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Rehab Measures: Cervical Joint Position Error Test

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Title of Assessment

Cervical Joint Position Error Test 

Acronym

Cervical JPET

Instrument Reviewer(s)

Jennifer L. Stoskus, PT, MSPT, DPT , Matthew R. Scherer PT, PhD, NCS and the Vestibular EDGE task force of the Neurology section of the APTA

Summary Date

11/12/2013 

Purpose

The cervical joint position error test (JPET) is used to assess cervicocephalic proprioception and neck reposition sense.

Description

The cervical JPET tests one’s ability to relocate the head back to center after maximal or submaximal rotation in the transverse and sagittal planes.

  • Patient should be seated in a chair that has a backrest with vision occluded with a blindfold or eyes closed.
  • The target should be placed 90 cm in front of the patient and able to be adjusted to the patient’s neutral head position (NHP). This is the zero point or center of the target.
  • The patient is fitted with a laser pointer or similar targeting device to measure magnitude of head displacement from the starting position.
  • The patient is instructed to perform an active head rotation to one side, after which he or she should return back to the “neutral” or starting head position.
  • The point where this lands indicates the global error related to the center of the target.
  • Modifications of this test include neutral head position to a pre-set target.
  • Some studies also perform body on head rotation as an error measurement.

Area of Assessment

Pain; Range of Motion; Vestibular 

Body Part

Neck 

ICF Domain

Body Structure; Body Function 

Domain

Motor; Sensory 

Assessment Type

Performance Measure 

Length of Test

05 Minutes or Less; 06 to 30 Minutes 

Time to Administer

5-10 minutes based on the number of rotational measurements taken

Number of Items

Cervical Joint Position Error Test can be performed in all planes, however it is most commonly tested for left and right (yaw plane) cervical rotation.   

Equipment Required

  • Common clinical practice uses a laser pointer fixed to a helmet or headband and a mobile target. Targets are typically 40 cm in diameter with concentric circles in 1 cm increments, divided into 4 quadrants intersecting at the zero.
  • Research applications commonly utilize highly technical devices such as 3 dimensional electromagnetic or ultrasound equipment.

Training Required

Ability to assess cervical range of motion and identify patient’s kinesthetic awareness of a neutral head position.

Type of training required

No Training; Reading an Article/Manual; Training Course 

Cost

Free 

Actual Cost

Cost of equipment (laser pointer and target or other equipment)

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

 

Diagnosis

Neck Injury; Pain 

Populations Tested

  • Cervicogenic dizziness
  • Whiplash injury with and without dizziness/imbalance

Standard Error of Measurement (SEM)

Healthy Controls :

(Strimpakos et al, 2006, n = 35, age range 19-63 years, control group n = 10, age range 20-32 years).

  • Absolute mean error: 1.3 - 4.7 degrees

· SEM: flexion = 2.1 degrees, R rotation = 2.9 degrees, L rotation = 1.9 degrees, R side bending = 1.2 degrees, L side bending = 0.7 degrees

Non-Traumatic Neck Pain :

(Lee et al, 2006, n = 20 with non-traumatic neck pain, mean age = 21.9 ± 3.9 years)

Head to NHP rotation:

· Root Mean Square Error, 2.8 ± 1.8- 6.5 ± 2.6, ICC = 0.53-0.80, extension = 0.29 (poor), SEM = 1.2 - 2.6 degrees

· Constant Error = 1.5 ± 3.4 to 5.2 ± 4 ICC = 0.54 - 0.84, extension = 0.38, SEM = 0.3 - 3.7 degrees

· Variable Error = 0.9 ± 0.6 degrees to 2.4 ± 1.6 degrees ICC = 0.55 - 0.83

Head to target:

· Root Mean Square Error, = 1.4 ± 1 degree- 3.1 ± 2.7, ICC = 0.42 - 0.9, SEM = 0.7 - 1.5 degrees

· Constant Error = 1.4 ± 4.8- .8 ±4.5, ICC = 0.72 - 0.83, SEM = 2 - 4 degrees

· Variable Error = 0.8 ± 0.5 - 2.2 ± 1.3 degrees, ICC =0 .44, 0.52 and 0.49) poor head to target L, R, L sidebend, SEM = 0.5 - 1.2 degrees

(Kristjansson et al, 2001; n = 19 asymptomatic, healthy control volunteers, mean age = 31.5 + 10 years).

  • Mean relocation error from full cervical rotation = 2.46 ± 0.2 degrees
  • Mean relocation error from 30 degrees to NHP = 5.8 (±0.6) degrees

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Chronic Cervical Pain :

(Revel et al, 1991; patients with cervicalgia: n = 32, mean age = 45 years; healthy controls: n = 30, mean age = 44 years)

  • < 4.5 degrees (horizontal) denotes “normal” cervical proprioception. (Sn 86%, Sp 93%)
  • > 4.5 degrees (horizontal) indicates abnormal cervical proprioception.

