy
found in some patients. This examination uses a scoring
system having 4 levels of neuropathy: normal, mild,
moderate, and severe. It consists of the following tests: pain
and light touch of the dorsum of the foot, vibration sense at
the ankle and position sense of the first toe. These tests are
scored separately as 0, normal; 2, impaired in comparison
with proximal sensation; and 4, absent. Light touch is also
evaluated in relation with the anatomic level below which it is
impaired and is scored as 1, toe; 2, midfoot; 3, ankle; 4,
midcalf; 5, knee. Strengths of the hallucis longus and
Journal of Manipulative and Physiological Therapeutics
March/April 2008
Fig 1. Visual conditions and temporal intervals selected for the
postural analyses.
gastrocnemius are scored separately as 0, normal; 2,
impaired; and 4, absent. Ankle jerks are scored as 0, normal;
2, impaired in comparison with other reflexes (eg, knee jerk)
and 4, absent. The total score varies between 0 and 33. A
score of 0 indicates an absence neuropathy; 1 to 9, mild
neuropathy; 10 to 18, moderate neuropathy; and 19 to 33,
severe neuropathy.
No patient had to be rejected after the clinical examina-
tions. Table 2 presents details of the clinical examination for
each group.
Postural Stability Evaluation
An AMTI force platform (Model OR6-5; Advance
Mechanical Technology Inc, Watertown, MA) was used to
measure the displacement of the center of foot pressure
(CoP). The force platform signal was sampled at 100 Hz, and
diagonal entries from the calibration matrix provided by the
manufacturer were used to calibrate the platform. For each
trial, subjects stood barefoot on the force platform using a
comfortable stance with feet together. They were asked to
fixate a cross located 2 m away at eye level. A total of twenty
20-second trials were given under 2 visual conditions. In
condition 1, vision was available throughout the 20-second
trial. In condition 2, subjects initiated the trials with their eyes
closed and opened them 10 seconds into the trial upon a
signal generated by the computer. For both conditions,
subjects were simply asked to maintain a stable upright
posture. The 2 conditions were presented randomly. Famil-
iarization with the experimental conditions was provided
before testing.
To examine the postural stability, we selected temporal
intervals of 5 seconds for analysis. For each trial, the sway
behavior was evaluated (1) between the fourth and the ninth
seconds (vision under condition 1 and no vision under
condition 2) and (2) between the 11th and the 16th seconds
(vision under condition 1 and vision after a period of non-
vision under condition 2). Figure 1 schematically illustrates
these temporal intervals.30
Six dependent variables were used to characterize the
sway behavior during these 5-second intervals: range
(anteroposterior and mediolateral), velocity (anteroposterior
Journal of Manipulative and Physiological Therapeutics Boucher et al 187
Volume 31, Number 3 Postural Control and Osteoarthritis

and mediolateral), and excursion (anteroposterior and

mediolateral). The range indicates how far the participant's
CoP deviates from the base of support. The excursion is the
sum of the displacement in each direction over time. The
velocity is the sum of the displacement vectors divided by
the sampling time. Previous data indicate that postural
balance parameters can be used to assess the age-related
changes of the postural steadiness and are good predictors
for risk of falling.34

Statistical Analysis
Using a 1-way analysis of variance (ANOVA) for
independent samples, participants' characteristics were
compared between each group (Table 2). All dependent
variables were found to be distributed normally and were
submitted to a 2-way repeated measures ANOVA. This
analysis tested for the main effect of Group, the main effect
of Condition and the possible Group Condition interaction.
Post hoc comparisons were performed using lysergic acid
diethylamide tests. For all analyses, statistical significance
was set at P b .05.

RESULTS
The subjects of group 1 presented a significantly higher
Valk score (P = .0001) and a significantly lower MMSE
score (P = .0232) when compared with subjects of groups 2
and 3. According to Crum et al,35 any score more than 24 (of
30) is considered normal. The scores are corrected for degree
of schooling and age in the English version of the test. There
are no validated corrective factors for degree of schooling
and age available yet for the French version. Although we
did not take into consideration the degree of schooling of our
subjects in this experiment, the results show that all our
subjects were well above the 24 score limit. Hence, the
observed statistical difference does not reflect any cognitive
incapacity of group 1 subjects.
No group difference in pain scores was noted at the time
of testing. Finally, a significant increase in the NDI scores
was noted in group 1 when compared with group 3 (P =
.0059). Subjects' demographic data and clinical examination
scores are presented in Table 2.
