The Ola Grimsby Institute
Doctor of Manual Therapy

Can peripheral vision affect cervical range

of movement?

Matteo Alessandro Cappelletti, PT

05/18/2016

Research Director: Richard Kring, PT, PhD, DMT, DPT, OCS, FAAOMPT

A. Specific aims
This study starts from the desire to understand if treating the visual system using low intensity twin prisms*,
that have also the goal to facilitate extra-ocular muscle activity, also has an effect on cervical spine mobility;
including flexion, extension, lateroflexion and rotation.
If so it would mean that cervical rehabilitation should also include visual training to restore the complete
cervical range of movement and proprioception.
Other studies have analyzed the interaction between the cervical spine and visual system but it’s not clear yet
how it works.
We propose to investigate to what extent peripheral vision can influence cervical muscle’s activity; in other
words does cervical ROM improve if we stimulate peripheral vision?
We plan to achieve this project by addressing the following aims:
1. To evaluate the presence of visual dysfunction in people who suffer cervical pathology
This aim tests the hypothesis that people who suffer of cervical pathology (after trauma or not) could also
demonstrate oculomotor dysfunctions that affect the visual system. This could involve binocular instability and
vergences and phorias dysfunctions.
2. To evaluate the efficacy of prismatic glasses to improve peripheral vision
The aim tests the possibility to improve peripheral vision using a pair of prismatic glasses with very low
refractive power*. That type of lenses couldn’t affect extra ocular or intra ocular muscles giving that there isn’t
enough refractive power to change visual axis. So the hypothesis is that an effect on visual processing that
decrease intra and extra ocular muscles tone could improve peripheral vision; in other words, the lens that we
are going to use doesn’t affect the musculoskeletal system but the perceptive system. In other studies authors
use twin prisms with high dioptric power to affect intra and extra ocular muscles, this is the common use in
visual reeducation. But this can improve the tone of some muscles (so it can decrease peripheral vision). Low
dioptric power lenses, instead, don’t affect muscles but only the visual processing: this is because with a very
low stimulation (low dioptric power lenses refract slightly the light and allow to give a little stimulation of the
peripheral part of the retina) we can stimulate the neural pathways of the visual processing giving more inputs
to the system (more peripheral vision means more datas to the system), so this can decrease the tone of the
intra and extra ocular muscles (the system needs less efforts to have informations about the surrounding
environment).
To clarify, a pair of prisms with high dioptric power will directly increase extra and intra ocular muscles
(hypertone) and change the visual axis but if a pair of prism with very low dioptric power is used they will not
affect so much intra and extra ocular muscles; the hypothesis is that I can affect more visual processing by
developing peripheral vision. Peripheral vision provides the “spatial coordinates”, by
*Prisms with centesimal power devised by Marco Grassi, Optometrist

