Manual Therapy 20 (2015) 68e78

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Cervical kinematic training with and without interactive VR training

for chronic neck pain e a randomized clinical trial*
Hilla Sarig Bahat a, b, *, Hiroshi Takasaki a, 1, Xiaoqi Chen a, 2, Yaheli Bet-Or a, 2,
Julia Treleaven a, 2
a
b

CCRE Spine, The University of Queensland, Brisbane 4072, Australia

Department of Physical Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa 31905, Israel

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 24 October 2013
Received in revised form
24 June 2014
Accepted 27 June 2014

Impairments in cervical kinematics are common in patients with neck pain. A virtual reality (VR) device
has potential to be effective in the management of these impairments. The objective of this study was to
investigate the effect of kinematic training (KT) with and without the use of an interactive VR device. In
this assessor-blinded, allocation-concealed pilot clinical trial, 32 participants with chronic neck pain
were randomised into the KT or kinematic plus VR training (KTVR) group. Both groups completed four to
six training sessions comprising of similar KT activities such as active and quick head movements and
ne head movement control and stability over ve weeks. Only the KTVR group used the VR device. The
primary outcome measures were neck disability index (NDI), cervical range of motion (ROM), head
movement velocity and accuracy. Kinematic measures were collected using the VR system that was also
used for training. Secondary measures included pain intensity, TAMPA scale of kinesiophobia, static and
dynamic balance, global perceived effect and participant satisfaction. The results demonstrated signicant (p < 0.05) improvements in NDI, ROM (rotation), velocity, and the step test in both groups postintervention. At 3-month post-intervention, these improvements were mostly sustained; however
there was no control group, which limits the interpretation of this. Between-group analysis showed a few
specic differences including global perceived change that was greater in the KTVR group.
This pilot study has provided directions and justication for future research exploring training using
kinematic training and VR for those with neck pain in a larger cohort.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Neck pain
RCT
Kinematics
Virtual reality

1. Introduction
Chronic neck pain is a common complaint in adults and a major
health burden (Borghouts et al., 1998; Hogg-Johnson et al., 2008).
Recent studies have supported a multimodal approach in the
treatment of neck pain, with exercise as an important component,
within a bio-psychosocial framework (Miller et al., 2010; Kay et al.,
2012). To date, exercise programmes have mainly focused on

*
The trial was registered in the Australia New Zealand Trial registry
ACTRN12612000677808.
* Corresponding author. Physical Therapy Department, Faculty of Social Welfare
& Health Sciences, University of Haifa, Mount Carmel, Haifa, 31905, Israel.
Tel.: 972 4 8288089; fax: 972 4 8288140.
E-mail addresses: hbahat@research.haifa.ac.il (H. Sarig Bahat), h.takasaki@uq.
edu.au (H. Takasaki), xiaoqi.chen@uq.net.au (X. Chen), y.betor@uq.edu.au
(Y. Bet-Or), j.treleaven@uq.edu.au (J. Treleaven).
1
Tel.: 61 733651510; fax: 61 733651284.
2
Tel.: 61 733654568; fax: 61 733001690.

http://dx.doi.org/10.1016/j.math.2014.06.008
1356-689X/ 2014 Elsevier Ltd. All rights reserved.

improving neuromuscular control, specic and general muscle activity (Miller et al., 2010). However, the cervical spine is unique
with an abundance of mechanoreceptors, muscle spindles and
cervical afferents associated with the vestibular, visual and central
nervous systems and an important function of the cervical spine is
quick and precise head movement in reaction to surrounding
stimuli (Selbie et al., 1993; McLain, 1994; Corneil et al., 2002; Liu
et al., 2003). Patients with neck pain have demonstrated impairments in cervical movement kinematics, such as reduced movement range, accuracy, velocity, smoothness and stability of neck
motion, which might impair their ability to react to surrounding
lander et al., 2008; Roijezon et al., 2010; Sarig Bahat
stimuli (Sjo
et al., 2010; Woodhouse et al., 2010). Such kinematic impairments
are also thought to contribute to functional difculties, such as
driving, and could be associated with fear of movement in some
with neck pain (Roijezon et al., 2008; Takasaki et al., 2013).
Considering the functional importance of cervical kinematics, exercise interventions encompassing this type of training are potentially relevant and should be investigated for their efcacy in the

H. Sarig Bahat et al. / Manual Therapy 20 (2015) 68e78

management of chronic neck pain. However, to date there has been

no research investigating this type of exercise training in neck pain.
Recently a virtual reality (VR) device to assess cervical kinematics has been developed and shown to be a valid and reliable
assessment tool for neck pain (Sarig Bahat et al., 2009; Sarig-Bahat
et al., 2010). It also has potential for use as a kinematic exercise
training tool. In other populations, VR has been effective in
reducing pain and anxiety levels (Hoffman et al., 2007; Sharar et al.,
2008), engaging and motivating physical activities, and in
improving exercise compliance and effectiveness (Holden et al.,
1999; Rizzo and Kim, 2005; Bryanton et al., 2006; Mirelman
et al., 2009). Another important advantage of VR is that it directs
attention to an external stimulus (external focus of attention),
rather than to the body movements (internal focus of attention)
(McNevin et al., 2003), which has been shown to be more effective
in advancing motor learning and performance (Zachry et al., 2005;
Wulf and Su, 2007).
The purpose of this randomized pilot study was to investigate
the effect of cervical kinematic training (KT) with and without VR
training in people with chronic neck pain. It is hypothesized that
both regimes would improve neck pain, disability and kinematics
but VR training would improve these factors more so considering
its interactive nature and potential ability to distract from pain and
anxiety.
This study is a rst step to investigate the effects of kinematic
training in neck pain. Future studies comparing kinematic training
to a control and other exercise interventions in neck pain can then
be investigated.
2. Methods
2.1. Design overview
This was an assessor-blinded randomized study with concealed
stratied allocation. There were two interventions arms. The rst
included supervised KT and VR training (KTVR group), and the
second, supervised KT training only (KT group). Both groups were
also encouraged to perform unsupervised, individually tailored
home KT training. Both groups completed 4e6 supervised intervention sessions for 30 min each over a period of ve weeks. The
supervised sessions were conducted by a physiotherapist. Both
groups were encouraged to continue their home KT exercise programme after the supervised sessions had ceased.

