South African Journal of Physiotherapy 
ISSN: (Online) 2410-8219, (Print) 0379-6175
Page 1 of 7 Original Research
Comparative joint position error in patients 
with non-specific neck disorders and 
asymptomatic age-matched individuals
Authors: Background: Neck pain is a common complaint worldwide and ranked seventh in 2010 as the 
Jonathan Quartey1 
2 cause of ‘years lived with disability’ in Ghana. Proprioceptive dysfunction, measured by joint Markus Ernst  
Ajediran Bello1 position error (JPE) tests, indicates an association with neck pain frequency, dizziness and 
Bertha Oppong-Yeboah1 balance problems in patients.
Emmanuel Bonney1 
Kow Acquaah3 Objectives: To examine proprioceptive deficits of the neck using a laser pointer attached to 
Felix Asomaning3 the head.
Margaret Foli3 
Sandra Asante3 Methods: Twenty patients within the age group 21–60 years, with at least five points on the 
Astrid Schaemann2 
2 neck disability index (NDI), and 20 age- and sex-matched controls with less than five points Christoph Bauer  
on the NDI were recruited for this study. The JPE was determined wearing a headlight laser 
Affiliations: pointer directed towards a Cartesian coordinate system adjusted to x/y = 0/0, placed on a 
1Department of wall after returning from left and right rotation, flexion and extension. From starting in an 
Physiotherapy, University 
of Ghana, Accra, Ghana upright sitting position, facing the Cartesian coordinate system, each participant performed 
five repetitions for each movement direction. The mean of five repetitions for each movement 
2Institute of Physiotherapy, direction was calculated as absolute error (AE), constant error (CE) and variable error (VE).
Zurich University of Applied 
Sciences, Winterthur, Results: Control participants showed larger JPE values for nearly all AE, CE and VE. After 
Switzerland repositioning from flexion controls showed an approximately 0.6 ° larger median JPE, and the 
opposite for extension, with median differences between 1 ° and 2 °.
3Physiotherapy Department, 
Korle-Bu Teaching Hospital, Conclusion: The results of this study do not reveal any meaningful differences between 
Accra, Ghana patients with mild disabled neck movement compared with controls.
Corresponding author: Clinical implications: Joint position error testing does not seem useful for patients with mild 
Jonathan Quartey,
neeayree@googlemail.com neck disability.
Dates: Keywords: joint position error; proprioceptive; neck disability; age-matched; neck disability 
Received: 14 Sept. 2018 index; sex-matched.
Accepted: 16 Apr. 2019
Published: 27 June 2019
How to cite this article: Introduction
Quartey, J., Ernst, M., Bello, A., Neck pain is a common complaint worldwide. Its point prevalence in sub-Saharan West Africa in 
Oppong-Yeboah, B., Bonney, E., 
Acquaah, K., et al., 2019, 2010 was 4.1% in men and 6% in women and peaked around 45 years with 7% in men and 10% in 
‘Comparative joint position women (Hoy et al. 2014). Its prevalence in southern Africa was about 1% more than the 
error in patients with aforementioned values (Hoy et al. 2014). In a Nigerian population back pain and neck pain 
non-specific neck disorders 
and asymptomatic age- together were reported to add up to a prevalence of more than 16% and a third of this are from 
matched individuals’, 60 or older (Gureje et al. 2007). In 2010 neck pain ranked seventh as the cause of ‘years lived with 
South African Journal of disability’ (YLD) in Ghana (http://vizhub.healthdata.org).