developing it, the subject can have more perception of the surrounding space, so the tone of the intra and
extra ocular muscles can decrease.
3. To evaluate if improving peripheral vision does improve cervical range of movement
The aim tests the hypothesis that if prismatic lenses with very low refractive power improve peripheral vision,
then patients will demonstrate a gain in cervical active and passive range of motion.
B. Background and Significance
Interactions between the musculoskeletal system and the visual system is understudied in the context of
musculoskeletal rehabilitation.
Fang et al. (2015) and Nakashima et al. (2014) analyzed the coordination between eye and head movement;
these studies demonstrate that this relationship has the purpose to improve visual activity. It is assumed that
head movements during gaze stability or visual tracking are useful to put the visual system in the best condition
to catch the right image so that correct central processing results. More specifically it has been observed by
Lennerstrand et al. (1996) and by Han and Lennerstrand (1999) that vibration of the neck muscles in subjects
with normal binocular function induces eye position changes related to the muscles that are stimulated
(SCOM, SC). Also Tjell and Rosenhall (1998), Wenngren et al. (2002), Prushansky et al. (2004) and Treleaven
et al. (2005) have demonstrated that whiplash can cause an alteration of oculomotor function (decreased
convergence and/or accommodation, abnormalities of both smooth pursuit and saccades).
Contrary to this view, Bexander et al. (2005) demonstrated how much the visual system can influence
muscular activity of some neck muscles (SCOM, SC and MF).
A study by Yarbus demonstrated how required tasks influence eye movements when a subject observes a
target. Eyes and head move in a coordinated manner when visual fixation changes. This coordination seems
to be related to visual cognition.
Other research (Nakashima and Shiori 2014) has shown how visual performance is more effective when a
person looks at a target in front rather than from the periphery. This study suggests the idea that coordination
between eyes and head is important during gaze shifts to allow high cognitive tasks. In fact our visual system
can’t process all the information that we receive simultaneously; usually we focus visual attention to a single
target or to a confined space, then we shift attention to other areas to evaluate surroundings. Visual fixation
allows attentional process, which is an automatic action. Coordination between the head and eyes is
unconscious and depends on several factors like duration of fixation, proximity of the examined target and a
precise balance by the CNS regarding the execution of a head movement.
The balance of cost to benefit whether to move the head or not isn’t sufficient to explain coordination between
eyes and head during fixation. In fact it has been observed that during reading of a page that could be done
with only saccadic movement of the eyes without using eccentric positions some head movements have been
registered. This coordination seems to depend also on the possibility of eye movement (“eye-only-range”,
EOR). This is individual, it presents an average of about ±18° and is determined by different physiological
factors like eye mobility (±55°) diminished gaze stability and gaze accuracy in the most eccentric positions of
the eyes.
Fang and Nakashima (2015) also studied how head movements during change of gaze fixation can be
predicted based on physiological factors. Eye direction related to the head influences perception and cognitive
factors. Changes of fixation are influenced by information precessed during previous fixation and the control
of the sequence of fixation changes is under the influence of visual cognitive processing. Furthermore some
authors have suggested that visual query task is better when eyes are oriented in the same direction of the
head, that is visual processing is better in this coordination condition.
Moreover, Heikkila and Wenngren (1998) suggest that a restriction of cervical spine movement and perceptual
changes in the cervical proprioceptive information affects voluntary eye movements. An accident in
flexion/extension to the cervical spine can cause proprioceptive disturbance; this can consequently cause
oculomotor disturbances.
Hildingsson and Wenngren, 1993 follow-up at more than 15 months from a cervical spine trauma underlining
how oculomotor disturbances improve during time in the study sample. In a previous study it has been already
demonstrated how velocity, accuracy and eye-movement pattern was disturbed after cervical soft tissue
accident (for example after whiplash). In these patients, oculomotor function was damaged and a chronic
brainstem injury has been hypothesized as cause. Brainstem contains neurons related to gaze and reticular
formation of medulla regions that determine head rotation.
Further research has shown (Helland et al. 2008 and 2011) how visual discomfort is associated with cervical
and shoulder pain.