Each subject was able to complete all trials throughout
every experimental condition. The 2-way ANOVA (Group
Condition) yielded a significant effect of condition for all 6
dependent variables (P b .0001). These differences were
characterized by a systematic significant increase of ranges,
velocity, and excursion under the no vision condition and Fig 2. Mean range (A), velocity (B), and excursion in the antero-
posterior plane (C). Group 1, clinical/high OA; group 2, age-
the vision after a period of no vision condition. matched low OA control group; group 3, healthy young controls.
Statistically significant group differences were only
present in the anteroposterior variables, whereas no group
differences were present for the mediolateral variables. anteroposterior excursion (F2,20 = 4.2474, P = .0290) were
Anteroposterior range (F2,20 = 5.1597, P = .0156), higher in group 1 when compared with group 2 (aged paired
anteroposterior velocity (F2,20 = 4.2468, P = .0290), and subjects) and group 3 (young adults). None of the Group
188 Boucher et al Journal of Manipulative and Physiological Therapeutics
Postural Control and Osteoarthritis March/April 2008

Table 3. Group means for the postural dependent variables in the proposed that disturbances of postural control in chronic neck
anteroposterior plane pain are dependent on the etiology. At this point, it is not clear
Group Mean SD CI 95% CI + 95% in the literature that postural balance is affected in
AP range 1 12.2 0.78 10.5 13.8 nontraumatized patients to the same extent as in traumatized
2 9.36 0.88 7.53 11.2 patients, and future studies should evaluate postural dis-
3 8.67 0.88 6.83 10.5 turbances in different cervical spine conditions.
AP velocity 1 6.29 0.41 5.43 7.15 It is the first time, to our knowledge, that postural control
2 4.81 0.47 3.83 5.78
3 4.70 0.47 3.73 5.68
in subjects with cervical osteoarthritis is studied. Postural
AP excursion 1 31.5 2.06 27.2 35.8 stability has been investigated in subjects with knee
2 24.0 2.34 19.2 28.9 osteoarthritis. 39,40 Those studies showed that postural
3 23.5 2.34 18.6 28.4 control is worse when these subjects are compared with
AP, Anteroposterior. healthy controls. Unfortunately, in these studies, the
presence of pain at the time of testing cannot be ruled out,
and therefore, changes in postural control may have been
Condition interactions were significant. Figure 2 illustrates triggered by the presence of pain rather than osteoarthritis.
the anteroposterior range, anteroposterior velocity, and Hassan et al41 investigated the effect of pain alleviation on
anteroposterior excursion for all 3 groups of subjects. quadriceps function and postural stability in subjects with
Group means for the postural dependent variables in the knee osteoarthritis. The authors showed that, even though
anteroposterior plane are presented in Table 3. marked knee pain reduction was associated with increased
activation and maximal voluntary contraction of the
quadriceps, postural sway did not change after significant
DISCUSSION decrease of pain. These results seem to indicate that
degenerative changes in articular tissues can affect postural
The main objective of this study was to determine if
control in presence or absence of pain. Conversely, Arokoski
postural balance parameters were modified in a group of
et al42 recently showed that hip osteoarthritis had no effect
patients with cervical osteoarthritis. The second objective
on static balance in men. Postural control can be modulated
was also to evaluate the possible combined effect of aging
by several factors such as joint flexibility, lower limb joint
and cervical osteoarthritis.
degeneration,39 vision problems,43,44 vestibular patholo-
gies,45 peripheral neuropathies,30 aging,46 muscle force, and
The Influence of Pain on Postural Control obesity.47,48 Conflicting results might be explained by
The present study suggests that postural sway quantified insufficient control of these different variables.
by anteroposterior range, anteroposterior velocity, and The association between pain and osteoarthritis remains
anteroposterior excursion is increased in patients with controversial, but many studies showed a relatively low
cervical osteoarthritis. In the past, postural stability and correlation between the 2 conditions. For instance, van der
trunk sway measures have been evaluated in whiplash Donk et al49 showed that osteoarthritis of the cervical facet
subjects with and without dizziness/vertigo.36,37 Sjstrm joints diagnosed by spinal x-rays was not related to neck
et al36 quantified postural stability of whiplash subjects pain, either in the men or the women. In the present study,
during 2-legged stance and 1-legged stance tasks. Their the significant differences in postural control between
results showed that whiplash subjects presented an increased subjects with cervical osteoarthritis and healthy age-paired
trunk sway in the 2-legged (eyes open) stance task performed subjects cannot be explained by the presence of pain because
on normal and foam surfaces. It is somehow difficult to visual analog scale scores were relatively low and similar for
compare subjects with cervical osteoarthritis and the all groups.
