Cervical Joint Position Error Test

Last Updated

November 12, 2013

Purpose

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

Acronym Cervical JPET

Area of Assessment

Pain
Range of Motion
Vestibular

Assessment Type

Performance Measure

Cost

Free

Cost Description

/rehabilitation-measures/cervical-joint-position-error-test

Movement and Gait Disorders

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.

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.

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.

5-10 minutes

based on number of measurements taken

Required Training

Training Course

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

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.

Body Part

Neck

ICF Domain

Body Structure
Body Function

Measurement Domain

Motor
Sensory

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.

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

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:

(graph)

Healthy Controls from Above Studies:

(graph)

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)

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

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%

Bibliography

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

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.

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

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.

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.

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

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

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.

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

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

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.

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.

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