Other studies (André-Deshays et al. 1988, 1991) demonstrate the existence of a “tonic association” between
cervical muscles activity and horizontal component of eyes position. This association is attendant not only
during target fixation but also during visual pursuits. During eye movements, phasic activity of the dorsal
muscles of the neck, has been registered, related to the velocity of displacement of the eyes.
It has been suggested that discrepancy between knowledge of motor intention, muscular and articular
proprioception and vision can cause pain.
Harmon, during ‘50s, demonstrated that change of muscular tone in the cervical spine has a relationship with
the refractive condition (myopia or hyperopia) and lateral phorias. It has been shown by Lie and Watten (1987)
that the neck has a connection to provide feedback between eyes and trunk. The supported cervical spine
influences the visual system and cervical spine tone influences eye refractivity. Through EMG of the head,
neck and shoulders the authors demonstrated that accommodative activation produced by the use of negative
lenses was associated with an increase of tone in striated muscles like frontalis, maseter, trapezius and deltoid
muscles.
Another study by Valentino and Fabozzo (1993) has hypothesized that an alteration of the head posture can
be due to increased tone in trapezius and sternocleidomastoid muscles in subjects affected by visual
problems. The analysis of the results of their EMG study demonstrate a significant increase in
the tonic activity of these muscles in miopes.
Lastly, it has also been demonstrated that the relationship between eye muscle and cervical spine muscles is
not one way. Han and Lennerstrand in 1999 studied that stimulating specific neck muscles with vibration at
70 Hz caused eye movement. The authors also verified that it was possible to determine which movement: for
example activating sternocleidomastoid and splenius capitis muscles results in horizontal eye movement. This
indicates that proprioceptive messages that originate in the cervical spine muscles are affected by visual inputs
and integration.
This study starts from the desire to understand if treating the visual system using low intensity twin prisms,
that have also the goal to facilitate extra-ocular muscles activity also has an effect on cervical spine mobility
in all directions.
C. Preliminary Studies
Yarbus AL. Eye Movements and Vision: New York: Plenum Press; 1967.
R. Nakashima, S. Shioiri – Why Do We Move Our Head to Look at an Object in Our Peripheral Region? Lateral
Viewing Interferes with Attentive Search
The authors investigated visual perceptual effects of head direction as an additional factor impacting on a
cost-benefit organization of eye-head control.
Three experiments using visual search tasks have been conducted, manipulating eye direction relative to head
orientation. The first experiment shows that lateral viewing increased the time required for a serial attentive
search task, but not a parallel pre-attentive search task. During the second experiment the task had been
obtained under conditions in which the task was accomplished without saccades. The third one was done
during monocular viewing. Results suggest that a difference between the head and eye direction interferes
with visual processing, and that the interference can be explained by the modulation of attention by the relative
positions of the eyes and head (or head direction).
Yu Fang, R. Nakashima, K. Matsumiya, I. Kuriki, S. Shioiri1,2,3 – Eye-Head
Coordination for Visual Cognitive Processing
This study investigated coordinated movements between the eyes and head. The authors examine how the
eyes and head move in coordination during visual search in a large visual field. Subjects moved their eyes,
head, and body without restriction inside a 360° visual display system. They found patterns of eye-head
coordination that differed from those observed in single gaze-shift studies: first a relationship between head
movements and sequential gaze shifts that suggest eye-head coordination over several saccade-fixation
sequences. This could be related to cognitive processing because saccade-fixation cycles are the result of
visual cognitive processing. Second, distribution bias of eye position during gaze fixation was highly correlated
with head orientation. This influence of head orientation suggests that eye-head coordination is involved in
gaze fixation, when the visual system processes retinal information. This further supports the role of eye-head
coordination in visual cognitive processing.
Heikkila HV., Wenngren BI. – Cervicocephalic kinesthetic sensibility, active range of cervical motion, and
oculomotor function in patients with whiplash injury

The authors investigated cervicocephalic kinesthetic sensibility, active range of cervical motion, and
oculomotor function in patients with whiplash injury.
Oculomotor function was tested at 2 months and at 2 years after whiplash injury.
The ability to appreciate both movement and head position was studied. Active range of cervical motion was
measured. Subjective intensity of neck pain and major medical symptoms were recorded.
The authors found that active head repositioning was significantly less precise in the whiplash subjects than
in the control group. Significant correlations occurred between smooth pursuit tests and active cervical range
of motion. Correlations were also established between the oculomotor test and the kinesthetic sensibility test.
The results suggest that restricted cervical movements and changes in the quality of proprioceptive information
from the cervical spine region affect voluntary eye movements. A flexion/extension injury to the neck may
result in dysfunction of the proprioceptive system. Oculomotor dysfunction after neck trauma might be related
to cervical afferent input disturbances.
Hildingsson C, Wenngren BI, Toolanen G. – Eye motility dysfunction after softtissue injury of the cervical spine.
A controlled, prospective study of 38 patients
The authors investigated eye motility prospectively in 40 patients with a softtissue injury of the cervical spine.
The initial oculomotor test, performed within 3 months, was pathologic in 8 patients. The follow-up test in 38
patients, on average 15 months after the accident, remained pathologic in the 8 patients and 5 additional
patients had changed from normal to pathologic test results. At follow-up, all 13 patients with oculomotor
dysfunction had persisting symptoms, while 5 of the 25 cases with normal test results still were symptomatic.
Hildingsson C, Wenngren BI, Bring G, Toolanen G. – Oculomotor problems after cervical spine injury
In this study oculomotor function was investigated in 39 patients with a previous soft-tissue injury of the cervical
spine. The velocity, the accuracy, and the pattern of the eye movements were disturbed in 20 patients with
chronic and disabling symptoms. Oculomotor function in the 19 asymptomatic patients did not differ from a
control group. The oculomotor function seems to be impaired, possibly by brain stem lesions, in patients with
chronic symptoms of whiplash injury of the cervical spine.
Andrée-Deshays C, Revel M, Berthoz A. – Eye-head coupling in humans. II.
Phasic components
The activity of isolated motor units was recorded in the splenius muscle during large horizontal eye movements
in head fixed subjects. The authors found two main types of motor unit discharge patterns in the splenius
(SPMU): the first type (type A, 14 SPMUs) shows a phasic modulation of firing rate during saccades with a
triphasic profile composed of a pre-saccadic suppression, a persaccadic burst and a post saccadic tonic
discharge proportional to eye position.
The second type (type B, 6 SPMUs) exhibits little, if any, modulation of firing rate with either fixation or
saccades. These results suggest that eye-head coupling is present not only during the fixation period but also
during saccades and that a phasic activity or suppression related to saccadic eye velocity is present in dorsal
neck muscle EMG.
Lie I, Watten RG. – Oculomotor factors in the aetiology of occupational cervicobrachial diseases (OCD)
Two experiments on ocularly induced neck muscular tension are reported. In both experiments EMG’s were
taken from six different muscles in the head, neck and shoulder region during a visual discrimination task. In
Experiment 1, accommodation and fusion requirements were systematically varied by changing
viewing distance in combination with the application of minus-lenses and baseout prisms. EMG was shown to
increase as a function of accommodation and fusion load. In Experiment 2, a clinical population with severe
and long lasting neck and shoulder problems and inappropriate optical corrections was studied with the same
experimental design. EMG was shown to decrease when habitual corrections were replaced by more
appropriate ones.
Valentino B, Fabozzo A. – Interaction between the muscles of the neck and the extraocular muscles of the
myopic eye. An electromyographic study.

