Cervical proprioception impairment in neck pain - pathophysiology, clinical evaluation, and management: a narrative review

Key points

1. 01Cervical muscle spindles, particularly in deep suboccipital muscles, are the primary proprioceptors of the neck and are disrupted in chronic neck pain
2. 02Eight sensorimotor control tests exist for assessing neck proprioception; the joint position error (JPE) test is the most commonly used and validated
3. 03Systematic reviews and meta-analyses confirm that JPE is significantly higher in people with chronic neck pain compared to asymptomatic controls
4. 04Proprioceptive retraining, craniocervical flexion training, and balance training each improve joint repositioning accuracy and reduce pain in RCTs
5. 05Erroneous afferent signals from degenerated discs and facet joints, plus structural muscle changes, contribute to a cycle of worsening sensorimotor dysfunction

How it was conducted

Design

Narrative review with comprehensive literature search (PubMed and MEDLINE from inception to September 2020)

Search terms

neck pain, cervical proprioception, cervical sensorimotor control, cervical joint position error, cervical proprioception impairment

Evidence prioritization

Systematic reviews and RCTs prioritized over lower-grade evidence

Scope

Pathophysiology of cervical proprioceptive impairment, clinical assessment methods, and rehabilitation approaches

Clinical trials summarized

Five RCTs on proprioceptive and sensorimotor retraining in chronic neck pain presented in detail

What they found

• Revel et al. found patients with chronic neck pain had poorer ability to restore original head position after rotation compared with healthy subjects (error 6.11 degrees vs 3.50 degrees)
• Alahmari et al. found patients with chronic neck pain had greater JPE error in all movement directions tested (p < 0.001) compared with age-matched healthy controls
• A systematic review including multiple studies found JPE was significantly higher in the neck pain group than in the control group
• A meta-analysis by De Zoete et al. found a significant difference between idiopathic neck pain and healthy groups in JPE testing
• Pooled estimates from Stanton et al. meta-analysis showed people with chronic idiopathic neck pain had moderately impaired cervical joint position sense during head-to-neutral repositioning tests compared with asymptomatic controls
• Jull et al. RCT (n=64): both proprioceptive training and craniocervical flexion training groups showed significant decreases in JPE, neck pain intensity, and perceived disability; proprioceptive training group had greater reduction in JPE from right rotation
• Beinert and Taube RCT (n=34): balance training intervention group showed improved joint repositioning accuracy and decreased pain; no effects in control group
• Duray et al. RCT (n=40): study group receiving conventional therapy plus gaze direction recognition exercise showed significantly lower neck pain intensity and disability scores than control group
• Saadat et al. double-blind RCT (n=53): combined sensorimotor and traditional exercise group showed significantly greater improvement in joint position sense, 10-m walk test, and step test compared to traditional exercise alone

Limitations

• Narrative review methodology is subject to selection bias; studies were chosen based on author expertise rather than a pre-registered systematic protocol
• High variability in JPE measurement methods across studies makes direct comparison of results difficult
• Some contradictory findings exist, with a few studies reporting no significant proprioceptive deficit in non-traumatic neck pain, suggesting the relationship is not universal
• Causal direction is unclear in many studies: it is uncertain whether proprioceptive impairment causes or results from neck pain

Why it matters

For patients

People with chronic neck pain may benefit from exercises specifically targeting balance and head repositioning accuracy, not just pain relief or muscle strengthening.

For clinicians

Assessing cervical joint position error and including proprioceptive retraining alongside deep cervical flexor training is supported by RCT evidence and should be considered part of standard management for chronic idiopathic neck pain.

For readers

This review synthesizes the biological mechanisms, eight clinical assessment tools, and rehabilitation evidence for cervical sensorimotor dysfunction, providing a structured framework for understanding a frequently overlooked dimension of neck pain.