Normative Data

Whiplash associated disorders (WAD) / cervical pain:

Study

Study Sample Size

Mean Age (SD)

Mean (between group) relocation error (degrees or centimeters) (± SE/SD)

Treleaven et al, 2003

Patients with WAD > 3 months since injury,

n = 102

n =76 also w dizziness

39.1(1.3) years

Mean time since injury = 1.24 years

Extension

3.5 ± 0.3

Rotation Left

3.6 ± 0.3

Rotation Right

4.1 ± 0.3

Sterling et al, 2003

WAD,

n = 66

36.3 (12.7) years

Moderate to severe group

4.8 ± 0.3 (Right)

3.2± 0.3 (Left)

4.1 ± 0.3 (Extension)

Mild symptoms group

2.7 ± 0.3 (Right)

2.7 ± 0.2 (Left)

3.4 ± 0.3 (Extension)

Recovered group

3.6 ± 0.3 (Right)

3.0 ± 0.2 (Left)

3.3 ± 0.3 (Extension)

Heikkila and Wengren, 1998

Whiplash injury,

n = 27

33.8 years

Mean repositioning error after whiplash injury

3.84 cm (SD = 3.2)

Mean repositioning error after whiplash injury with dizziness

4.21 cm (SD = 1.9)

Horizontal error for those after whiplash with radiculopathy

1.04 cm (SD = 3.16) in left rotation, compared to -.003 cm (SD =3.4) in controls

Heikkila and Astrom, 1996

Whiplash

6 mo-10 years s/p injury,

n = 14

36 years

Horizontal- noted overshooting after left rotation

4.2 cm (SD: 2.93)

Vertical- noted overshooting after flexion

5.2 cm (SD = 3.52)

Revel et al, 1991

Chronic cervical pain,

n = 30

45 years

Horizontal global error

3.37± 0.73

Vertical

5.47± 1.75

Healthy Controls from Above Studies

Study

Study Sample Size

Mean Age (SD)

Mean relocation error (degrees or centimeters) (± SE/SD)

Treleaven et al, 2003

n = 44

34.1 (1.8) years

Extension

2.4 ± 0.3

Rotation Left

2.0 ± 0.2

Rotation Right

2.5 ± 0.3

Sterling et al, 2003

n = 20

40.1 (13.6) years

Mean relocation

2.8 ± 0.5

Heikkila and Wengren, 1998

n =39

35 years

Mean relocation in all directions

2.75 cm (SD= 1.9)

Heikkila and Astrom, 1996

n = 34

35 years

Mean global error value for all directions

2.7 cm (SD= 0.81)s

Revel et al, 1991

n = 30

44 years

Horizontal

3.5± 0.82

Vertical

3.37 ± 0.73

Whiplash Injury :

(Heikkila and Wengren, 1998)

  • Incidence of repositioning dysfunction and pathologic oculomotor testing = 62% in patients with whiplash trauma > 2 years.

Test-retest Reliability

Asymptomatic (Healthy Control)

(Kristjansson et al, 2001)

  • Poor to Adequate: relocation from full cervical rotation ICC= 0.35 / 0.44 (R/L), from 30 degrees of cervical rotation ICC = 0.62 / 0.82 (R/L)

Chronic Cervical Pain :

(Lee et al, 2006)

  • Adequate to Excellent: relocation to neutral head position: ICC = 0.45 - 0.80;
  • Poor relocation from Extension to NHP: ICC = 0.29
  • Adequate to Excellent: head to target: ICC = 0.42 - 0.90

S/P Whiplash Injury:

(Heikkila and Astrom, 1996):

  • No significant difference (p < 0.001) in test-retest reliability in healthy subjects at evaluation, 1, and 2 month increments

Interrater/Intrarater Reliability

Healthy Controls:

(Strimpakos et al, 2006)

  • Interrater reliability: Poor to Adequate- Absolute Error, ICC = -0.20 to 0.64; Variable Error- Poor:, ICC = -0.31 to 0.38
  • Intrarater reliability: Poor to Adequate in standing- Absolute Error = 0.17 - 0.50; Poor in sitting: ICC = -0.01 to 0.35; Variable Error, = Poor: ICC = 0.01 to 0.25

S/P Whiplash Injury:

(Loudon et al, 1997: total n = 22; whiplash injury n = 11, mean age = 42, time from injury > 3 months < 2 years; control group n = 11, mean age = 43)

  • Interrater reliability ICC = 0.972
  • Intrarater reliability ICC = 0.975 (therapist 1), ICC = 0.985 (therapist 2)

Internal Consistency

Not Established

Criterion Validity (Predictive/Concurrent)

Heikkila and Wengren, 1998:

  • Adequate association between oculomotor dysfunction and repositioning dysfunction: Spearman r = 0.51, p = 0.007, alpha = 0.68
  • No significant correlation between neck pain measured by VAS with oculomotor performance and kinesthetic sensibility.