The aim of this study is to demonstrate a possible alteration of the posture of the head due to abnormal tonus
of the trapezius and sternocleidomastoid mm. In subjects with defective vision. The authors studied the
functional relationships between the extraocular muscles of the myopic eye and the muscles of the neck by
means of electromyography. Electromyographic recordings of the relevant muscles were made during varied
eye movements. Analysis of the results demonstrated a marked difference in tonic activity of the named
muscles between the myopic and the normal groups. The findings suggest that, in the correction of visual
defects, attention should be paid to postural adjustment of the neck by means of a series of programmed
exercises directed towards the trapezius and sternocleidomastoid mm.
Han Y, Lennerstrand G. – Changes of visual localization induced by eye and neck muscle vibration in normal
and strabismic subjects.
This study investigated the effects of proprioception in the eye and neck muscles on space localization.
Vibration was applied to either the eye or neck muscle in normal subjects, intermittent exotropes, and constant
exotropes/esotropes. With vibration of the vertically moving muscles of the eye and neck, the direction of the
pointing shifts was the same in all groups of the subjects and under all viewing conditions. With vibration of
the horizontally moving muscles of the eye and neck, the directions were the same in the normals and in most
of the intermittent exotropes. However, in the constant exotropes and esotropes, the directional shifts were
dependent on which eye was vibrated, and the directions were more variable, always directed only to one
side. The authors infer that proprioception in the eye and neck muscles participates in visual space localization,
but the effects of proprioceptive activation were differed in normal
subjects from those in patients having constant strabismus and that the differences may be related to the level
of binocular function.
Lennerstrand G, Han Y, Velay JL. – Properties of eye movements induced by activation of neck muscle
proprioceptors.
In this study the authors examine the properties of the cervico-ocular reactions and reveal any artefacts in the
eye movement recordings. They have studied (1) the effect of increasing the ambient light, which made visual
illusory movements disappear, (2) the timing between the illusory movement and the eye movement in
subdued light, (3) the effect of viewing the target through a pin-hole, which would reveal artefacts due to head
movement, and (4) the effect of mounting the eye movement recording system on the head support, which
would allow recording to the absolute eye position change. The results showed that eye movements of about
the same amplitude were induced in both eyes under all conditions, and there was no time difference in the
occurrence of visual illusory movements and eye movements. The results of this study confirm that neck
muscle vibration can induce eye position changes. This seems to confirm that the proprioceptive messages
originating in the neck muscles are processed together with visual information of eye position in determining
gaze direction.
Tjell C, Rosenhall U. – Smooth pursuit neck torsion test: a specific test for cervical dizziness.
This study aimed to determine how the smooth pursuit neck torsion (SPNT) test is affected by various diseases
associated with disturbances in balance and arising in the neck, in the posterior intracranial fossa, and in the
labyrinth in patients having such conditions, and to compare the findings with those in healthy subjects. The
patients have been divided in two group: the study group, people who were affected by whiplash- associated
disorders (WAD) after car accidents, and a control group, composed by people who were affected by central
vertigo, Meniere’s disease and healthy subjects. They have been all submitted to smooth pursuit in neutral
and at 45 degrees of cervical rotation to the left and to the right. The results have been that In WAD group
neck torsion reduced the SP gain (p < 0.001), but in control patients with central and peripheral vertigo and in
the healthy control subjects, it did not. The authors infer that the SPNT test seems to be useful for diagnosing
cervical dizziness, at least in patients with WAD having symptoms of dizziness, because it has a high
sensitivity and specificity.

