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324 Computational Intelligence Algorithms
FIGURE 21.1 Muscles of the cervical spine.
21.3 SENSORIMOTOR SYSTEM AND PROPRIOCEPTION
Dr. Vladimir Janda, during the 1950s and 1960s, advocated that sensory and motor
systems cannot be taken as two different, separately working systems; instead,
he integrated them in his approach to manage chronic pain syndromes[20] (see
Figure 21.2). Janda and VaVrova (1996) developed rehabilitation of the lower
extremities as well as the spine [21]. It was recommended that there are three locations in the body where enormous amounts of proprioceptors are present, which
are mainly the foot, sacroiliac joint (SI), and the cervical spine. The aim was to
increase proprioception of these sites to facilitate a smooth, well-coordinated
movement pattern.
Proprioception was rst devised by Dr. Charles Sherrington (1906). It was
dened as a sense of position, posture, and movement. Freeman and Wyke (1966)
did further research and declared that proprioceptive receptors were found in the
nerve endings of the joints of cats, and if these receptors were disconnected from
the CNS, cats were incapable of walking correctly [22]. To describe proprioception
includes afferent information arising from joint mechanoreceptors that are responsible for postural control, joint stability, and other conscious sensations. Thus, it
includes subsystems: joint position sense (posture of segment), kinaesthesia (which
can be active or passive), and resistance to movement as described by Sherrington
[23, 24]. Contrary to this, Somatosensory System is a broader term that encircles
FIGURE 21.2 The sensorimotor system.
325 Targeting Upper-Limb Sensory Gaps
mechanoreceptors, thermoreceptors, and nociceptors [24]. Proprioceptors are
present in muscle, tendon, ligament, and capsule, while other mechanoreceptors
are also found in deep skin and fascia [25]. Those located in the musculotendinous
junction are known as Golgi tendon organs (GTOs), whereas muscle spindles are
found in muscle tissue. The main function of GTOs is to cue for active muscle tension, i.e., during the state of contraction, and not during an inactive or passive state
[26]. Any goal-directed movement requires feedback through mechanoreceptors
and feed-forward control, i.e., anticipating change [24].
21.4 ALTERED PROPRIOCEPTION IN MUSCULOSKELETAL
DISORDERS
Altered proprioception can be related to various clinical ndings like pain, muscle fatigue, and effusion [27]. Cervical spine disorders can lead to the develop-
ment of impaired proprioception, as stated [28].
21.5 ALTERED PROPRIOCEPTION AND ITS CONSEQUENCES
Consequences such as changes in motor control strategies were observed.
For instance, decreased activation of deep cervical exors was observed during upper-limb tasks [29]. Painful musculoskeletal disorders alter load sharing
among muscles and result in various neuromuscular adaptations and decreased
repositioning acuity in performing movement tasks [10, 30]. These dysfunctions
326 Computational Intelligence Algorithms
result in clinical symptoms of disrupted coordination and smoothness of movement [28].
21.6 UPPER-LIMB PROPRIOCEPTION IN CHRONIC NECK PAIN
Cervical muscles of the spine have abundant proprioceptive receptors, which have
an association with central and peripheral reexes, including the vestibular system,
postural control, and visual systems [31]. Additionally, the suboccipital muscles particularly own a high density of muscle spindles [27, 32]. The upper-cervical spine
from C1 to C3 has direct connections to the vestibular nuclear complex and the superior colliculus, for synchronization between the head and neck movement with vision
[33, 34]. It was seen in a handful of studies that position sense in arm movement, i.e.,
repositioning acuity, is reduced. Reduced repositioning acuity of the elbow in people
with whiplash-associated disorder (WAD) and of the shoulder in CNP and WAD has
been observed [10, 35]. Röijezon et al. (2009) hypothesized that CNP has decreased
neck-shoulder proprioception due to reduced precision in fast pointing movements
[36]. Moreover, CNP was found to have more jerky movements of the cervical spine
with decreased smoothness of the movement, leading to poor motor control [28].
The head position has a major impact on the organization of sensory information for
upper-limb proprioception [35, 36]. Furthermore, it was postulated that any change
in the position of the head and neck with vision occlusion affects sensory information and elbow joint position sense in neck pain patients with WAD [35]. Thus, they
demonstrated that the position of the head determines the position of upper-limb segments as CNS constantly matches the position of the head and neck with the upper
limb; consequently, head movements and altered proprioception result in reduced
accuracy of upper-arm movements [11]. It is suggested that the acuity tasks of point-
ing, especially endpoint acuity, were variably affected in CNP patients compared to
healthier controls [10]. From a functional point of view, affected proprioception and
goal-directed movements reduce the ability of an individual to carry out activities
like carrying, reaching for objects, and lifting. If there is a small increase in endpoint
variability, it will affect precision and timing, which will eventually compromise the
performance of an individual whether in playing sports or any musical instrument
[10]. Possible mechanisms as postulated by Yilmaz et al. (2024) are quite tentative.