Heikkila and Astrom, 1996:

  • Significant difference found between whiplash subjects and healthy controls (p < 0.001)

Revel et al, 1994: (n = 60, mean age = 49 ± 14, amount of time with neck pain x = 36 months, 3 month-18 years)

  • Sensitivity = 82%

Revel et al,1991

  • Sensitivity = 86%, Specificity = 93%

Trealeven et al 2006 (n = 100 with WAD, n = 40 healthy controls)

  • Positive Predictive Value: 88%
  • Sensitivity: 60%
  • Specificity: 54%

Construct Validity (Convergent/Discriminant)

Teng et al, 2007: (n total = 60: n asymptomatic young adults = 20, age range = 21.9 ± 3.9; middle- aged adults with neck pain n = 20, mean age = 58.8 ± 5.7; without neck pain n = 20, mean age= 54.4 ± 5, n20)

  • Significant difference between head to Neutral Head Position (NHP) in the sagittal plane in middle aged adults compared to the control group
  • Head to target repositioning in the transverse plane is less accurate in middle aged-adults compare to controls.
  • Cervicocephalic kinesthetic sensibility in the sagittal plane is significantly reduced in middle-aged adults, regardless of neck pain.

Sterling et al, 2003:

  • Significant difference between mean relocation between moderate/severe symptom group compared to recovered, mild symptoms, and control groups

Loudon et al, 1997

  • Significant difference between whiplash group average: 5.01 degrees compared to control group = 1.75 degrees (p < 0.05)

Discriminant Validity:

Treleaven et al, 2003: (Whiplash Associated Dizziness (WAD) > 3 months since injury n = 102 (WAD-D n = 76), mean age = 39.34 years, mean time since injury = 1.24 years; control n = 44, mean age = 34.1 years)

  • WAD-D group scored higher on Northwick Park Neck Pain Questionnaire (neck pain and disability index) than those without dizziness: 55.3% compared to 43.1%

Content Validity

Not Established

Face Validity

Not Established

Floor/Ceiling Effects

Not Established

Responsiveness

Not Established

Professional Association Recommendations

Considerations

  • Patient should be cleared of vascular and orthopedic contraindications (i.e. vertebral artery integrity and cervical stability) and demonstrate full, pain-free active range of motion in the plane of testing.
  • The Joint Positional Error Test can be assessed on return from all active cervical movements or to pre-set targets; this test may reproduce dizziness or unsteadiness with the task. A computerized method is currently being developed for use in the clinical setting. (Kristjansson and Treleaven, 2009).
  • Revel et al, 1994 demonstrated improvement in cervicocephalic kinesthesia with a cervical proprioceptive program in patients with neck pain.

Bibliography

Heikkila, H. and Astrom, P. G. (1996). "Cervicocephalic kinesthetic sensibility in patients with whiplash injury." Scand J Rehabil Med 28(3): 133-138. Find it on PubMed

Heikkila, H. V. and Wenngren, B. I. (1998). "Cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury." Arch Phys Med Rehabil 79(9): 1089-1094. Find it on PubMed

Kristjansson, E., Dall'Alba, P., et al. (2001). "Cervicocephalic kinaesthesia: reliability of a new test approach." Physiother Res Int 6(4): 224-235. Find it on PubMed

Kristjansson, E. and Treleaven, J. (2009). "Sensorimotor function and dizziness in neck pain: implications for assessment and management." J Orthop Sports Phys Ther 39(5): 364-377. Find it on PubMed

Lee, H. Y., Teng, C. C., et al. (2006). "Test-retest reliability of cervicocephalic kinesthetic sensibility in three cardinal planes." Man Ther 11(1): 61-68. Find it on PubMed

Loudon, J. K., Ruhl, M., et al. (1997). "Ability to reproduce head position after whiplash injury." Spine (Phila Pa 1976) 22(8): 865-868. Find it on PubMed

Revel, M., Andre-Deshays, C., et al. (1991). "Cervicocephalic kinesthetic sensibility in patients with cervical pain." Arch Phys Med Rehabil 72(5): 288-291. Find it on PubMed

Revel, M., Minguet, M., et al. (1994). "Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study." Arch Phys Med Rehabil 75(8): 895-899. Find it on PubMed

Sterling, M., Jull, G., et al. (2003). "Development of motor system dysfunction following whiplash injury." Pain 103(1-2): 65-73. Find it on PubMed

Strimpakos, N., Sakellari, V., et al. (2006). "Cervical joint position sense: an intra- and inter-examiner reliability study." Gait Posture 23(1): 22-31. Find it on PubMed

Teng, C.-C., Chai, H., et al. (2007). "Cervicocephalic kinesthetic sensibility in young and middle-aged adults with or without a history of mild neck pain." Manual therapy 12(1): 22-28.

Treleaven, J., Jull, G., et al. (2006). "The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash." Man Ther 11(2): 99-106. Find it on PubMed

Treleaven, J., Jull, G., et al. (2003). "Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error." J Rehabil Med 35(1): 36-43. Find it on PubMed

Year published

1991 

Instrument in PDF Format

No 
Approval Status Approved 
 
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Created at 1/22/2014 1:52 PM  by Jason Raad 
Last modified at 1/24/2014 2:41 PM  by Jason Raad