Physiotherapy 75(1), a568. 
https://doi.org/10.4102/sajp.
v75i1.568 Proprioceptive dysfunction, typically measured by joint position error (JPE) tests, has been found 
to be associated with neck pain frequency (Lee et al. 2008), dizziness and balance problems in 
patients with whiplash injury (Treleaven 2011; Treleaven, Jull & Lowchoy 2006). Treleaven (2011) 
found JPE closely related to upper cervical spine complaints. Daenen et al. (2013) reported a 
predictive validity of proprioceptive dysfunction for long-term outcomes in patients who were 
moderately and severely affected by whiplash injury. Although recent reviews indicate that 
Read online: healthy controls differ in JPE measurements when compared with patients with whiplash injury, 
Scan this QR 
code with your the differences in patients with idiopathic neck pain remain inconclusive (De Vries et al. 2015; De 
smart phone or 
mobile device Zoete et al. 2017; Stanton et al. 2016).
to read online.
Copyright: © 2019. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License.
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Page 2 of 7 Original Research
Joint position error measurements are regarded to reflect assessment instruments to reliably determine values of 
proprioceptive functioning of the head and neck (Kristjansson proprioceptive functioning. The assessment should also be 
& Treleaven 2009; Treleaven 2008, 2009). Afferent information able to demonstrate differences between known groups, 
derived by mechanoreceptors like muscle spindles, which which are supposed to differ for the trait (proprioception) 
are plentiful in the upper cervical spine, is directed to the measured. It appears that there were no similar studies that 
central nervous system (Kristjansson & Treleaven 2009; have examined proprioceptive dysfunction by using JPE in 
Treleaven 2008, 2009) and via reflex connections to the visual, Ghanaians or even African populations suffering from neck 
the vestibular and somatosensory systems. Thus, eyes, head pain. This study may therefore form the basis to enhance the 
and body movements are guided and constantly rearranged possibilities of similar studies with useful variations.
to modify the input system of the neuromuscular pathway. 
A mismatch of information derived by these systems can The aim of this study was to examine the effect of neck pain 
lead to symptoms like dizziness or unsteadiness, which are and disability on JPE of the cervical spine in a Ghanaian 
especially prevalent in patients with whiplash injury population.
(Treleaven 2011). Whether a disturbed JPE sense due to injury 
or mechanical disturbances of the neck is the reason for these Methods
symptoms should be evaluated clinically by examination of 
all contributing systems (Kristjansson & Treleaven 2009; This cross-sectional study involving 40 participants (20 
Treleaven 2008, 2009, 2011). patients with neck pain and 20 participants without neck 
pain) was conducted at the outpatient unit, physiotherapy 
Joint position error has been examined since the early Department, Korle-Bu Teaching hospital, Accra, Ghana. The 
nineties, when Revel, Andre-Deshays and Minguet (1991) unit sees patients with a wide variety of conditions including 
mentioned a best specific and sensitive cut-off of 4.5 ° cervical spondylosis on an outpatient basis.
between participants with neck pain and healthy controls 
in horizontal and sagittal plane movements. Values of more Patients with neck pain who reported to the outpatient 
than four and a half degrees (> 4.5 °) were more frequently physiotherapy unit and were within the age group of 
found in patients with neck pain (Revel et al. 1991). This 21–60 years, suffering from sub-acute (≥ 6 weeks) or chronic 
cut-off value has been reported to be relatively robust in (> 3 months) non-specific head and neck pain with disability 
some studies (De Hertogh et al. 2008; Heikkila & Astrom due to neck pain (with at least five points on the neck 
1996; Humphreys & Irgens 2002; Kristjansson et al. 2001; disability index [NDI]), were recruited for the study as cases. 