Wenngren BI, Pettersson K, Lowenhielm G, Hildingsson C. – Eye motility and auditory brainstem response
dysfunction after whiplash injury.

The aim of this study was to identify the prevalence of brain/brainstem dysfunction after acute whiplash trauma
and to investigate a possible correlation between the development of chronic symptoms and objective findings
from auditory brainstem response (ABR) and eye motility tests. The authors used ABR and oculomotor tests
and a thorough clinical, subjective and psychological evaluation in a sample of prospective whiplash trauma
patients who were followed up for 2 years after the trauma. The initial test results did not reveal any prognostic
clinical signs for the tested group as a whole, but it is possible to discriminate some patients with clinical
symptoms and signs paired with pathologic test results. Over time, some patients normalized clinically and
their test results improved while others deteriorated clinically and their test results were worse at the 2-year
investigation. The findings of moderate derangements in the tests could be the effects of pain and/or changed
cervical afferent activity at the brain/brainstem level, while eye motility dysfunction, in addition to pathological
neuro-otological findings in a small proportion of the patients with severe symptoms, could be explained by
lesions to the brain/brainstem.
Prushansky T, Dvir Z, Pevzner E, Gordon CR. – Electro-oculographic measures in patients with chronic
whiplash and healthy subjects: a comparative study.
The main objective of this study was to examine the applicability of some electro-oculography (EOG)
parameters during neck torsion in differentiating patients from uninvolved subjects. Smooth pursuit and
saccadic eye movements were assessed to the patients. All tests were executed in three neck positions:
neutral and rotations to left and right. The authors found that neck torsion did not influence eye movement
performance of either the WAD or healthy groups.
However, compared with the healthy group, patients with WAD had significantly lower smooth pursuit velocity
gain and prolonged saccadic latency, irrespective of neck position. The electro-oculographic measures used
in this study do not seem to offer a clinically relevant method for differentiating between patients with WAD
and normal subjects.
Treleaven J, Jull G, LowChoy N. – Smooth pursuit neck torsion test in whiplashassociated disorders:
relationship to self-reports of neck pain and disability, dizziness and anxiety.
The aim of the study is to know whether impairments identified relate only to abnormal cervical afferentation
or are influenced by levels of anxiety or neck pain. The authors observed 100 subjects with persistent whiplash
and 50 healthy subjects. The smooth pursuit neck torsion test was performed and analysed taking into account
subjects’ reported levels of pain, anxiety and dizziness. The results confirm that there are significant
differences in the smooth pursuit neck torsion test between subjects with persistent whiplash compared with
healthy control subjects. The results suggest that the test is not influenced by a patients’ level of anxiety, but
may be influenced by both nocioceptive and proprioceptive
factors. The smooth pursuit neck torsion test seems to be useful to identify eye movement disturbances in
patients with whiplash, which are likely to be due to disturbed cervical afferentation.
Concise Summary of preliminary studies
Many authors affirm that eye – head coordination has a role in cognitive visual processing and that, based on
binocularity, proprioception of the eyes and of the neck participate in spatial localization. Proprioceptive
messages of the neck are processed with visual information to determine gaze direction. Other authors infer
that eye movements are influenced by cervical proprioceptive afferents.
More specifically, we know that stimulating cervical muscles can affect the extraocular muscles; but we also
know that cervical muscles are activated during gaze fixation and saccades and it depends upon gaze shift
velocity. So there seems to be a two way connection between cervical afferent inputs and visual inputs. Visual
dysfunction is correlated to chronic pain.
Current rehabilitation of the cervical spine usually doesn’t associate cervical proprioceptive training to other
systems, like for example visual system. There are some authors that infer that visual training could affect
cervical proprioception.