whiplash population studied by Sjstrm et al because most
of the whiplash subjects included in their study presented Influence of Somatosensory Changes in Postural Control
with vertigo or dizziness. Nevertheless, it was suggested that In this experiment, subjects with osteoarthritis of the
postural sway modifications in whiplash subjects may be due cervical spine showed clinical signs of degenerative
to a change weighting of sensory cues for balance control. neuropathy of the lower limbs. On one hand, it is well
Madeleine et al37 showed a greater center of pressure known that aging may affect all aspects of the nervous
displacement and greater displacement path values in system, from mental status to motor and sensory function
whiplash subjects compared with healthy controls. The and reflexes.50 For example, decreases in the number of hair
authors proposed that chronic whiplash subjects have a cells in both the canals and the otolith organs, and in the
distortion of the postural control system originating from number of nerve fibers in the vestibular nerve, may
cervical facet joints. Michaelson et al38 showed that whiplash eventually result in reduced vestibular excitability.51 On
subjects' postural balance was affected more than postural the other hand, this is a surprising result considering the fact
balance in chronic work-related cervical pain and therefore that group 2 patients showed very few signs of peripheral
Journal of Manipulative and Physiological Therapeutics
Volume 31, Number 3
neurologic deficits. It is thus possible that our osteoarthritic
group (ie, group 1) corresponded to a group of individuals
showing a larger degree of biologic aging of the neuromus-
culoskeletal system than the control group (group 2). The
postural instability shown by the osteoarthritic group may be
due to the effects of the lower limb peripheral neuropathy
alone or by a combination of both cervical degenerative
changes and peripheral changes.
Limitations
The protocol used in this experiment only explored the
modification of the visual inputs to the postural behavior of
our subjects. Additional methods of investigations such as
muscle vibration of the neck or galvanic stimulation could
be used to better disclose the respective contribution of
muscle afferents, vestibular system, and their possible
interaction effects with cervical spine degenerative changes.
Besides, a larger sample of subjects could have yielded
significant differences between postural balance of young
subjects and healthy elderly subjects. Finally, future studies
should control for neck trauma history. Because postural
sway is a temporally dynamic process, more advanced
analyses of the CoP, such as time-frequency analysis,
wavelet analysis, or recurrence analysis, should be use to
better discriminate among postural strategies used by
different subject populations.
CONCLUSION
Further research is needed to clearly isolate the effects of
cervical spine degeneration on postural control. For clin-
icians and researchers evaluating patients with degenerative
changes of the cervical spine, special care should be directed
to the examination of the peripheral nervous system because
comorbidities may be present. Tools such as the Valk score,
originally designed for the evaluation of neurologic deficits
in diabetic patients, may be appropriate to screen for lower
limb neurologic deficits in the general population.
Practical Applications
Cervical osteoarthritis may alter postural and
kinesthetic sensations.
Clinical signs of peripheral neuropathy may be
found in patients with cervical osteoarthritis.
ACKNOWLEDGMENT
The authors acknowledge Mr Pierre Black for his
technical assistance and Dr Claude Dugas, PhD, for critical
review of the manuscript. This study was funded by the
Universit du Qubec Trois-Rivires, Canada.
Boucher et al 189
Postural Control and Osteoarthritis
REFERENCES
1. Alexander NB. Postural control in older adults. J Am Geriatr
Soc 1994;42:93-108.
2. Horak FB, Shupert CL, Mirka A. Components of postural
dyscontrol in the elderly: a review. Neurobiol Ageing 1989;10:
727-38.
3. Horak FB. Postural orientation and equilibrium: what do we
need to know about neural control of balance to prevent falls?
Age Ageing 2006;35(Suppl 2):ii7-ii11.
4. de Jong PTVM, Vianney de Jong JMB, Cohen B, Jongkees
LBW. Ataxia and nystagmus induced by injection of local
anesthetics in the neck. Ann Neurol 1977;1:240-6.
5. Christiansen J, Juhl E. The prevention of falls in later life. A
report of the Kellogg International Work Group on the
Prevention of Falls by the Elderly. Dan Med Bull 1987;34
(Suppl 4):1-24.