They include reduced acuity of signals from the muscle spindle system and injuries
of the peripheral nervous system somewhere along the sensory pathways, although
they argue that it is not a major factor, as there are no symptoms of paresthesia or
sensory loss in their patient population [10]. Visual disturbances and oculomotor
decits have been found to affect those with chronic neck pain. A strong association
between self-rated neck function and endpoint acuity was found. [37].
21.7 IMPLICATIONS IN REHABILITATION
The main objective of this analysis is to provide an update on the rehabilitation of CNP patients and to extend the knowledge of clinicians to develop a
new treatment regimen of scapular stabilizers and upper-limb proprioception
327 Targeting Upper-Limb Sensory Gaps
training as an adjunct in the current exercise methods. Active joint repositioning
technique for enhancing upper-limb proprioception is based on motor learning.
Motor learning is dened as relative or permanent changes in behavior that are
enhanced by the practice of movements [38]. The two main effects of motor
learning are retention and transfer. Retention is when the changes last for a
longer time due to neuroplastic changes in the CNS, and the transfer effect is
when the transfer of this training is seen in other similar tasks or daily activity
task requirements [38]. To enhance the training, the factors responsible are that
we must ensure that exercise is not too easy or too difcult for the patient and
should be adjusted accordingly to the patient’s skills (challenge point framework). Secondly, it should include repetitive solving skills rather than repeating
it only once [38, 39].
Each patient will encounter three phases of motor skills acquisition: the cognitive
phase, the associative phase, and the autonomous phase (see Figure 21.3).
Cognitive phase: It involves making the patient understand what to do. This
phase has inconsistent but large gains.
Associative phase: When the patient determines the strategy to perform the
task. Here the gains are more gradual.
Autonomous phase: When less conscious is needed to perform the task and is
simultaneously performed with other tasks [39, 40].
Looking at these aspects, we can determine whether motor learning improves
after proprioceptive training. Ostry et al. (2010) postulated that teaching an individual to reach with a directional force will result in systematic change in the perception
FIGURE 21.3 Phases of motor skill acquisition.
328 Computational Intelligence Algorithms
of hand position in space, and the perceptual change persisted for 24 hours even
when the duration of training is as short as ten minutes [41]. Thus, learning to produce accurate movements is both sensory and motor [42]. Wong et al. (2012) experimentally concluded that motor learning is improved by proprioceptive training [43].
The observed motor learning improvement results from changes in motor cortical
regions and subcortical regions. The other areas involved are the cerebellar cortex
and dorsal premotor cortex [42].
21.8 CONCLUSION
There is a scarcity of research on the aforementioned concept, i.e., upper-limb proprioceptive training in CNP patients. Although the work of Cagnie et al. (2014) and
Cools et al. (2013) signies the scapulothoracic muscle’s role in neck pain patients,
literature still lacks any evidence-based study for upper-limb proprioceptive training to the best of our knowledge and skills [8, 9]. The prognosis of CNP is poor
as indicated that 50−85% of patients who experience CNP report neck pain in the
next ve years [44]. Thus, it depicts that most of this patient population does not
recover absolutely. A ne-tuned sensorimotor system is essential for various tasks
that require precision. When the proprioception is the decit, the vision outweighs
performing movements [45]. Another method to improve accuracy in goal-directed
movements is the co-contraction of antagonistic muscles or stiffening of the muscles
to improve endpoint movement variability. Their hypothesis is based on neuromotor
noise theory, which describes that prolonged and repetitive movements will result in
increased muscle co-contraction [46]. This leads to greater stress on the head and
neck and makes it more vulnerable to strains. Consequently, this co-contraction of
the muscles reduces the error of the movement but results in wear and tear of small
bers [47].
Other than these large bodies of previous works, recent research is more
focused on the kinetic chain. Abichandani and Parkar (2015) postulated that there
is a repositioning error in the shoulder, elbow, and wrist joints in CNP patients as
compared to healthier controls [48]. Zabihhosseinian et al. (2015) concluded in
their study that altered or disrupted upper-limb proprioception due to neck muscle
fatigue has negative implications in workplace settings as well as in sports and
recreation by increasing the chances of upper-limb injuries [11]. Lastly, a recent
study conrmed that in CNP patients with neck fatigue, wrist joint position sense
is affected [49].