69

2.3.1. Primary outcome measures

2.3.1.1. NDI. NDI: (Vernon and Mior, 1991) was used to examine
self-reported disability associated with neck pain. Higher percentage scores indicate greater disability. The NDI has been shown
to demonstrate good validity and reliability (Pietrobon et al., 2002;
Hoving et al., 2003; Cleland et al., 2006). A minimal clinical
important change (MCIC) of 7% is thought to be realistic (Pool et al.,
2007).
2.3.1.2. Cervical range of motion (ROM) and kinematics.
Cervical range of motion (ROM) and kinematics: were collected
using a customised VR system that used newer hardware and
software to execute the same rationale of the rst VR system previously studied (Sarig-Bahat et al., 2010). The concept of neck
motion control remained the same however, the graphics were
changed (plane vs. ies), tracking was now integrated into the HMD
and a new module of accuracy was added. The VR system used in
this study consisted of off-the-shelf hardware and customized
software. Hardware included a head-mounted display with a threedimensional (3D) motion tracker built in (Wrap 1200VR by Vuzix,
Rochester, New York).
The interactive 3D virtual environment was developed using the
Unity-pro software, version 3.5(Unity Technologies, San Francisco).
The Vuzix Software development kit including their calibration and
tracking data tools was also used. Dynamic motion tracking data
were analysed by the developed software in real-time. Three
modules were developed, including range of motion (ROM), velocity and accuracy modules. These modules enable elicitation of
cervical motion by the patient's response to the provided visual
stimuli. A full kinematic report for each patient was generated after
completion of the modules. During the VR session, the virtual pilot
ying the red aeroplane (in the web version) is controlled by the
patient's head motion and interacts with targets appearing from
four directions (exion, extension, right rotation, left rotation)
(Fig. 1). The VR modules are described in detail below under the
section Interventions.
In all kinematic measures of this study, motion initiation was
determined as the point in time when 5% of peak velocity was
obtained (Sarig Bahat et al., 2010). Data was low-pass ltered
(frequency 6 Hz, order 4). The cervical movement kinematic variables were calculated for each trial in each of the four directions
assessed (F, E, RR, LR). These results were calculated from the
tracker's angular displacement output i.e. pitch and yaw. The

2.2. Setting and participants

The study was conducted at the Neck Pain and Whiplash
Research Unit at The University of Queensland, Brisbane, Australia.
Participants were recruited via advertising in the local community
during JuneeOctober 2012.
Inclusion criteria included: age 18 years or more; prolonged
neck pain for more than three months; and the Neck Disability
Index (NDI) score greater than 10%. Exclusion criteria included:
existing vestibular pathology; cervical fracture/dislocation; systemic diseases; neurological/cardiovascular/respiratory disorders
affecting physical performance; history of traumatic head injury;
inability to provide informed consent; or pregnancy.
Each participant provided a written consent before data
collection.
2.3. Outcome measures
Outcome measures were collected at pre-intervention, immediate post-intervention and at 3-month post-intervention.

Fig. 1. The ROM module. The red aeroplane is controlled by head motion. The
participant is required to align the head of the pilot with the yellow targets by moving
the head in the direction of the targets. The appearance of the targets in the various
directions is randomized so that the participant cannot foresee where the next target
will appear. The game algorithm is also made to challenge the participant's head
movement (from mid-position) by gradually increasing the ROM required following
success of hitting each target. After three consecutive failures to reach a target in each
direction this module was completed. (For interpretation of the references to colour in
this gure legend, the reader is referred to the web version of this article.)

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H. Sarig Bahat et al. / Manual Therapy 20 (2015) 68e78

Fig. 2. The Velocity module. The velocity module is designed to randomly display a total of 16 yellow ball targets, in four different directions of exion, extension, right and left
rotation. (a) At the beginning of each trial, the participant has to activate the game by positioning the pilot's head in the centre of a red ring, which will then change in colour from
red to green once the correct mid-position is achieved for 3 s. During this 3s period static head sway was recorded. (b) Once the ring turns green, a yellow target appears in a
random direction, and the participant is required to move the head in that direction within 7 s before the target disappears. Target's life time is visualized using a green circle around
the target that diminishes gradually and functions as a timer. This feature aims to motivate the participant to move quickly towards the target before it disappears. During this
dynamic part of the velocity module, velocity and TTP% were recorded. (For interpretation of the references to colour in this gure legend, the reader is referred to the web version
of this article.)

following are the denitions of the cervical motion kinematics

outcomes. Measure 1 was collected with the ROM module, 2e5
with the velocity module, and 6 with the accuracy module of the VR
device:
1. Cervical ROM results were calculated by averaging the three best
values from each direction. This methodology has previously
demonstrated good repeatability and sensitivity (Sarig Bahat
et al., 2009; Sarig-Bahat et al., 2010). A change of ROM greater
than 6.5 in any direction is considered to reect a true change
(Audette et al., 2010).
2. Peak velocity (Vpeak,  /sec) was collected from 16 trials, four
from each direction. The overall Vpeak result was calculated as
the mean of three maximal results achieved from each direction.
3. Mean velocity (Vmean,  /sec) was calculated as the mean
angular velocity of three maximal results achieved from each
direction.
4. Time to peak velocity percentage (TTP%) was the time from
motion initiation to peak velocity moment, as a percentage of
total movement time.
5. Static head stability (sway) was dened as the sway in pitch and
yaw from the mid-position and calculated in terms of 3D mean
and standard deviation amplitude. Vpeak, Vmean, TTP%, and
head sway were collected during the velocity module (Fig. 2).
6. Head movement accuracy was collected during the accuracy
module (Figs. 3 and 4), where the participant was required to
keep the pilot's head on the virtual moving target. Motion accuracy was dened as the difference between target position
and participant's head location. This difference (target positionplayer's head position) in the pitch and the yaw plane were
derived from the sum of the trials in each plane. To date data on
MCIC and MDC are not available for measures 2e6.

