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Table of Contents
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 13-18

Impact of neck proprioception and central sensitization on balance outcomes in patients with chronic neck pain

1 Department of Physiotherapy, Sarvajanik College of Physiotherapy, Surat, Gujarat, India
2 SJ Nursing Home, Nagercoil, Tamil Nadu, India

Date of Submission18-Jun-2020
Date of Decision31-Oct-2020
Date of Acceptance18-Jun-2021
Date of Web Publication31-Jul-2021

Correspondence Address:
Dr. A Thangamani Ramalingam
Sarvajanik College of Physiotherapy, Surat - 395 003, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_15_20

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Context: Currently, multiple researches demonstrate that proprioception of the neck has a favorable effect and a direct association with balance in individuals with chronic neck pain (CNP). However, there is a paucity of the literature that has attempted to quantify the impact of proprioception on balance in CNP patients and to determine the function of central nervous system sensitization (CS) in CNP patients.
Aims: The goal of this study was to determine the variance component of proprioception on balance in CNP patients and to examine if there was a difference between centrally sensitized and nonsensitized CNP patients.
Settings and Design: A cross-sectional, observational study was conducted in the outpatient department of a tertiary care hospital.
Materials and Methods: Thirty-seven patients with CNP were assessed for proprioception, static and dynamic balance was using head repositioning accuracy (HRA) test, Brief Balance Evaluation Systems Test, step test, four-step square test, and Y-balance test. Disability and nervous system sensitization was assessed using the Neck Pain and Disability Scale and central sensitization inventory (CSI).
Statistical Analysis Used: Kolmogrov–Smirnov test, Pearson correlation coefficient was used for statistical analysis.
Results: The impact of CSI and HRA scores on static and dynamic balance scores was unpredictable, ranging from a minimum of 10% to a maximum of 38.7%.
Conclusion: There is a weak evidence to suggest that proprioception component could have contributed to the variance in static, dynamic balance and disability in patients with centrally sensitized CNP.

Keywords: Balance, Central sensitization, Chronic neck pain, Neck proprioception

How to cite this article:
Ramalingam A T, Senthil Kumar S N, Rana D, Gadhiya A, Patel S, Khan N. Impact of neck proprioception and central sensitization on balance outcomes in patients with chronic neck pain. Indian J Phys Ther Res 2021;3:13-8

How to cite this URL:
Ramalingam A T, Senthil Kumar S N, Rana D, Gadhiya A, Patel S, Khan N. Impact of neck proprioception and central sensitization on balance outcomes in patients with chronic neck pain. Indian J Phys Ther Res [serial online] 2021 [cited 2022 Nov 29];3:13-8. Available from: https://www.ijptr.org/text.asp?2021/3/1/13/322912

  Introduction Top

Chronic neck pain (CNP) can range from a dull ache to a shock-like discomfort that radiates into the arm and lasts for at least 3 months. A nonspecific CNP is one of the most frequent life-long musculoskeletal illnesses, with a fluctuating frequency of 43%–66.7% in the middle-aged individuals. The physiological mechanisms for recurrence or persistence remain unclear or maybe considered due to central sensitization (CS) phenomenon occurring in the central nervous system but could be linked with altered proprioception, a component of cervical sensorimotor control (CSMC).[1],[2] Ongoing research studies on the sensorimotor functions in CNP identified a reduced proprioceptive ability, impaired postural control and balance, reduced range of cervical spine movements, cervicogenic headache, and occasional visual symptoms.[3],[4],[5]