Pinsault et al. 2008; Rix & Bagust 2001; Roren et al. 2008); Gender- and age-matched participants (within ± 3 years of 
however, a recent meta-analysis by De Zoete et al. (2017) age) who had no neck pain, no relevant history of neck or 
reported a large variability of values between patients with upper limb pain or injury over the last 3 years that limited 
idiopathic neck pain and healthy controls across studies, their function or required treatment from a health professional 
which provide indications that a 4.5 ° threshold might be with a score of less than five points on the NDI were recruited 
specific to detect healthy or asymptomatic participants but as controls.
does not mean that it is sensitive enough. It also indicates 
that probably different cut-offs for flexion or extension and Participants were requested to sit upright, in a neutral but 
rotation exist. Another meta-analysis by Stanton et al. in comfortable head position (NHP) with hips and knees flexed 
2016 reported a moderate overall standardised mean at 90 ° at a fixed distance of 90 cm to a target, wearing a 
difference of 0.44 between patients with idiopathic headlight laser pointer on the head (Figure 1). The target, a 
pain and healthy controls. Both reviews (De Zoete et al. white piece of paper with a starting point (reticle), in the 
2017; Stanton et al. 2016) reported a possible expectation middle (Figure 1) was placed on a wall and adjusted 
bias in most studies since investigators were most often according to the upright position of the participant, by using 
not adequately blinded to patient condition. With no adhesive tape.
known risk previously reported, JPE can easily be examined 
in daily clinical practice, by using instruments such as Participants were blindfolded and asked to move their head 
laser pointers attached to an Alice band or a helmet and neck from NHP into approximately 50% of maximal 
(Clark, Roijezon & Treleaven 2015; Roijezon, Clark & range in one of four directions, which were left and right 
Treleaven 2015). rotations (LR and RR), flexion (F) and extension (E). 
Participants were asked to move slowly, in order not to 
Another review on the effectiveness of proprioceptive stimulate the vestibular organ.
exercising for improving sensorimotor control for several 
health conditions by Aman et al. (2014) demonstrated Participants were then asked to actively and slowly 
general benefits of ‘proprioceptive training’, but it included reposition to the NHP while still blindfolded and verbally 
only one study with a neck pain condition. A more recent asked to indicate when they perceived that NHP had been 
randomised controlled trial by Treleaven et al. (2016) attained.
reported on the effectiveness of neck-specific exercising 
in patients with chronic whiplash injury on proprioceptive One of two authors indicated the end position of all 
and disability outcomes. Patients and therapists need movements (F, E, RL, RR) at the target by using a pen. One of 
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Page 3 of 7 Original Research
FIGURE 2: Cartesian coordinate system. 
overshooting (positive values), CE represents the mean in 
error magnitude of five repetitions incorporated in the 
Source: Photo courtesy of the author, Jonathan Quartey direction of error and VE represents the variability of 
FIGURE 1: Participant seated wearing a headlight laser pointer on the head. subjects’ performance (Hill et al. 2009).
the other authors helped the blindfolded participants after The generalisability theory (Brennan 2001) with the design 
each repetition to find the accurate starting position again. p × t (participants × trials) was used as a framework to estimate 
After repetition the position was readjusted actively by reliability of trunk movement measures, based on the linear 
ensuring that the laser point rested at the starting point model:
(0 ° / 0 °) again. An assessor, observing the participant, 
assured upright position. Five repetitions for each direction Xpt=μ + vp + vt + vpt
(F, E, RL and RR) were carried out by each participant as 
recommended in previous studies (Demaille-Wlodyka et al. with μ representing the global mean and v any one of the 
2007; Pinsault et al. 2008; Strimpakos et al. 2006). Short three components.
relaxations/distractions were allowed after each repetition.
The index of dependability Φ was calculated:
After five repetitions the authors removed the target and σ 2
measured the deviations from the target position for each Φ = p
2 2
repetition on both axes (ordinate and abscissae) by using σ σσ 2 + t + pt
a common ruler with millimetre distances. The whole p nt nt
procedure including short breaks took 10–15 min to complete 
(per participant). with σ being the variance and n the number of the corresponding 
components. The index of dependability (Φ) was interpreted 
Values for x (abscissa) and y (ordinate) were written and as: < 0.25 – little, 0.26–0.49 – low, 0.50–0.69 – moderate, 0.70–0.89 
listed with a minus sign as a prefix, if indicated and according – high and > 0.90 – very high reliability (Carter, Lubinsky & 
to the Cartesian coordinate system (Figure 2). The resultant Domholdt 2005). An index of dependability (Φ) ≥ 0.70 was 
(d) of x and y values were then calculated by using the interpreted as sufficient. D-studies (Brennan 2001) were 
Pythagoras theorem. Centimetre values for the resultant (d ) simulated where the number of trials varied up to 10 trials 
were then converted to degrees with the formula (Chen & and number of days varied across 2 days, which represent 
Treleaven 2013; Roren et al. 2009): acceptable measurement strategies. Thereby, the number of 
required trials per day to achieve high reliability was evaluated.