2.3.2.2. Tampa scale of kinesiophobia (TSK). Tampa scale of kinesiophobia (TSK): was used to assess fear of movement (Kori et al.,
1990). The TSK has been shown to demonstrate good validity and
reliability in people with neck pain (Buitenhuis et al., 2006; Cleland
et al., 2008). Higher summed scores (0e68) correspond to higher
kinesiophobia, and scores greater than 37 indicate a high degree of
kinesiophobia (Vlaeyen et al., 1995). The MDC of the TSK 11, scored
out of 44, was 5.6 (Hapidou et al., 2012). This would suggest that a
change of at least or greater than this amount would be required in
the TSK/68 used here.
2.3.2.3. Global perceived effect (GPE). Global perceived effect (GPE):
was rated using an 11-point scale (5 vastly worse, 0 no change,
5 completely recovered). The GPE appears to capture change in
different domains important to the individual (Evans et al., 2014).

2.3.2. Secondary outcome measures

2.3.2.1. Neck pain intensity. A 0e100 mm visual analogue scale
(VAS) was used to investigate the average neck pain intensity
during the last week, respectively. Higher scores indicate greater
intensity (0 no pain, 10 worst pain imaginable). The MCICs of
21 mm and 25 mm has been suggested (Cleland et al., 2006; Pool
et al., 2007).

Fig. 3. The accuracy module. A moving yellow target is presented on a vertical or

horizontal line, at a constant velocity of 10  /s. The participant is required to maintain
the pilot's head position on the moving target as closely as possible by tracing the
vertical/horizontal line. The order of the movement directions of exion/extension/
right rotation/left rotation is randomized. (For interpretation of the references to
colour in this gure legend, the reader is referred to the web version of this article.)

H. Sarig Bahat et al. / Manual Therapy 20 (2015) 68e78

71

Fig. 4. Head pursuit task conducted with the VR system (right), and without (left- with laser pointer and poster), to train cervical motion control and accuracy. A similar concept
was applied in all training modules.

2.3.2.4. Patient satisfaction. Patient satisfaction: was measured by

asking the participants to rate their overall satisfaction with the
intervention on an 11-point scale (5 totally dissatised, 0 no
satisfaction, 5 totally satised)(Hurwitz et al., 2004).
2.3.2.5. Static balance. Static balance was measured using a
computerized, stable force platform (40  60 cm) (Kistler 9286AA,
North America) (Treleaven et al., 2005) using a test protocol
directed by previous studies (Treleaven et al., 2005; Field et al.,
2008). Participants were assessed with eyes closed while standing on a rm surface (on the force platform itself). Participants were
instructed to stand as steadily and quietly as possible with their
arms by their sides for 30 s. A customized Matlab program
calculated the root mean square of the total sway for the test in the
anterior-posterior direction. Measures of MDC and MCIC have not
been established.
2.3.2.6. Functional balance. Functional balance measures included
a single leg standing (SLS) task and the step test. The average
number of seconds (up to 30) the person could stand in single leg
stance with the eyes closed on the left and right leg was used to
assess SLS (Bohannon et al., 1984; Hill et al., 1996). The step test was
the number of times one foot was completely placed onto and off a
10 cm block within 15 s. This was performed with the left leg and
then the right. The average number of steps was calculated (Hill
et al., 1996; LowChoy et al., 2006). A change in score of 2 steps
has been shown to reect an MCIC (Tyson and Connell, 2009).
2.4. Procedure
Patients who met the inclusion criteria rst completed a general
questionnaire concerning their demographics and neck pain. They
also completed the NDI, VAS pain and TSK. In order to determine
any possible inuence on adverse effects of motion sickness a
0e100 mm visual analogue scale (VAS) was used to investigate the
average dizziness intensity during the last week. Higher scores
indicate greater intensity (0 no dizziness/, 10 worst dizziness
imaginable). Patients then completed the physical examination
consisting of the static and functional balance assessment and then
the 3 modules of the kinematic assessment. Kinematic assessment
was performed last in case of any adverse effects. One shortened
practice trial of each module was then conducted to familiarise the
patient and diminish the learning effect. Then the kinematic

assessment was performed. The order of the kinematic assessment

was ROM, velocity and accuracy. Rest breaks of approximately
2e5 min were given between the modules and extended if any
motion sickness was reported. Subjects only continued to the next
module if this subsided. Data was collected as to whether or not the
subject reported motion sickness (subjective report of feeling
nausea) whilst using the device.
At the post intervention assessment, the subjects completed the
same assessment and were also asked to complete the GPE, satisfaction rating and home exercise compliance level on a 4-point
scale (1 daily, 2 3e5 times per week, 3 1e2 times per
week, 4 did not exercise). At three months post-intervention
subjects completed all of the above apart from the patient satisfaction scale.
2.5. Stratication and randomization
Participants were stratied to either mild to moderate or severe
impairment of motor control on completion of the initial assessment. Severe impairment was dened as decits greater than two
standard deviations (SDs) of the mean for normative values for at
least two to three of the measures including ROM, velocity and
balance (Treleaven et al., 2003; Field et al., 2008; Sarig-Bahat et al.,
2010).
Treatment group allocation was made using a block randomization table generated by a computerised sequence according to
the stratied group. Allocation was concealed from the assessors as
each patient was nominated to their treatment group after the
completion of the assessment by one of the treating therapists.
Further, the group nomination was coded on the patients' les so it
remained concealed from the two assessors and the statistician
throughout the duration of the study.
2.6. Interventions
The KT group undertook a 30-min training session using a laser
pointer that was mounted on the participant's head and projected
onto a poster for feedback (Fig. 4). Kinematic training involved
active neck movements to increase ROM, quick head movement in
between targets to facilitate quick cervical motion control, static
head positioning while moving the body was used to advance head
stability, and smooth head movement following a target was used
to train accurate neck movement. These exercises were supervised