When the vision is absent, the dorsomedial pathway provides information about the exact position of the body in the space including range, direction of movement of the joint in a space. CSMC comprises of multiple subsystems such as proprioception and kinesthesia, occulo-motor system, and the vestibular system.[6],[7] Several studies have shown that this proprioception is vital in maintaining joint stability under the static and dynamic conditions. The development of postural instability and clinical pain is predisposed by impaired proprioception.[3],[5],[8],[9],[10],[11],[12] CSMC impairments can lead to decreased physical performance and increased risk of fall particularly in elderly.[13],[14] The reason for impaired proprioception in the cervical joint could be an altered or impaired afferent input from receptors, increased sensitivity of the nervous system which changes the integration and temporal variables of sensorimotor control, in neck pain patients.[12],[15],[16],[17],[18],[19],[20],[21] As a result, one of the primary goals of this study was to determine the direct effect of neck proprioception on balance in CNP patients with and without CS, which could have clinical consequences in the treatment of CNP patients with proprioception, balance, and sensitization difficulties.

  Materials And Methods Top

The present study was a cross-sectional, prospective study with nonprobability sampling. The study was endorsed by the Institutional Ethics Committee and was conducted at the physiotherapy outpatient department. The purpose of the study was explained, and written informed consent was obtained from the participants. A total of 37 patients with CNP were enrolled. The inclusion criteria for the study participants were patients with CNP for more than 3 months and classified chronic pain patients based on central sensitization inventory (CSI) scores as with or without CS (CS/NO CS), patients of both gender in the age group of 20–70 years, and patients willing to participate in the study. The exclusion criteria were patients with progressive neurological, history of cervical spine or shoulder fracture, disc herniation, cervical stenosis, history of cervical spine surgery, congenital anomalies, and pregnancy.

Data were obtained from the patients who came to OPD for the treatment of neck pain. Based on the inclusion criteria, participants with CNP participated in a single testing session, and a neck evaluation form was given to collect the clinical data of the participants. Neck Pain and Disability Scale (NPAD) and CSI were used to assess functional neck disability and nerve sensitization. NPAD consists of 20 items with a scoring range of 0–5 and a total score of 0–100.[22],[23] The CSI consists of 25 statements related to current health symptoms. Each of these items is measured on a 5-point temporal Linkert scale. A cumulative score ranges from 0 to 100. Scores ≥40/100 indicate the presence of central sensitization.[24],[25] The head repositioning accuracy (HRA)[26] was used to examine neck proprioception. Balance was assessed using the Brief Balance Evaluation Systems Test (brief BEST),[27] step test,[28],[29] four step square test (FSST),[30] and Y-balance test.[31],[32]

Assessment of neck proprioception

Proprioception was assessed using the head repositioning accuracy test. A circular headband with a laser pointer was placed on the participant's head. The laser was pointed at a bull's-eye target (90 cm in front of the participant). To convert HRA readings from centimeters to degrees formula angle = tan–1 (error distance/90 cm) was used.[12],[25],[33] Initially, the participants were made to perform cervical spine movements (flexion, extension, left rotation, and right rotation) with eyes open to understand the actual test following which the test was performed with eyes closed, three trials were taken for each cervical movement, and the average of three was considered as the final score.

Assessment of balance

Brief-BEST a clinical balance assessment too was used. It is a tool that measures six different dimensions contributing to postural control in standing and walking. It is a 6-item clinical balance assessment test in which two of the 6 items were scored bilaterally, resulting in an 8-item balance test. The item scores ranged from 0 to 3 (severe balance impairment to no balance impairment) and the maximum possible score was 24 points. Lower scores indicate severe balance impairment.[27],[34]

Balance was also assessed using the step test which incorporates dynamic single limb stance in this the participants stood in front of 15 cm block were asked to lead with a stepping leg and place the whole foot onto the block, then returns it fully back down to the floor, repeatedly as fast as possible for 15 s for each leg 3 readings were taken and the average number of steps for each leg was calculated.[28],[29]

FSST was used to examine the dynamic balance. A 90 cm × 90 cm square was drawn, and the main square was then divided into four small equal squares. Participants were instructed to stand in square 1 facing forward with their shoes on and move clockwise then counterclockwise into each square while retaining both feet in each square.[30],[35]

