Cervical Joint Position Error Test

Introduction

The Cervical Joint Position Error (JPE) Test is a measurement tool used to clinically assess an individual’s cervicocephalic proprioception ability. Cervicocephalic proprioception describes one’s sense of position of their head and neck in space. (Newcomer et al., 2000). The Cervical JPE Test measures the ability of a blindfolded patient to accurately relocate their head position back to a predetermined neutral point after cervical joint movement. The test is most commonly performed with head movement in the transverse and sagittal planes. The Cervical JPE Test has strong clinical value in identifying proprioceptive deficits in patients with neck pain, where neck pain originating from trauma (i.e., WAD) or those with gradual onset both demonstrating a higher JPE those without neck pain (Feipel et al., 2006; Cheng et al., 2010).

Theory The cervical muscles play an essential role in relaying important sensory information regarding head position to our central nervous system (Bolton et al., 1998). Sensory organs called muscle spindle receptors respond to changes in length of cervical muscles. The afferent information provided from cervical muscle length changes will converge at the vestibular nuclei with information from the visual and vestibular systems (Corneil et al., 2002). Together this information is then relayed to the cerebellum and cerebrum and contributes to our body’s sense of head-neck position sense. Patients suffering from traumatic neck injury (i.e., whiplash) or chronic neck pain may have disturbances to cervical afferent input leading to abnormalities with sensorimotor control of the neck and head (Treleaven, Jull, & LowChoy., 2006).

Technique

To best isolate the head and neck the cervical JPE test should be performed with the patient in sitting to reduce any contribution of balance impairments or other postural compensations affecting the findings of the test.

A target is placed on a wall 90cm away from the patient, at the patient’s head height in sitting. The target is typically 40cm in diameter with concentric circles in 1cm increments (Kristjansson E, Treleaven J. 2009).

A laser pointer or similar targeting device is mounted onto a lightweight headband is then placed on the patient’s head (Kristjansson E, Treleaven J. 2009).

The patient is then asked to focus on finding natural resting head position so that the laser pointer is in line with the centre or “bullseye” of the target.

With eyes closed, the patient will actively move their head in one plane of motion and attempt to return to the starting position as accurately as possible (Kristjansson E, Treleaven J. 2009).

The patient should verbally indicate when they feel they have returned to the starting position before opening their eyes again (Treleaven et al., 2003).

Three trials should be performed for each direction of motion assessed (the best score recorded), with the subject given opportunity to re-centre their starting position prior to each test (Treleaven et al., 2003).

The difference between the position of the laser beam on the target at starting position and end test is measured with greater displacement indicating cervical JPE and greater impairment of proprioception.

Positive Result The difference between the starting and finishing position of the laser beam on the wall is measured in centimeters and then converted into degrees:

(angle = tan-1[error distance/90 cm]).

Thus, an approximately 7.1-cm error distance indicates meaningful error of 4.5° (Revel et al. 1991).

Other clinical findings of the cervical JPE test include: Jerky or altered movement patterns Overshooting of the position in order to gain more proprioceptive feedback for the task “Searching” for the position.

Evidence:

Normative Results Revel et al. in 1991 found in healthy controls less than 4.5 degrees error denotes “normal” cervical proprioception, with a reported sensitivity of 86% and specificity of 93%.

Test/Retest Reliability Heikkilä and Aström in 1996 found when testing healthy controls, no significant difference (p<0.001) between test results separated by 1- and 2-month time periods.

Inter/Intra-rater Reliability Louden et al. in their study on JPE is subjects with whiplash report: Inter-rater reliability ICC = 0.972 Intra-rater reliability ICC = 0.975 (for therapist 1) and 0.985 (for therapist 2)

Validity Sterling et al. in 2003 report a significant difference between whiplash group average: 5.01 degrees compared to healthy controls: 1.75 degrees (P<0.05)

In 2015 de Vries et al. published a systematic review on Joint position sense error in people with neck pain. Their review found withing the field of research participants with traumatic neck pain had a significantly higher JPSE than healthy controls (Heikkila and Wenngren, 1998; Kristjansson et al., 2003; Sterling et al., 2003; Treleaven et al., 2003). The 2015 systematic review concluded that the current body of literature shows the JPSE to be a relevant measure when it is used correctly, with JPSE is overall higher in subjects with neck pain of chronic or traumatic origin when measured over at least 6 trials (de Vries et al. 2015).

VIDEO

Chris Worsfold Assessing proprioception of the neck - YouTube. Available from: https://www.youtube.com/watch?v=SFjAMaAdqXY&ab_channel=ChrisWorsfold

Physiotutors JPSE assessment tutorial – YouTube. Available from: https://www.youtube.com/watch?v=UuNkX2B1vWw&t=158s&ab_channel=Physiotutors