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H. Sarig Bahat et al. / Manual Therapy 20 (2015) 68e78

by the physiotherapist and performed in the clinic by the KT group,

and then encouraged to be performed at home. The kinematic
home exercises were tailored to each individual and their performance re-evaluated and progressed during each supervised
session.
The KTVR group undertook a total of 30 min of training, which
included 15e20 min using the VR device, interspersed with
10e15 min of kinematic training in preparation for home exercises.
This was done to ensure that both groups had opportunities to
learn their home exercises, and that participants in the KTVR group
had sufcient breaks from use of the VR device to limit motion
sickness. All participants were also requested to perform their
home training for 30 min, at least three times a week and to
continue this following completion of the supervised sessions until
the 3-month post-intervention. The VR training programme was
tailored to each participant and progressed according to the patients' performance. For example, the ROM module was used only
with patients who demonstrated limited ROM. To stimulate
maximal ROM, the system positioned targets further away
following each success. This commenced at 30 minimum,
increased to 50 in 5 increments, and then continued to increase in
3 increments until either the patient failed to reach a target 3
times or reached 80/90 (F-E/Rot). Further description of the VR
modules is provided in Figs. 1e4. In both groups training position
was progressed from sitting initially, to standing and to dynamic
positions on unstable surfaces which required dynamic stability in
addition to the required cervical task. In the VR training system,
range of motion was individually challenged by positioning targets
further away, velocity by reducing targets lifetime (the shorter time
a target appeared it required faster response), and accuracy by
increasing velocity of the moving target to pursuit in the accuracy
module. Patients were instructed to continue exercising at home
with the laser after the 6 intervention weeks until the3-months
follow up.
Three physiotherapists provided treatment in the study and all
were trained in the use and progression of the KT and VR training
by the principle investigator (HSB).
2.7. Statistical analysis
Data was explored for normality and the majority of variables
were found to be normally distributed. Thus parametric statistics
was used. Within-group differences between pre- and postintervention, and pre- and 3-month-post-intervention were evaluated for each group using a paired two-tailed t-test. Betweengroup differences were compared using an independent twotailed t-test. Between-group analysis compared the differences
between pre- and post-interventions, and pre-intervention and 3month post-intervention. Cohen's d was calculated to determine
the effect size (Cohen, 1988). Due to the exploratory nature of this
pilot, no adjustments were made with regard to multiple tests, in
order not to lose sensitivity to potentially interesting effects, even
at the risk of increased Type I error. Intention-to-treat analysis was
not used in this pilot study as the small sample sizes and impact of
any dropouts on interpretation of data was likely to be considerable. Signicance level was set at 5%. Descriptive analysis with
mean SD was used to present results unless specied. SPSS and
SAS were used for statistical analysis.
3. Results
3.1. Baseline measures
Thirty-two participants with chronic neck pain were randomly
assigned to the two intervention groups. Five were stratied as

severely impaired (three of which were admitted to the KTVR and

two to the KT group). Fig. 5 describes the ow of patients
throughout the study.
Table 1 demonstrates patients' characteristics in each group.
Overall, patients presented with high chronicity, mild pain intensity, mild to moderate disability levels, and mild to moderate
fear of motion. In regards to medication intake, 45% of patients
reported regularly taking medication- 7 took pain control medication, 8- systemic medication (e.g. for hypertension, hypercholesterol, hormonal therapy etc), and 5 reported regular intake
of anti-depressants. Patients did not receive additional physiotherapy during the intervention period. There were no signicant
differences between the groups at baseline (P > 0.05) in all demographics or outcome measures except for RR TTP%, which was
signicantly greater in the KT group (Table 2a and 2b).
3.2. Within-group differences
Table 2a and 2b presents the within-group changes within each
intervention group for each outcome measure in pre-, postintervention, and 3-month post-intervention. Changes pre- to
post-intervention within the groups demonstrated that both
groups improved in the primary outcome measures. Both signicantly improved in NDI immediately post-intervention, but at 3month post-intervention only the KTVR group maintained this
improvement (Tables 2a and 2b). Both groups had signicant improvements in ROM in rotation left and right and exion at both
immediate and three months post intervention, apart from exion
in the KT group post intervention. The only improvement in
extension ROM was in the KTVR group at 3-month postintervention. Immediately post-intervention, the KTVR group
improved signicantly in 9/14 velocity module measures compared
to 2/14 in the KT group (Tables 2a and 2b). At 3-months postintervention the KTVR group improved in 5/14 compared to 9/14
velocity module measures in the KT group. In accuracy for rotation,
improvement was seen for both groups at both time points apart
from KTVR post-intervention. In accuracy for exion/extension
both groups improved at 3 months post intervention. All signicant
differences demonstrated a medium (absolute d between 0.5 and
0.8) to large effect size (absolute d  0.8) (Cohen, 1988), with one
exclusion where a small (d 0.39) effect size (Cohen, 1988) was
found for mean velocity in extension at 3-month post-intervention.
Fig. 6 presents improvements in velocity and accuracy during the
course of the study in a single patient example.
Changes in secondary outcome measures between pre-and
post-interventions within the groups demonstrated that both
groups improved in the step test at both time points (Table 2a).
Both groups reported an improvement in global perceived effect,
and expressed good satisfaction from therapy and recovery post
intervention (Table 3). At 3 months post, the KTVR group demonstrated a signicantly greater improvement in GPE (Table 3). At
post-intervention only the KTVR group improved signicantly in
VAS (Table 2a and 2b). At no point were there any signicant differences pre- to post in the TSK.
3.3. Between-group differences
There were six variables with signicant between-group differences and with a large effect size (absolute d  0.8). Two related
to greater improvement in the KTVR group, which included exion
ROM post-intervention and greater GPE at 3-months postintervention (Table 3).
Four variables related to greater improvement in rotation velocity and ROM in the KT group (one at post- and three at 3-month
post-intervention).