The Y-balance test was also used to assesses dynamic postural balance by measuring the maximum attained distance in the posterior-medial (PM), posterior-lateral (PL), and anterior (ANT) directions.[31],[32] The maximal reach distance in each direction in centimeters was measured in the three reach directions PM, PL, and ANT in reference to the stance leg. Between trials, a 5-s break was allowed. Using the formula (normalized ANT + normalized PM + normalized PL)/3 = Absolute reach distance. The composite score was derived as the average of the three normalized reach direction scores for each leg for each trial.[36],[37],[38]

Statistical analyses

Data were analyzed using the SPSS software version 25 (IBM. New York, NY, United States). For the various outcome measures developed, categorical variables are reported as percentages, whereas numerical variables are expressed as mean and standard deviation. The Kolmogrov–Smirnov test was used to determine the data's normality. On the whole data set acquired, descriptive and exploratory data analysis was performed, as well as Pearson correlation coefficients and linear regression analyses to determine the variance impact.

  Results Top

The current study included 37 CNP participants, with 4 males and 33 females ranging in age from 20 to 70 years old with a mean difference of 38.78 ± 14.5 years. The demographic and health characteristics of all individuals, as well as descriptive data for the outcome measures, are shown in [Table 1] and [Table 2]. The correlation between the HRA test, balance, and CSI of the participants with CNP is seen in [Table 3] and [Table 4]. HRA horizontal had a negative correlation with FSST, step test, and Y-balance test with P < 0.05. CSI is negatively correlated with all the balance tests and Neck Pain and Disability Score except Y balance test with P < 0.05. Further, there is no correlation between proprioception and central sensitization. The linear regression analysis showed the variance component between HRA, CSI, and balance scores [Table 5]. There was an inconsistent impact of CSI and HRA scores on static and dynamic balance scores. The results in [Table 6] indicate that there was difference found between the balance scores of centrally sensitized and nonsensitized patients with CNP (P < 0.05).
Table 1: Demographic and health characteristics of participants (n=37)

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Table 2: Descriptive statistics of outcome measures (n=37)

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Table 3: Correlation between balance, central sensitization, and proprioception

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Table 4: Correlation between central sensitization and balance and disability

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Table 5: Linear regression analysis results of central sensitization, proprioception, and balance

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Table 6: Difference of balance between central sensitization and no central sensitization patients with chronic neck pain

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  Discussion Top

In the current study, the proprioception outcome HRA had lower scores in both vertical and horizontal components, indicating that the selected group of patients has minimal proprioceptive abnormalities. The current study echoes similar findings in a comparative study of patients diagnosed with cervical disc degeneration and healthy participants examined by HRA, in which researchers discovered alterations in the range of motion in patients with cervical illness and attributed the change to proprioception.[39] However, the findings also suggest the difference in HRA in a group of CNP patients should be interpreted with caution, since the participants are more likely to be centrally sensitized than to have cervical disc disease. In addition to HRA, the participants also had to deal with central sensitization as an end measure. In the current study, 75% of the participants were said to be struggling with CS, and the average CSI score ranged from mild to moderate. Similarly, the majority of the static and dynamic balance outcomes had a negative connection with HRA, showing that as proprioceptive impairments develop, so does balance.

One important observation noted in the study is that the horizontal cervical movements in HRA seemed to be significantly better correlated than vertical movements, i.e. rotatory or horizontal movements has a role in balance than vertical. This has to be taken cautiously as whether proprioception deficits reflected in terms of HRA, could be one directional and whether it can exert an effect on wider balance outcomes and to our knowledge has not been reported in previous literature. Further whether, this could be because of the proprioceptive input or not, needs to be studied as the CNP participants varies with respect to severity in our selected sample population. In addition, among the balance scales, Brief BEST test considered one of the key dynamic balance assessment scales showed no significant correlation with HRA.