Θ = tan−1 (error distance/90 cm)
The coefficient of variation (CV) (Hopkins 2000) was also 
Absolute (AE), constant (CE) and variable (VE) errors calculated:
during F, E, RR and RL were calculated and reported as 
degrees. Absolute error represents the mean in error σ diff
magnitude of five repetitions irrespective of the direction of CV = *100n * x
error in terms of undershooting (negative values) or d
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Page 4 of 7 Original Research
with x̄ being the grand mean and σdiff being the standard diagnostic suitability of those variables should differences 
deviation of the differences between days and calculated from between groups exist. The CVs exceeded 10% of the grand 
the mean of seven trials per day. The CV values were rated as mean indicating that these variables are not suitable to 
follows: > 10% not reliable, 6% – 10% adequately reliable and measure changes over time.
5% highly reliable. Coefficient of variations ≤ 10% were 
construed as sufficient (Suni, Rinne & Ruiz 2014). Discussion
Our study showed minor differences in JPE measurements of 
The diagnostic value of a variable was assessed by the index 
Φ the neck in a Ghanaian population of patients with neck pain of dependability ( ), whereas the ability to detect changes 
with mild disability compared with age- and sex-matched 
over time was evaluated by the CV. Data from both 
asymptomatic controls.
populations were pooled for this analysis. Wilcoxon tests 
between cases and matched controls for the resultant (d ) for 
However, the asymptomatic controls showed larger values 
all dependent variables (AE, CE; VE) were performed. All 
for most of the AE, CE and VE, although differences were 
analyses were performed by using the R statistical software, 
small, except for extension (AE), which was of no statistical 
version 3.2.3. significance.
Ethical considerations This could be the first study that has measured JPE of the 
Ethical approval for this study was sought and obtained neck in a Ghanaian or probably African population. Most 
(SBAHS – ET./AA/2014–2015) from the Ethics and Protocol previous studies were conducted in North America, Western 
Review Committee of the School of Biomedical and Allied Europe or Australia.
Health Sciences, University of Ghana. Permission was also 
sought and obtained from the Physiotherapy Department of The AEs of patients with neck pain showed comparable 
Korle-Bu Teaching Hospital. Written informed consent was values to pooled mean values reported by a recent meta-
obtained from participants before measurements were analysis (De Zoete et al. 2017). With values of 4.0 ° – 4.5 ° for 
carried out. repositioning after rotation and 3.4 ° after extension, the 
outcome values of our study are within reported values by 
Results De Zoete et al. (2017).
Forty participants (20 cases and 20 controls) were recruited However, values for flexion and extension for the 
and measured. Each group consisted of 15 women and five asymptomatic participants and flexion values from patients 
men. Baseline characteristics are shown in Table 1. with neck pain exceeded those reported in that meta-analysis 
(De Zoete et al. 2017).