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73

Fig. 5. Flow chart describing the numbers of participants for each group, from recruitment, to group allocation, treatment, follow up and analysis, including drop outs and reasons.

3.4. Exercise compliance and number of treatments

There was no difference in the average number of treatments
received (KTVR mean 4.81 0.23 KT mean 5.43 0.23). On average
there was no difference between self-reported exercise compliance
between the groups (KTVR mean 2.06 0.23 KT mean 2.14 0.25)
which suggests that on average they exercised 3e5 times per week.
3.5. Side effects
Four participants experienced motion sickness with the use of
the VR device during assessment. Two participants reported motion sickness prior to randomization, and therefore were excluded.
Two other participants experienced delayed motion sickness (up to
24 h after assessment) and after being randomized to the KT group
and hence withdrew from further participation. There were no
reports of pain exacerbation.
4. Discussion
4.1. Overall the results of this pilot study demonstrated several
signicant changes pre to post intervention within both groups but
few differences between the groups
Within group analysis demonstrated pre to post intervention
improvements after kinematic training with and without the use of
the VR device with some suggestion that the group using the virtual

reality device may have some advantages in the short term for pain
intensity, neck disability, ROM, and fast neck motion control and
longer term for global perceived effect 3 months post intervention.
Nevertheless, direct comparison between the groups suggested
that the KTVR was not superior to the KT training.
The lack of between group ndings may have been due to the
KTVR group not receiving sufcient therapy with the VR device. In
this study, the KTVR group used the device for 15e20 min per
session and participants were not provided with the device for
home use. In addition, this group performed the same home

Table 1
Patients' characteristics by groups.
Parameter

KTVR group
(N 16)

KT group
(N 16)

Age (years)
Duration of neck pain
(months)
100 mm-Dizziness Visual
Analogue Scale
Gender: females, males
Aetiology: idiopathic neck
pain, traumatic neck pain
Symptoms distribution:
bilateral symptoms,
unilateral symptoms

40.63 14.18
98.06 96.81

41.13 12.59
87.31 111.99

18.31 27.6

10.02 17.6

11,6
12, 5

11,5
10, 6

7, 9

8,8

KTVR e kinematic and virtual reality training; KT e kinematic training.

Values are presented with mean SD or numbers.

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H. Sarig Bahat et al. / Manual Therapy 20 (2015) 68e78

Table 2a
Within group changes in the KTVR group, presenting results of the pre-, post- and three-month post-intervention assessment.
Phase

Pre-intervention

Measure

Mean SD

Subjective
Pain intensity (VAS, 0e100mm)
Neck Disability Index (%)
TSK (0e68)
VR Kinematics
ROM
Flexion
Extension
Right Rotation
Left Rotation
Peak velocity
Flexion
Extension
Right Rotation
Left Rotation
Mean velocity
Flexion
Extension
Right Rotation
Left Rotation
TTP%
Flexion
Extension
Right Rotation
Left Rotation
Sway SD
Pitch
Yaw
Accuracy
Pitch
Yaw
Sensorimotor
Eyes closed balance
Single leg stance
Step test

N 16
35.72 17.7
20.38 7.6
32.75 6.8
N 16
38.69 14.6
48.72 15.1
62.32 13.1
58.58 15.3
52.32 20.6
56.36 38.9
66.99 35.8
72.75 30.8
20.86 9.3
28.47 21.0
29.63 16.5
30.95 12.0
24.59 11.2
30.27 12.2
22.28 11.8
35.36 18.7
0.47 0.2
0.53 0.1
14.39 5.7
11.45 4.5
N 16
28.05 15.3
16.72 10.4
16.16 3.7

Post-intervention
Mean SD
N 16
22.10 24.1*
12.85 7.5**
30.13 5.7
N 16
57.31 11.3**
57.45 14.1
71.84 14.0**
77.74 16.0**
71.40 26.6**
80.23 38.2**
85.35 41.7*
102.16 52.6**
28.82 15.4
42.23 25.3*
41.06 16.0*
48.10 19.9**
21.98 13.9
43.39 25.7*
31.40 19.8*
47.66 22.8
0.40 0.1
0.53 0.1
16.68 15.9
13.66 17.1
N 16
26.67 11.6
20.18 10.3
17.97 3.8**

Three-month post-intervention

Cohen's d

Mean SD

Cohen's d
N 14

0.65
0.99
0.42

26.95 16.5
13.57 7.9**
31.23 6.5

0.51
0.88
0.23
N 11

1.44
0.60
0.70
1.22
0.81
0.62
0.47
0.71
0.65
0.59
0.70
1.08
0.21
0.69
0.58
0.59
0.50
0.00
0.21
0.20

55.38
57.64
72.04
70.38
64.78
68.84
70.48
77.72
21.56
35.55
33.41
40.37
17.14
35.69
30.07
42.17
0.44
0.43
10.96
7.60

0.10
0.33
0.49

31.73 19.2
17.76 9.0
19.39 2.3**

1.26
0.71
0.68
0.68
0.70
0.40
0.12
0.18
0.08
0.39
0.22
0.64
0.64
0.42
0.43
0.31
0.20
1.07
0.81
0.95

11.2**
8.8*
16.2*
20.6*
13.5**
19.6**
19.1
23.3
9.2
14.3*
17.4
18.6
12.2*
14.0
27.3
26.8
0.1
0.1**
2.1*
3.3*
N 11

0.22
0.11
1.04

KT e Kinematic training group; KTVR e kinematic and virtual reality training group; VAS e visual analogue scale for pain intensity; TSK e TAMPA scale of kinesiophobia; ROM
e range of motion; TTP e time to peak velocity in percentage; Sway SD e standard deviation of the static head sway, during the 3 s wait in mid-position prior to the appearance
of each VR target in the velocity module; Pitch e up/down displacement in the sagittal plane; Yaw e side to side displacement in the horizontal plane; Cohen's d provides a
value for size effect of the pre- minus post-intervention analysis within groups. Positive d values indicate that the post-value was smaller, e.g. VAS, NDI, TSK, and negative ds
indicate the post value was larger, e.g. ROM and kinematics. Bold values indicate a signicant advantage; * P < 0.05, ** P < 0.01 indicating signicant difference pre- to postintervention within group analysis.