The analysis of the present study further revealed that there was a significant negative correlation between disability and central sensitization to balance. However, this relationship needs to be looked up with caution as the CSI scores of the selected participants predominantly falls within the mild-to-moderate category.[40] There is no research that we are aware of that have examined the effects of balance and disability combination on clinical scores such as CS. As a result of this preliminary research, we may claim with caution that there appears to be a weak association between balance and CS in CNP patients.

The regression analysis might have helped in identifying FSST and step test has the ability to predict balance better than other tests in CNP patients with proprioceptive deficits. Further, although there was no correlation between proprioception and sensitization, but both showed to have impact on balance and could be considered as independent factors affecting balance.

On the contrary, many previous studies have shown that neck pain is associated with poor balance and low HRA. To do so, we attempted to quantify these variables using multiple scales to increase rigor and investigate their relationship, which strengthens our study. As previously stated, despite using various static and dynamic balance tests to increase rigor in this study, the findings still revealed inconsistencies between the clinical and outcome variables.[1],[39],[41],[42],[43] Moreover, this study also stated that, statistically there is no connection between pain perception or sensitization and proprioception in CNP patients. This results on pain and proprioception in our study reflect similar relationship results as reported by a study on chronic knee osteoarthritis.[44] Further the role of proprioceptive exercise training as the treatment protocol in practice may also be reconsidered for a second thought as there is inconsistency of proprioceptive impact on various balance tests which also supported by a systematic review.[45]

As limitations of the study, despite using the standardized measurement tools such as CSI and HRA, it is assumed that the inconsistencies in the correlation and regression analysis could be due to the various factors associated with the methodology of research such as smaller sample size, sampling, and gender bias. An individual relationship between the clinical variables and performance scales through better methodology of research would reveal more insights into the actual relationship between the variables. Hence, having considered the limitation of the study, proprioception and central sensitization could not be strictly considered as prime factors behind the balance deficits of CNP patients which may be a reliable clinical implication for practice.

  Conclusion Top

The proprioception component and clinically classified centrally sensitized pain contributed to the weak associative relationship of the static, dynamic balance, and disability of patients with CNP.