6. Bille J, Bille-Truc F. Troubles de l'quilibre d'origine
mdullaire chez le sujet g. Revue Geriatr 1993;18:83-4.
7. Overstall PW. Falls. In: Pathy MSJ, editor. Principles and
practice of geriatric medicine. 2nd ed. John Wiley & Sons Ltd;
1991. p. 1331-40.
8. Patterson C, Torresin W. Falls in the elderly: keep your patients
feet on the ground. Geriatrics 1989:15-25.
9. Tinetti ME, Speechley M. Prevention of falls among the
elderly. N Engl J Med 1989;320:1055-9.
10. Tideiksaar R. Falls in the elderly. Bull N Y Acad Med 1988;64:
145-63.
11. Allard J. Chutes. In: Arcand M, Hbert R, editors. Prcis
pratique de griatrie (board book). St-Hyacinthe: Edisem;
1987. p. 110-21.
12. Wyke B. Cervical articular contribution to posture and gait:
their relation to senile disequilibrium. Age Ageing 1979;8:
251-8.
13. Gabell A, Simons MA, Nayak USL. Falls in the healthy
elderly: predisposing causes. Ergonomics 1985;28:965-75.
14. Rubenstein LZ, Robbins AS. Falls in the elderly: a clinical
perspective. Geriatrics 1984;39:67-78.
15. Brandt KD. Arthrose. In: Harrisson TR, editor. Principe de
mdecine interne. Paris: Mdecine-Science Flammarion; 2006.
p. 2036-45.
16. Ghez C. Posture. In: Kandel ER, Schwartz JH, Jessell TM,
editors. Principles of neural science. 3rd ed. New York:
Elsevier; 1991. p. 596-607.
17. Wyke B. Neurology of the cervical spinal joints. Physiotherapy
1979;65:72-6.
18. McLain RF. Mechanoreceptor endings in human cervical facet
joints. Spine 1994;19:495-501.
19. Richmond FJ, Bakker DA. Anatomical organization and
sensory receptor content of soft tissues surrounding upper
cervical vertebrae in the cat. J Neurophysiol 1982;48:
49-61.
20. Nyland J, Brosky T, Currier D, Nitz A, Caborn D. Review
of the afferent neural system of the knee and its con-
tribution to motor learning. J Orthop Sports Phys Ther 1994;19:
2-11.
21. Wilson VJ. Physiologic properties and central actions of neck
muscle spindles. In: Berthoz A, Vidal P, Graf W, editors. The
head-neck sensory motor system. New York: Oxford Uni-
versity Press; 1992. p. 175-8.
22. Hallgren RC, Greenman PE, Rechtien JJ. Atrophy of
suboccipital muscles in patients with chronic pain: a pilot
study. J Am Osteopath Assoc 1994;94:1032-8.
23. Enns JT, Brodeur DA. A developmental study of covert
orienting to peripheral visual cues. J Exp Child Psychol 1989;
48:171-89.
190 Boucher et al
Postural Control and Osteoarthritis
24. McPartland JM, Brodeur RR, Hallgren RC. Chronic neck pain,
standing balance, and suboccipital muscle atrophya pilot
study. J Manipulative Physiol Ther 1997;20:24-9.
25. Treleaven J, Jull G, Lowchoy N. The relationship of cervical
joint position error to balance and eye movement disturbances
in persistent whiplash. Man Ther 2006;11:99-106.
26. Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness
following whiplash injury: characteristic features and relation-
ship with cervical joint position error. J Rehabil Med 2003;35:
36-43.
27. Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R.
Development of motor system dysfunction following whiplash
injury. Pain 2003;103:65-73.
28. De Filippis L, Gulli S, Caliri A, Romano C, Munao F,
Trimarchi G, et al. Epidemiology and risk factors in
osteoarthritis: literature review data from OASIS study.
Reumatismo 2004;56:169-84.
29. Boucher P, Teasdale N, Courtemanche R, Bard C, Fleury M.
Postural stability in diabetic polyneuropathy. Diabetes Care
1995;18:638-45.
30. Peterson C, Bolton J, Wood AR, Humphreys BK. A cross-
sectional study correlating degeneration of the cervical spine
with disability and pain in United kingdom patients. Spine
2003;28:129-33.