programme as the KT group. Similarly, when the supervised

treatment sessions ceased, the KTVR group performed the same
unsupervised home exercises as the KT group. Another limitation of
the between-group results is that the kinematic assessment used
the same VR system that was used for training. This could have
biased the VR group in favour, which may be relevant in the postintervention assessment, but the results indicate that in 3 months
follow up such advantage was not present.
The results of this pilot study also suggest that four to six sessions over ve weeks of a kinematic training regime delivered with
a laser beam for feedback (KT group), or with an interactive VR
device (KTVR group), may have led to the immediate improvements in neck disability as well as several kinematic variables
associated with ROM, velocity and accuracy. Continued unsupervised home kinematic exercises appeared to lead to further improvements in cervical motion accuracy and static head control, 3
months post-intervention. In addition a positive global perceived
effect and good satisfaction with the treatment was noted. Nevertheless, due to the lack of a control group, we are unable to
determine whether or not the pre- to post-intervention changes
may be the result of a placebo effect for example. In spite of this
limitation, the signicant kinematic differences found were of
medium to large effect size indicating that the change is statistically
correct. Any marginally signicant/trend effect could possibly be
due to multiplicity of tests, and, of course, further research is
necessary. However, ROM for rotation improved by at least 10 up
to 38 in each direction, and were more consistent than improvements in the sagittal plane, although, in the majority of cases, improvements were greater than the MCD of 6.5 (Audette et al.,

2010). Velocity measures increased in the majority by 10e20 per

second in each direction, with some exceeding 20 per second.
Further, intervention studies for neck pain that have used ROM as
an outcome measure seem to demonstrate less or similar
improvement (Hoving et al., 2006; Huang et al., 2010). Although
these studies used somewhat different methodologies and populations, it seems that the similarities in ndings may provide
support to the reported ndings and the possibility that the intervention was effective and warrants future studies on KT and
comparing this type of training to a control and other evidencebased interventions.
The possible effectiveness of this training regime on neck kinematics and neck pain and disability may be explained by improvements in the person's ability to move the head further and
more quickly and accurately. Thus advancing ne motor control and
co-ordination and enhancing neural connections between the eyes,
neck and the vestibular systems, which is an important function of
the neck. . In addition, the use of an external focus of attention
(either the VR or laser), rather than an internal focus, may have led
to advances in motor learning and performance and be an important feature of kinematic training (Wulf et al., 1998, 2001; McNevin
et al., 2003; Zachry et al., 2005).
However, whilst there was some improvement noted in neck
pain and disability and neck pain, the only time that these values
reached the MCIC of 7% for NDI was for the KTVR group (7.5%) post
intervention, the KT group almost reached this at 6.8%. This nding
rez et al.,
is not unusual in intervention studies in neck pain (Pe
2014), although others have demonstrated signicant and clinically relevant improvements in NDI (Hoving et al., 2006). This

H. Sarig Bahat et al. / Manual Therapy 20 (2015) 68e78

75

Table 2b
Within group changes in the KT group, presenting results of the pre-, post- and three-month post-intervention assessment.
Phase

Pre-intervention

Measure

Mean SD

Subjective
Pain intensity (VAS, 0e100mm)
Neck Disability Index (%)
TSK (0e68)
VR Kinematics
ROM
Flexion
Extension
Right Rotation
Left Rotation
Peak velocity
Flexion
Extension
Right Rotation
Left Rotation
Mean velocity
Flexion
Extension
Right Rotation
Left Rotation
TTP%
Flexion
Extension
Right Rotation
Left Rotation
Sway SD
Pitch
Yaw
Accuracy
Pitch
Yaw
Sensorimotor
Eyes closed balance
Single leg stance
Step test

N 16
35.17 16.7
20.19 6.5
30.38 5.8
N 16
43.94 14.3
51.09 13.2
57.06 16.6
57.94 15.3
50.81 18.8
57.88 21.9
68.54 24.8
81.32 27.1
20.53 9.1
32.08 13.4
35.37 12.9
38.54 13.7
38.44 12.8
24.11 11.1
31.61 12.0
50.48 28.4
0.44 0.1
0.50 0.1
15.39 3.5
11.98 3.3
N 16
24.23 20.1
17.19 9.3
16.63 4.2

Post-intervention
Mean SD

Three-month post-intervention

Cohen's d

Mean SD

N 14
27.72 21.9
14.00 8.5*
28.64 9.9
N 12
17.2
12.8
10.6**
13.6*
20.7*
24.1*
36.8
135.7
13.3
15.9
18.8
82.1
22.2
11.6
13.6
28.8
0.1
0.1
4.6
1.7**
N 14
25.08 17.3
18.17 10.0
18.69 3.4**

49.87
54.19
77.21
72.58
72.48
80.41
90.27
140.94
29.14
44.62
46.22
72.90
46.77
23.37
29.17
56.92
0.41
0.45
13.30
8.74

Cohen's d
N 12

0.39
0.83
0.23

30.33 18.5
17.00 15.1
30.00 5.9

0.28
0.31
0.06
N9

0.38
0.24
1.43
1.00
1.10
0.99
0.73
0.81
0.79
0.87
0.70
0.80
0.50
0.07
0.19
0.23
0.23
0.45
0.52
1.26

58.40
54.50
88.89
84.26
63.81
67.62
87.2
107.7
25.86
36.60
52.25
52.47
43.09
21.31
48.46
50.54
0.36
0.47
11.07
6.18

0.05
0.10
0.54

27.87 32.1
15.74 11.4
19.64 3.8*

1.09
0.27
1.74
1.45
0.83
0.51
0.76
0.92
0.58
0.39
1.36
1.05
0.34
0.24
1.35
0.00
0.74
0.30
1.15
2.15