The authors would like to thank the participants and the Lockhatmullasarvajanik Hospital, Surat for the support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Duray M, Şimşek Ş, Altuğ F, Cavlak U. Effect of proprioceptive training on balance in patients with chronic neck pain. Agri 2018;30:130-7.  Back to cited text no. 1
Sremakaew M, Jull G, Treleaven J, Barbero M, Falla D, Uthaikhup S. Effects of local treatment with and without sensorimotor and balance exercise in individuals with neck pain: Protocol for a randomized controlled trial. BMC Musculoskelet Disord 2018;19:48.  Back to cited text no. 2
Kristjansson E, Dall'Alba P, Jull G. A study of five cervicocephalic relocation tests in three different subject groups. Clin Rehabil 2003;17:768-74.  Back to cited text no. 3
Sjölander P, Michaelson P, Jaric S, Djupsjöbacka M. Sensorimotor disturbances in chronic neck pain – Range of motion, peak velocity, smoothness of movement, and repositioning acuity. Man Ther 2008;13:122-31.  Back to cited text no. 4
Jørgensen MB, Skotte JH, Holtermann A, Sjøgaard G, Petersen NC, Søgaard K. Neck pain and postural balance among workers with high postural demands – A cross-sectional study. BMC Musculoskelet Disord 2011;12:176.  Back to cited text no. 5
Kiernan JA, Barr ML. Barr's the human nervous system: an anatomical viewpoint. Lippincott Williams & Wilkins; 2009.  Back to cited text no. 6
de Zoete RM, Osmotherly PG, Rivett DA, Snodgrass SJ. Seven cervical sensorimotor control tests measure different skills in individuals with chronic idiopathic neck pain. Braz J Phys Ther 2020;24:69-78.  Back to cited text no. 7
Lee HY, Wang JD, Yao G, Wang SF. Association between cervicocephalic kinesthetic sensibility and frequency of subclinical neck pain. Man Ther 2008;13:419-25.  Back to cited text no. 8
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.  Back to cited text no. 9
Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: Characteristic features and relationship with cervical joint position error. J Rehabil Med 2003;35:36-43.  Back to cited text no. 10
Field S, Treleaven J, Jull G. Standing balance: A comparison between idiopathic and whiplash-induced neck pain. Man Ther 2008;13:183-91.  Back to cited text no. 11
Revel M, Andre-Deshays C, Minguet M. Cervicocephalic kinesthetic sensibility in patients with cervical pain. Arch Phys Med Rehabil 1991;72:288-91.  Back to cited text no. 12
Kendall JC, Boyle E, Hartvigsen J, Hvid LG, Azari MF, Skjødt M, et al. Neck pain, concerns of falling and physical performance in community-dwelling Danish citizens over 75 years of age: A cross-sectional study. Scand J Public Health 2016;44:695-701.  Back to cited text no. 13
Poole E, Treleaven J, Jull G. The influence of neck pain on balance and gait parameters in community-dwelling elders. Man Ther 2008;13:317-24.  Back to cited text no. 14
Richmond FJ, Abrahams VC. Morphology and distribution of muscle spindles in dorsal muscles of the cat neck. J Neurophysiol 1975;38:1322-39.  Back to cited text no. 15
Rix GD, Bagust J. Cervicocephalic kinesthetic sensibility in patients with chronic, nontraumatic cervical spine pain. Arch Phys Med Rehabil 2001;82:911-9.  Back to cited text no. 16
Shumway-Cook A, Woollacott MH. Motor Control: Translating Research into Clinical Practice. Philadelphia: Lippincott Williams and Wilkins; 2007.  Back to cited text no. 17
Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain 2011;152:S2-15.  Back to cited text no. 18
Kosek E, Ordeberg G. Lack of pressure pain modulation by heterotopic noxious conditioning stimulation in patients with painful osteoarthritis before, but not following, surgical pain relief. Pain 2000;88:69-78.  Back to cited text no. 19
Sterling M, Jull G, Vicenzino B, Kenardy J. Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery. Pain 2003;104:509-17.  Back to cited text no. 20
Greening J, Lynn B, Leary R. Sensory and autonomic function in the hands of patients with non-specific arm pain (NSAP) and asymptomatic office workers. Pain 2003;104:275-81.  Back to cited text no. 21
Goolkasian P, Wheeler AH, Gretz SS. The neck pain and disability scale: Test-retest reliability and construct validity. Clin J Pain 2002;18:245-50.  Back to cited text no. 22
Blozik E, Himmel W, Kochen MM, Herrmann-Lingen C, Scherer M. Sensitivity to change of the neck pain and disability scale. Eur Spine J 2011;20:882-9.  Back to cited text no. 23
Bid Dibyendunarayan D, Soni Neela C, Rathod Priyanshu V, Thangamani Ramalingam A. Content validity and test-retest reliability of the Gujarati version of the Central Sensitization Inventory. Natl J Integr Res Med 2016;7:18-24.  Back to cited text no. 24