The controls showed larger JPE values for the resultant 
(vector of x and y values) for nearly any AE, CE and VE as TABLE 2: Median differences of scores.
well as movement direction, apart from the RR CE and Direction Values Patients (n = 20) Controls (n = 20) p  (error) (Wilcoxon-test)
flexion VE. Differences were small for LR and RR JPEs. For LR (AE) Median (IQR) 4.41 (2.59) 4.59 (2.56) 0.24
flexion VE, cases had an approximately 0.6 ° larger median LR (CE) Median (IQR) 2.55 (2.97) 3.46 (2.54) 0.25
JPE, and the extension CE and AE showed median differences LR (VE) Median (IQR) 1.79 (1.08) 1.65 (0.81) 0.70
close to 1 ° and 2 ° respectively, which revealed a statistical RR (AE) Median (IQR) 4.28 (3.71) 4.11 (3.11) 0.88
RR (CE) Median (IQR) 2.38 (3.73) 2.60 (2.33) 0.74
significance (Table 2).
RR (VE) Median (IQR) 1.57 (0.83) 1.65 (1.43) 0.99
F(AE) Median (IQR) 4.99 (1.89) 5.13 (5.46) 0.55
Table 3 shows the summary of the grand mean, the index of F (CE) Median (IQR) 3.30 (2.23) 3.82 (3.91) 0.86
dependability (Φ) coefficients, the number of trials averaged F (VE) Median (IQR) 1.65 (0.93) 1.06 (1.02) 0.13
on one measurement day, which are needed to gain Φ ≥ 0.70 E (AE) Median (IQR) 3.38 (1.76) 5.09 (2.67) 0.02*
and the CV for each variable. On average, two trials on one E (CE) Median (IQR) 1.81 (1.96) 2.86 (2.92) 0.17
day were sufficient to reach high reliability, indicating the E (CE) Median (IQR) 1.42 (0.59) 1.57 (1.26) 0.55
AE, absolute error; CE, constant error; VE, variable error; LR, left rotation; RR, right rotation; 
F, flexion; E, extension; IQR, interquartile range.
TABLE 1: Baseline characteristics of participants. *, Statistically significant
Variable Cases Controls p
Total number (female participants) 20 (15) 20 (15) 1.00 TABLE 3: Reliability of a single measure, number of trials averaged on one day, 
Age in years (SD) 51.70 (9.90) 52.1 (8.30) 0.90 needed to achieve high reliability and coefficient of variation.
Height in cm (SD) 165.00 (5.40) 165.0 (7.60) 0.98 Test Mean (SEM) Φ one trial Number of trials CV (%)Φ > 0.7 One day
Weight in kg (SD) 73.50 (8.03) 79.1 (18.20) 0.28
Flexion 5.82 (4.01) 0.77 1 69
NDI in points (SD) 6.45 (0.89) 2.4 (1.00) 4.569e-16
Extension 4.81 (3.82) 0.60 2 79 
Duration of complaints in weeks (SD) 18.50 (17.50) na na
LR 5.14 (3.98) 0.62 2 77 
Note: All values are mean values and standard deviations (SD), otherwise indicated. p-values 
are derived from unpaired t-tests and chi square tests (sex distribution). RR 4.98 (3.93) 0.61 2 78 
NDI, Neck Disability Index; na, not applicable. Φ, index of dependability; CV, coefficient of variation, SEM, standard error of the measurement.
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Our study is not the only one that has reported larger Studies that examined the responsiveness of JPE tests in a 
errors for the control group. Rix and Bagust (2001) reported clinical population were not found. A minimal detectable 
similar values for LR and RR and larger values for extension change for returning to NHP from extension was examined 
in controls. In contrast to the results of this study Rix and by Alahmari et al. (2017) for a mixed group of patients with 
Bagust (2001) reported statistically significant differences and without neck pain by using a similar protocol used in 
for F. this study.