11.4*
11.0
21.4*
23.3*
10.2**
14.3**
24.2**
31.3*
9.6
8.1*
11.5**
12.4**
15.4
12.2
13.5**
23.1
0.1*
0.1
4.2*
1.7**
N9

0.15
0.14
0.75

KT e Kinematic training group; KTVR e kinematic and virtual reality training group; VAS e visual analogue scale for pain intensity; TSK e TAMPA scale of kinesiophobia; ROM
e range of motion; TTP e time to peak velocity in percentage; Sway SD e standard deviation of the static head sway, during the 3 s wait in mid-position prior to the appearance
of each VR target in the velocity module; Pitch e up/down displacement in the sagittal plane; Yaw e side to side displacement in the horizontal plane; Cohen's d provides a
value for size effect of the pre- minus post-intervention analysis within groups. Positive d values indicate that the post-value was smaller, e.g. VAS, NDI, TSK, and negative ds
indicate the post value was larger, e.g. ROM and kinematics. Bold values indicate a signicant advantage; * P < 0.05, ** P < 0.01 indicating signicant difference pre- to postintervention within group analysis.

Fig. 6. (a) An example of neck movement velocity improvement of one participant's data output using the VR device. The participant was required to align the virtual pilot with a
yellow target as quickly as possible with head movement in various directions. These plots demonstrate faster neck motion in the post-intervention phase (right) as compared with
pre-intervention (left). (b) An example of neck movement accuracy improvement of one participant's data output using the VR device. Head movement accuracy was dened as the
difference between the target trajectory (the target moved in a constant velocity of 10  /s), and the player trajectory. The plots demonstrate the pre- to post-intervention
improvement as there is more overlapping between the player and target trajectories in post-intervention, reecting the higher accuracy of head movement. (For interpretation of the references to colour in this gure legend, the reader is referred to the web version of this article.)

76

H. Sarig Bahat et al. / Manual Therapy 20 (2015) 68e78

Table 3
Between group mean and SD differences, analysed by comparing deltas in groups: post minus pre intervention, and 3 months minus pre intervention.
Delta analysed

Post-pre intervention

Group

KTVR

Measure

Mean

SD

Mean

12.52
7.76
2.13

19.5
6.2
4.2

7.66
5.64
1.50

20.2
7.0
8.3

0.25
0.32
0.10

2.59
4.03

0.3
0.3

2.11
3.38

0.4
0.4

1.43
1.97

18.62*
8.73
9.52
19.16
19.08
23.87
18.37
29.41
7.96
13.77
11.44
17.14
2.61
13.13
9.12
12.30
2.21
0.55
2.29
0.88

13.4
17.1
12.8
17.6
19.1
30.8
29.7
34.8
16.5
20.2
17.8
18.1
16.5
23.3
17.1
27.3
13.7
3.2
12.4
2.9

5.79
1.68
21.18*
17.14
22.05
28.67
26.99
65.99
7.64
14.91
13.26
35.76
0.41
10.37
2.27
1.24
2.29
0.68
1.12
1.35

19.1
16.2
13.2
19.2
31.8
29.6
42.7
138.3
18.8
19.2
25.0
86.1
14.3
23.7
16.4
33.2
4.3
3.3
6.5
4.3

0.79
0.42
0.90
0.11
0.12
0.16
0.24
0.42
0.02
0.06
0.09
0.36
0.20
0.12
0.68
0.37
0.50
0.37
0.36
0.61

19.01
11.92
12.36
12.84
15.10
19.30
7.59
6.76
2.03
9.89
6.61
11.25
9.97
5.65
8.66
8.44
0.98
6.55
5.94
0.52

1.39
3.47
1.81

20.7
7.3
1.3

1.07
1.76
0.86

25.9
7.7
8.6

0.11
0.23
0.19

3.00
1.26
3.44

Subjective
Pain intensity (VAS, 0e100 mm)
Neck Disability Index (%)
TSK (0e68)
Global Perceived change
Global perceived effect
Overall satisfaction with treatment
VR Kinematics
ROM
Flexion
Extension
Right rotation
Left rotation
Peak velocity
Flexion
Extension
Right rotation
Left rotation
Mean velocity
Flexion
Extension
Right rotation
Left rotation
TTP%
Flexion
Extension
Right rotation
Left rotation
Sway SD
Pitch
Yaw
Accuracy
Pitch
Yaw
Sensorimotor
Eyes closed balance
Single leg stance
Step test

Three months- pre intervention

KT

Cohen's d
SD

KTVR

KT

Mean

SD

7.77
6.92
1.23

16.6
6.0
6.8

2.27*
0.25

Cohen's d

Mean

SD

7.07
3.42
0.92

19.9
14.9
4.5

0.04
0.34
0.06

0.25
e

0.7
e

13.7
13.3
15.9
18.9
12.6
15.6
16.4
23.9
11.6
13.9
15.6
18.7
13.4
19.4
23.0
31.2
3.0
6.7
5.9
4.0

15.70
1.38
37.48
38.95
19.46
22.69
36.36*
40.07*
4.77
9.62
27.30*
14.28
6.76
6.89
22.61
21.23
1.77
0.57
2.96
0.84

17.8
18.7
30.7
30.6
17.2
22.5
34.7
43.3
14.7
13.6
17.6
18.8
16.1
18.1
13.4
10.2
7.4
9.9
4.5
3.2

0.21
0.66
1.08
1.05
0.29
0.18
1.13
0.99
0.21
0.02
1.24
0.16
0.22
0.07
0.77
1.43
0.53
0.72
0.57
0.38