There is a need to understand these interconnections and their impact on the
population of CNP. This will help clinicians identify the cause of the symptoms
and treat patients with long-term goals to prevent reoccurrences. Integration of
these systems should be the focus of all treatment regimens rather than treating
the condition in isolation. The entire purpose of presenting this literature is to
bring forward an insight into recent advances in the physiological basis of our
treatment approaches. Regimens that are more focused on movement control and
that integrate vision and proprioception of the neck and upper extremities should
be a part or adjunct to the rehabilitation of CNP.
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Index
Note: Bold page numbers refer to tables and Italic page numbers refer to gures.
A
Acoustic analysis, 148
Adaptive convolution neural network, 161, 162,
Alzheimer’s disease (AD), 3, 174, 175, 176, 177,
Alzheimer’s Disease Neuroimaging Initiative
Amyotrophic lateral sclerosis, 8
Articial intelligence (AI), 45, 46, 48, 49, 81,
Articial neural network, 206, 207, 243, 244,
Attention mechanism, 39, 167
AUC-ROC, 208, 209, 210
Auditing, 46
Autism spectrum disorder, 5, 12, 109, 113, 2 61
Autoencoder, 227, 229, 243
Auto nom y,
163, 164, 16 6, 167
182 , 183, 184 , 188, 219, 224, 228, 229,
290, 291, 292, 293
(ADNI), 127, 128, 137, 175, 228,
292, 293
195, 196, 254, 311, 313, 317
246, 249, 250
, 248
42, 46, 47, 48, 54, 55, 56, 60, 61
B
Batch normalization, 189
Beta-amyloid plaques, 7
Bioavailability, 90, 92, 97, 98, 103
Biomedical signal analysis, 311
Blood, 91
Brain anatomy, 9
Brain computer interface (BCI), 101
Brain hemorrhage, 239
Brain MRI, 291
Brain targeting, 97, 99, 102
Brain tumor, 9, 81, 87, 92, 98, 99, 112, 125, 136,
Breath hold techniques, 74
137, 161, 162, 163, 164, 165, 166, 167,
169, 171, 172 , 173
C
Central Nervous System (CNS), 90, 91, 93, 95,
Cerebral palsy, 7
Cerebrospinal uid, 10
Cerebrovascular diseases, 5
Chronic stress, 13
CI algorithms, 59, 60
98, 102, 103
Classication accuracy, 127, 128, 149, 163, 169,
175, 17 7, 179, 18 4
Clinical psychiatry, 56
Computational complexity, 294
Computational intelligence, 54, 55
Computational neurology, 18, 19, 20, 26
Confusion matrix, 157, 18 4, 185, 186 , 276, 278,
279, 280, 281, 283, 284
Convolutional neural network, 72, 81, 101, 126,
133, 148 , 162, 163 , 175, 176, 197, 220,
224, 242, 244, 271, 290, 291, 313
Cyclegan, 131
, 185, 186, 188
D
Data augmentation, 124, 133, 139, 140, 141, 14 4,
Data privacy, 45, 47, 49, 51, 61, 126, 232, 293, 295
Decision tree, 114, 14 8, 150, 153, 156, 157, 158,
Deep belief network (DBN), 247, 291
Deep learning (DL), 10, 39, 71, 72, 101, 109, 111,
Deep neural network (DNN), 36, 37, 166, 177,
Deep residual network, 174 , 188
Dementia, 8, 7, 10, 13, 56, 76, 77, 101, 113, 174 ,
Dendrimers, 97
Detection, 81, 82, 86, 87, 90, 101, 110, 114, 115,
Diabetes, 7, 8, 13, 91, 210
Diffusion tensor imaging, 9, 34, 207, 242, 244, 291
Digital therapeutics, 315
Disorder, 90, 93, 94, 96, 98, 100, 101, 109, 111,
Diseases, 3, 5, 6, 8, 9, 10, 12, 13, 18, 21, 22, 25, 26,
168, 176 , 182, 183, 244, 248, 271,
272, 293
159, 195, 197, 199, 206, 210, 221, 224,
225, 226, 243, 260, 271, 292, 311, 314
114, 124, 126, 162, 175, 195, 199, 227,
229, 239, 272, 290, 291, 295, 311, 31 2,
313, 316
227, 243, 246, 316
177, 182, 18 5, 186, 219
122, 125, 126, 128, 133, 136, 139, 140,
141, 143, 144, 148, 150, 159, 162, 163,
164, 16 9, 174, 175, 176, 18 2, 195, 196,
200, 206, 207, 211, 213, 219
112 , 113, 138, 139, 141, 14 2, 143, 14 4,
148 , 161, 193, 200
253, 254, 2 61, 270
29, 45, 54, 56, 59, 76, 77, 82, 83, 84, 85,
87, 90, 91, 92, 94, 95, 98, 100, 101, 102
, 220, 290, 291
, 204, 231, 239, 242,
333
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