D. Research Design and Methods
A total of 60 patients will be recruited to participate in this study divided into two groups of 30 patients each
presenting cervical pathology, that determine reduction of the range of movement, and oculomotor dysfunction

(diminished peripheral vision). These patients will be recruited from “Clinic Rehabilitation Center Sport” located
in Bresso (MI, Italy), a physical therapy clinic. The patients presenting with the appropriate criteria will be
offered the opportunity to partecipate in a double blind study. This would include cervical sprain/strain without
ligamentous lesion and its sequelae, cervical facet derangement and its sequelae, cervical articulation
degeneration (arthrosis) and its sequelae, cervical disc degeneration and its sequelae. Excluded diagnoses
include cervical fracture, dislocation, post operative patients, neoplasm, a diagnosed cervical vascular disorder
or overt psychiatric disorder. Acute and chronic injuries less than 5 years since the accident will be eligible for
study inclusion. All patients will be
adults older than 18 years of age in order to give informed consent, and under the age of 70. Those consenting
to the study will be randomly placed into one of the two groups.
The first group will consist of 30 patients. These subjects will receive standard physical therapy for their
cervical problems with the addition of visual reeducation using prismatic lenses with very low refractive power*.
The second group will consist of the same frequency of visits and therapy treatment with exception of the
visual reeducation protocol. All patients will be assessed using the same instruments at baseline and at the
5th visit. Testing will be digitally recorded in order to review and analyze the performance of each study
participant by one clinician. Following the conclusion of the rehabilitation program to those randomly selected
into the non visual reeducation group, the patient may request or be offered visual training sessions if it is
appropriate for their continuing care and services at the clinic.
There will be a case with 60 notes, 30 with letter A (meaning the first group, the one who will receive cervical
physical therapy more visual reeducation) and 30 with letter B (meaning the second group, the one who will
receive only cervical physical therapy). At recruitment patients will draw out one note by themselves; based
on the letter, they will be assigned to one of the two groups.
The study will be conducted by 4 people, one optometrist, two physical therapists and a fourth person who will
be responsible of the recruitment of the patients, of their consenting process and of their management. The
optometrist will record data regarding visual function as the amount of peripheral vision, smooth pursuit,
vergences and phorias and will decide the refractive power of the prismatic lenses and their positioning based
on the results of the tests of visual function only for the first group. One of the two physical therapist will be
responsible to measure cervical ROM using Bioval® System. The second
physical therapist will be responsible of the cervical treatment with soft tissue work, joint mobilization (no
manipulation), self-mobilization, modalities, education, exercise, posture and general home exercise for
cervical program.
Each practitioner will record patient’s datas on a file and only after the last session (after 8 weeks) they will
send their datas to others. Both practitioners and patients are not allowed to talk about the datas they have
collected before the end of the study. In this way we should avoid investigator bias.
D.2. Inclusion/Exclusion Criteria
• Included: Patients referred to physical therapy for rehabilitation of a cervical disorders. This will include both
acute (6 months or less) and chronic (more than 6 months but less than 5 years since the injury).
Patients must be between the ages of 18 and 70 with informed consent.
Vestibular symptoms such as dizziness do not exclude the patient if determined to be related to cervical
disorder and not overt vestibular system pathology.
• Excluded: Those patients presenting with cervical fracture, dislocation, post operative patients, neoplasm, a
diagnosed cervical vascular disorder or overt psychiatric disorder.
D.3. Measured Variables
The following variables will be assessed at the first, 5th and at 9th visit follow ups. The following assessment
will be performed: Visual Analog Scale for subjective pain, Cervical Range of motion with ROM unit with
Bioval® System, Peripheral Vision, Smooth pursuit, Vergences, Phorias.
D.4. Timeline of study
The goal is an 8-week treatment period at 1X per week. The subject can remain in the study if they miss or
cancel an appointment as long as the 9th visit reassessment can take place after 8 weeks. A patient can elect
to drop from the study at anytime.
• A patient will be removed from the study if they cannot attend 5 visits within the 8 week time frame.
• A patient can be discharged from care prior to 4 weeks if all clinical goals are met.
• The patient must still attend the 8th week reassessment. The patient, or their insurance company, will not be
charged for these post-discharge visits.