Mayer TG, Neblett R, Cohen H, Howard KJ, Choi YH, Williams MJ, et al. The development and psychometric validation of the central sensitization inventory. Pain Pract 2012;12:276-85.  Back to cited text no. 25
Dugailly PM, De Santis R, Tits M, Sobczak S, Vigne A, Feipel V. Head repositioning accuracy in patients with neck pain and asymptomatic subjects: Concurrent validity, influence of motion speed, motion direction and target distance. Eur Spine J 2015;24:2885-91.  Back to cited text no. 26
Huang M, Pang MY. Psychometric properties of Brief-Balance Evaluation Systems Test (Brief-BESTest) in evaluating balance performance in individuals with chronic stroke. Brain Behav 2017;7:e00649.  Back to cited text no. 27
Mercer VS, Freburger JK, Chang SH, Purser JL. Step Test scores are related to measures of activity and participation in the first 6 months after stroke. Phys Ther 2009;89:1061-71.  Back to cited text no. 28
Hill K. A new test of dynamic standing balance for stroke patients: Reliability, validity and comparison with healthy elderly. Physiother Can 1996;48:257-62.  Back to cited text no. 29
Moore M, Barker K. The validity and reliability of the four square step test in different adult populations: A systematic review. Syst Rev 2017;6:187.  Back to cited text no. 30
Gribble PA, Kelly SE, Refshauge KM, Hiller CE. Interrater reliability of the star excursion balance test. J Athl Train 2013;48:621-6.  Back to cited text no. 31
Kinzey SJ, Armstrong CW. The reliability of the star-excursion test in assessing dynamic balance. J Orthop Sports Phys Ther 1998;27:356-60.  Back to cited text no. 32
Chen X, Treleaven J. The effect of neck torsion on joint position error in subjects with chronic neck pain. Man Ther 2013;18:562-7.  Back to cited text no. 33
Marques A, Almeida S, Carvalho J, Cruz J, Oliveira A, Jácome C. Reliability, validity, and ability to identify fall status of the balance evaluation systems test, mini-balance evaluation systems test, and brief-balance evaluation systems test in older people living in the community. Arch Phys Med Rehabil 2016;97:2166-73.e1.  Back to cited text no. 34
Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med Rehabil 2002;83:1566-71.  Back to cited text no. 35
Gribble PA, Hertel J. Considerations for normalizing measures of the star excursion balance test. Meas Phys Educ Exerc Sci 2003;7:89-100.  Back to cited text no. 36
Gribble PA, Hertel J, Plisky P. Using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower extremity injury: A literature and systematic review. J Athl Train 2012;47:339-57.  Back to cited text no. 37
Gribble PA, Tucker WS, White PA. Time-of-day influences on static and dynamic postural control. J Athl Train 2007;42:35-41.  Back to cited text no. 38
Wibault J, Vaillant J, Vuillerme N, Dedering Å, Peolsson A. Using the cervical range of motion (CROM) device to assess head repositioning accuracy in individuals with cervical radiculopathy in comparison to neck- healthy individuals. Man Ther 2013;18:403-9.  Back to cited text no. 39
Neblett R, Hartzell MM, Mayer TG, Cohen H, Gatchel RJ. Establishing clinically relevant severity levels for the central sensitization inventory. Pain Pract 2017;17:166-75.  Back to cited text no. 40
Siu E, Wing T. The relationship between cervical range of motion, head-repositioning accuracy, and postural stability in healthy adults. Int J Ther Rehabil 2013;20:9-17.  Back to cited text no. 41
Treleaven J, Murison R, Jull G, LowChoy N, Brauer S. Is the method of signal analysis and test selection important for measuring standing balance in subjects with persistent whiplash? Gait Posture 2005;21:395-402.  Back to cited text no. 42
Palmgren PJ, Sandström PJ, Lundqvist FJ, Heikkilä H. Improvement after chiropractic care in cervicocephalic kinesthetic sensibility and subjective pain intensity in patients with nontraumatic chronic neck pain. J Manipulative Physiol Ther 2006;29:100-6.  Back to cited text no. 43
De Oliveira DC, Barboza SD, da Costa FD, Cabral MP, Silva VM, Dionisio VC. Can pain influence the proprioception and the motor behavior in subjects with mild and moderate knee osteoarthritis? BMC Musculoskelet Disord 2014;15:321.  Back to cited text no. 44
McCaskey MA, Schuster-Amft C, Wirth B, Suica Z, de Bruin ED. Effects of proprioceptive exercises on pain and function in chronic neck- and low back pain rehabilitation: A systematic literature review. BMC Musculoskelet Disord 2014;15:382.  Back to cited text no. 45


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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