22.6
8.1
2.7

0.35
0.89
2.93

22.6
8.1
2.7

0.12
0.26
0.19

0.5
0.7

3.64

KT e Kinematic training group; KTVR e kinematic and virtual reality training group; VAS e visual analogue scale for pain intensity; TSK e TAMPA scale of kinesiophobia; ROM
e range of motion; TTP e time to peak velocity in percentage; Sway SD e standard deviation of the static head sway, during the 3 s wait in mid-position prior to the appearance
of each VR target in the velocity module; Pitch e up/down displacement in the sagittal plane; Yaw e side to side displacement in the horizontal plane; NR e not relevant;
Cohen's d provides a value for size effect of the pre- minus post-intervention analysis within groups. Positive d values indicate that the post-value was smaller, e.g. VAS, NDI,
TSK, and negative ds indicate the post value was larger, e.g. ROM and kinematics. Bold values indicate a signicant advantage, P < 0.05. Global perceived effect was measured
using an 11-item tool: 5 vastly worse, 0 no change, 5 completely recovered; Overall satisfaction with treatment was measured using an 11-item tool: 5 totally
dissatised, 0 no satisfaction, 5 totally satised.

nding in the current study may have been due to the relatively low
VAS scores (mean 35 mm) and lower NDI mean scores (20%) and
future studies should consider higher inclusion criteria for these
variables. Nevertheless the study demonstrated a positive global
perceived effect post intervention, for both groups and at three
months post for the KTVR group, which is thought to be an
important relevant outcome measure for people with neck pain
(Evans et al., 2014).
Improvements were also seen in the functional balance step
test, which reached the MCIC for both groups at both time points.
There was however no improvement in fear of movement, as
measured by the TSK, which was predicted to be important in KTVR
due to its known ability to assist in the distraction from pain and
decrease anxiety. This could have been due to a lack of substantial
fear of movement seen in participants in this trial. Future research
looking at the effect of VR kinematic training in those with significant fear of movement is also warranted.
4.2. Future research
Future research should establish the denitive efcacy of KT by
comparing it to a control group to determine if placebo effect or
natural change effects are possible contributors to the observed
changes. The benets of kinematic training over other evidenced

based exercise interventions for neck pain should also be further

explored.
Future research should establish a normative data base of neck
kinematics and cut offs for each measure to allow relevant treatment prescription by classication, i.e. each patient will be assessed
for kinematic impairments and treatment will be oriented by the
ndings. This will prevent a possible wash out effect such as may
have presented here, where all patients receive uniform treatment
to address all impairments, while it was not relevant to some patients. Once such thresholds will be dened, future studies should
provide training modules only when relevant to the impairment
identied.
Future provision of home VR units to the KTVR group will help
overcome the limitation of restricted exposure to VR in the clinical
setting and allow exploration of the benets of home KTVR
training. This has potential relevance for tele-medicine and
remote health care, as the VR device offers an interactive and
progressive assessment and training of cervical movement kinematics. The results suggest potential use of the VR device for telemedicine and remote assessment and training of cervical kinematics in patients with chronic neck pain of mild-moderate intensity (Eysenbach, 2001), but also provided potential for the use
of a less sophisticated method of kinematic training using a simple
laser.

H. Sarig Bahat et al. / Manual Therapy 20 (2015) 68e78

However, prior to the implementation of remote use of the VR

device, future research should investigate the effect of home VR
therapy, and consider the possible side-effects of motion sickness
and dizziness associated with KTVR training. At the moment, it is
difcult to accurately anticipate those who have a high risk of
motion sickness due to virtual reality (Takasaki et al., 2013) unless
an actual VR assessment is conducted. Interestingly, six subjects in
the KTVR group, who reported more signicant dizziness (20e60/
100 mm VAS), did not experience motion sickness with the use of
the VR and instead had improved dizziness post-intervention.
Overall, it appears that dizziness at baseline is unlikely a predictor of motion sickness with VR use. Thus, future studies could use a
motion sickness scale such as the Modied Motion Sickness
Assessment Questionnaire (M-MSAQ) (Brooks et al., 2010), and
further investigation into the possible causes and predictors of
motion sickness associated with VR use and the potential benecial
effects of KTVR in the reduction of dizziness symptoms are
warranted.
4.3. Limitations
There are several limitations of this study. Despite the fact that
the participants had chronic neck pain, their pain intensity and
associated disability were only mild to moderate. This may have
created a ooring effect to response to treatment. It is unknown
whether the effects would be similar in a group with more severe
pain and disability. Another limitation was there was no control
group, however, our improvements in ROM and NDI were above
minimal clinically important difference reported (Pool et al., 2007;
Audette et al., 2010) which suggests their clinical relevance and that
it is likely that the improvement was achieved by the interventions
rather than a placebo effect or natural recovery.
This study includes multiple measures which may seem too
many for this sample size. However, this contributes new knowledge of movement characteristics in 4 directions unlike previous
studies that looked at one direction. The large effect size suggests
that in spite of the number of measures, ndings of signicant
differences were valid. Future study may limit this number by half
by looking at two planes rather than 4 directions, and including
outcome measures which will demonstrate highest accuracy.
An additional limitation relates to the assessment of kinematic
measures which used the same VR system that was used to train
the VR group. This may have had a different effect in between
groups due to a learning effect in the VR group for kinematic
measures, however, differences in other outcome measures such
as the NDI and GPE would suggest that this was not the case. A
nal limitation is that we included a non-supervised home exercise programme in the post-intervention period, which is
customary in normal clinical practice but not in controlled trials.
It could be argued that this limits the interpretation of the results
in the intermediate term as it is unknown whether the results
would have lasted if home exercises were discontinued postintervention.
5. Conclusion
Kinematic training exercises designed to provide an external
focus of attention and delivered with or without an interactive VR
device, appeared to improve neck disability, cervical motion kinematics, dynamic balance, global perceived effect and patient
satisfaction rates in people with mild-moderate chronic neck pain.
This was seen immediately post-intervention and for some measures up to 3-months post-intervention, when participants were
encouraged to continue unsupervised home exercises. There were
few between-group differences, which might be related to limited

77

exposure of VR device in the KTVR group. This research has provided several directions and justication for future research
exploring the potential benet of both KTVR and KT interventions
in those with neck pain in a larger cohort.
Acknowledgements
Our gratitude is extended to Prof. Gwen Jull and Dr. Elliot
Sprecher for their professional support, and to the Faculty of Health
sciences, University of Haifa for their nancial support.
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