D.5. Cervical Range of Motion
The cervical range of motion will be measured in right and left rotation, right and left lateroflexion, flexion and
extension. The measure will be taken using the Bioval® System by RM Ingegnerie, a system of
accelerometers that measures the change of position of a sensor in space or relative to another sensor. The
first sensor will be positioned on the forehead of the patient, the second sensor will be positioned at the level
of C7. The patient will be asked to move the head in the all positions and every time to come back in neutral
position. For every direction the patient will repeat the movement for 3 times and the therapist will register the
average of the three measures.
D.6. Peripheral Vision
The patient will sit at 0,5 m in front of a panel. The panel will have a target in the center that will be put at eye
level and letters in concentric and increasing circles. Fixing the target the patient will read the different letters
using peripheral vision, the therapist will record which circle the patient is able to read.
D.7. Smooth Pursuit
The patient will sit in front of the therapist. The therapist will move a target in horizontal, vertical and diagonal
direction drawing 8 lines from center position.
The patient will be instructed to maintain an upright position and to follow the target only moving the eyes
while the head and the body must remain fixed. The therapist will count any saccades and any times the
patient loose the target.
D.8. Vergences
The patient will sit in front of the therapist. The therapist will move a target to the patient’s nose in a straight
line; the patient will be instructed to report when he loses the focus first and then when the target splits. The
therapist will record the two distances, then will bring back the target and will count when it returns single and
then when the patient refocuses.
D.9. Phorias
The patient will sit in front of a panel where there will be some letters in line and, under those letter in the
center of the line, an indicator. The therapist will put in front of an eye of the patient a horizontal prism in a
way that the patient will start to see a second line of letters under the indicator. The patient will be instructed
to say which letter of the second line the indicator marks.
D.10. Treatment Guidelines
General treatment is to include soft tissue work, joint mobilization (no manipulation), self-mobilization,
modalities, education, exercise, posture and general home exercise for cervical program. The first group will
receive also a pair of prismatic glasses with very low refractive power* oriented according to the visual
assessment done by an optometrist. The patient belonging to the first group will wear the glasses every day
during the period of the study at least 5 hours per day. The prismatic lenses with very low refractive power*
have also the goal to facilitate extra-ocular muscles activity.
E. Long Term Aims
• LTA1: To develop a new rehabilitation tool or system to be integrated into the treatment of cervical pathology
patients.
• LTA2: To move forward to understand if visual aspects can interfere with musculoskeletal disorders.
F. Literature Cited
*Prisms with centesimal power devised by Marco Grassi, Optometrist
1. Yarbus AL. Eye Movements and Vision: New York: Plenum Press; 1967
2. R. Nakashima, S. Shioiri – Why Do We Move Our Head to Look at an Object in Our Peripheral Region?
Lateral Viewing Interferes with Attentive Search
3. Yu Fang, R. Nakashima, K. Matsumiya, I. Kuriki, S. Shioiri1,2,3 – Eye-Head Coordination for Visual
Cognitive Processing
4. Heikkila HV., Wenngren BI. – Cervicocephalic kinesthetic sensibility, active range of cervical motion, and
oculomotor function in patients with whiplash injury
5. Hildingsson C, Wenngren BI, Toolanen G. – Eye motility dysfunction after softtissue injury of the cervical
spine. A controlled, prospective study of 38 patients
6. Hildingsson C, Wenngren BI, Bring G, Toolanen G. – Oculomotor problems after cervical spine injury

7. Helland M, Horgen G, Kvikstad TM, Garthus T, Aarås A. – Will musculoskeletal and visual stress change
when Visual Display Unit (VDU) operators move from small offices to an ergonomically optimized office
landscape?
8. André-Deshays C, Revel M, Berthoz A. – Eye-head coupling in humans. II. Phasic components
9. Lie I, Watten RG. – Oculomotor factors in the aetiology of occupational cervicobrachial diseases (OCD)
10. Valentino B, Fabozzo A. – Interaction between the muscles of the neck and the extraocular muscles of the
myopic eye. An electromyographic study.
11. Han Y, Lennerstrand G. – Changes of visual localization induced by eye and neck muscle vibration in
normal and strabismic subjects.
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