The study by Rix and Bagust (2001) consisted of 11 Alahmari et al. (2017) reported standard error of 
participants in each group, with an almost equal distribution measurements (SEMs) of approximately 2 ° and minimal 
of men and women, but with participants who were on detectable changes of approximately 5 °. A larger homogeneity 
average 10 years younger than those of this study. They did compared with the study carried out by Alahmari et al. as 
not use the NDI, but reported pain intensity values for the expressed in the NDI score and the smaller sample size 
patient group of 5.1 ± 1.9 on an 11-point numeric rating 
(n = 69 for Alahmari et al. and n = 40 for this study) might 
scale on the day of measurement. For JPE measurement 
have led to larger SEMs of approximately 4 ° within our 
they used a helmet with the laser pointer attached to its 
study as shown in Table 3 (Alahmari et al. 2017; Streiner & 
top; participants had to move into full range of motion for 
all directions measured. Norman 2008).
Rix and Bagust (2001) reported that this full range of motion The high Φ coefficients indicate diagnostic ability of the 
movement and the speed of their repositioning movement variables of this study and compare favourably to other 
could have been possible factors for not finding meaningful protocols (Juul et al. 2013; Lee et al. 2006; Pinsault et al. 2008; 
results. Strimpakos et al. 2006; Wibault et al. 2013), whereas the high 
CVs indicate that the protocol of our study might not be 
Zito, Jull and Story (2006) reported no differences between suitable to monitor changes over time. Improving the 
patients with migraine, participants suffering from standardisation of the protocol of this study regarding the 
cervicogenic headache and controls. Most mean values placement of the laser pointer, target or sitting position may 
reported by these authors exceeded the 4.5° cut-off, but reduce the CV in future studies.
for all three groups and like in this study the control 
participants showed larger values although not statistically Cases had to fulfil inclusion criteria of at least five points 
significant. Zito et al. (2006) reported that neck pain from on the NDI (Vernon & Mior 1991). Five points has been 
traumatic conditions might have led to group differences promoted as cut-off to differentiate mild neck pain and 
that are more distinct. However, this assumption could not disability from no pain and disability as indicated by Vernon 
be determined in any of those studies comparing patients an Mior (1991). However, controls were described as eligible 
with whiplash injury to controls, as De Vries et al. (2015) with a value of 10 points or 20% in a JPE study by Wibault 
reported in a systematic review. Sterling et al. (2003) et al. (2013). Within our study, the mean NDI values for cases 
demonstrated differences, but only for patients suffering and controls were 2.4 and 6.5 points, respectively (Table 1), 
from whiplash injury with severe pain and disability, and all the cases in this study would have fulfilled the 
indicated by > 30 points on the NDI, and only for RR. eligibility criteria to be a ‘control’ in the study by Wibault 
However, Sterling et al. (2003) did not report differences et al. (2013). Besides this, the relationship of the NDI and JPE 
between patients with mild or moderate disability and does not seem to have been examined by any study so far. 
control participants. So it might be questionable whether the NDI or the cut-off 
of 5 points is suitable to determine meaningful JPE 
More recent studies (Chen & Treleaven 2013; Elsig et al. 2014; 
differences in participants with NDI scores ranging 0–5 
Meisingset et al. 2015) have also shown a large overlap 
between JPE values from patients with neck pain and compared with 5–10 points
controls, and even in patients reporting larger pain and 
disability values than the participants of this study. Even the The duration of symptoms might be a better indicator to find 
presence of subjectively perceived dizziness as shown by differences between patients with neck pain and controls. 
Chen and Treleaven (2013) could not demonstrate larger Cheng et al. (2010) reported on average 50% larger values 
differences for the classic JPE test to NHP. for flexion and twice the values for extension in young 
patients suffering on average for 4 years from non-traumatic 
De Zoete et al. (2017) pooled data from 22 primarily neck pain (Cheng et al. 2010). An unknown history of 
cross-sectional case control studies with 340 patients with neck pain in the control group might have also influenced 
idiopathic neck pain and 630 healthy controls and reported results, as shown in a similar case–control study by Teng 
a median group difference of approximately 0.5 °. This et al. (2007). Those with a history of, but no current neck pain, 
clearly puts the measurement or the population measured had similar JPEs as participants in the neck pain sample 
into question. (Teng et al. 2007).
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