31. Wlodyka-Demaille S, Poiraudeau S, Catanzariti JF, Rannou F,
Fermanian J, Revel M. French translation and validation of 3
functional disability scales for neck pain. Arch Phys Med
Rehabil 2002;83:376-82.
32. Kalafat M, Hugonot-Diener L, Poitrenaud J. Standardisation et
talonnage franais du Mini Mental State (MMS) version
GRCO. Rev Neuropsychol 2003;13:209-36.
33. Valk GD, Nauta JJP, Strijers RLM, Bertelsman FW. Clinical
examination versus neurophysiological examination in the
diagnosis of diabetic polyneuropathy. Diabet Med 1992;9:
716-21.
34. Maki BE, Holliday PJ, Fernie GR. Aging and postural control.
A comparison of spontaneous- and induced-sway balance tests.
J Am Geriatr Soc 1990;38:1-9.
35. Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-
based norms for the Mini-Mental State Examination by age and
educational level. JAMA 1993;269:2386-91.
36. Sjostrom H, Allum JH, Carpenter MG, Adkin AL, Honegger F,
Ettlin T. Trunk sway measures of postural stability during
clinical balance tests in patients with chronic whiplash injury
symptoms. Spine 2003;28:1725-34.
37. Madeleine P, Prietzel H, Svarrer H, Arendt-Nielsen L.
Quantitative posturography in altered sensory conditions: a
way to assess balance instability in patients with chronic
whiplash injury. Arch Phys Med Rehabil 2004;85:432-8.
Journal of Manipulative and Physiological Therapeutics
March/April 2008
38. Michaelson P, Michaelson M, Jaric S, Latash ML, Sjolander
P, Djupsjobacka M. Vertical posture and head stability in
patients with chronic neck pain. J Rehabil Med 2003;35:
229-35.
39. Jones G, Nguyen T, Sambrook PN, Lord SR, Kelly PJ, Eisman
JA. Osteoarthritis, bone density, postural stability, and
osteoporotic fractures: a population based study. J Rheumatol
1995;22:921-5.
40. Hinman RS, Bennell KL, Metcalf BR, Crossley KM. Balance
impairments in individuals with symptomatic knee osteoar-
thritis: a comparison with matched controls using clinical tests.
Rheumatology (Oxford) 2002;41:1388-94.
41. Hassan BS, Doherty SA, Mockett S, Doherty M. Effect of pain
reduction on postural sway, proprioception, and quadriceps
strength in subjects with knee osteoarthritis. Ann Rheum Dis
2002;61:422-8.
42. Arokoski JP, Leinonen V, Arokoski MH, Aalto H, Valtonen H.
Postural control in male patients with hip osteoarthritis. Gait
Posture 2006;23:45-50.
43. Lord SR. Visual risk factors for falls in older people. Age
Ageing 2006;35(Suppl 2):ii42-5.
44. Lord SR, Dayhew J. Visual risk factors for falls in older people.
J Am Geriatr Soc 2001;49:508-15.
45. Horak FB, Nashner LM, Diener HC. Postural strategies
associated with somatosensory and vestibular loss. Exp Brain
Res 1990;82:167-77.
46. Hay L. Posture control and muscle proprioception in the
elderly. In: Ferrandez AM, Teasdale N, editors. Changes in
sensory motor behavior in aging. Amsterdam: North-Holland;
1995. p. 133-61.
47. Corbeil P, Simoneau M, Rancourt D, Tremblay A, Teasdale N.
Increased risk for falling associated with obesity: mathematical
modeling of postural control. IEEE Trans Neural Syst Rehabil
Eng 2001;9:126-36.
48. Hue O, Marcotte J, Berrigan F, Simoneau M, Dore J, Marceau
P, et al. Plasma concentration of organochlorine compounds is
associated with age and not obesity. Chemosphere 2007;67:
1463-7.
49. van der Donk J, Schouten JS, Passchier J, van Romunde
LK, Valkenburg HA. The associations of neck pain with
radiological abnormalities of the cervical spine and person-
ality traits in a general population. J Rheumatol 1991;18:
1884-9.
50. Bickley LS, Szilagyi PG. Bates' guide to physical examination
and history taking. 8th ed. Philadelphia: Lippincott Williams &
Wilkins; 2003.
51. Speers RA, Kuo AD, Horak FB. Contributions of altered
sensation and feedback responses to changes in coordination of
postural control due to aging. Gait Posture 2002;16:20-30.