Cervicothoracic Mechanical Impairment as Part of Complete Neurological Fall Risk Appraisal

Abstract

Background: Assessment of individuals at risk for falling entails comprehensive neurological and vestibular examinations. Chronic limitation in cervical mobility reduces gaze accuracy, potentially impairing navigation through complex visual environments. Additionally, humans with scoliosis have altered otolithic vestibular responses, causing imbalance. We sought to determine whether dynamic cervical mobility restrictions or static cervicothoracic impairments are also fall risk factors. Methods: We examined 435 patients referred for soft-tissue musculoskeletal complaints; 376 met criteria for inclusion (mean age 52; 266 women). Patients were divided into nonfallers, single fallers, and multiple fallers, less or greater than 65 years old. Subject characteristics, dynamic cervical rotations, and static cervicothoracic axial measurements were compared between groups. Fear of falling was evaluated using the Falls Efficacy Scale-International questionnaire. Results: Long-standing cervicothoracic pain and stiffness conferred increased risk of falling. Neck rotation amplitudes decreased with longer duration musculoskeletal symptoms and were significantly more restricted in fallers, doubling the risk of falling and contributing to increased fear of falling. Mid-thoracic scoliosis amplitudes increased over time, but static axial abnormalities were not greater among fallers, although thoracic kyphoscoliosis heightened fear of falling. Conclusion: In patients at fall risk, thoracic kyphoscoliosis and dynamic neck movements should be assessed, in addition to standard vestibular and neurological evaluations. Additionally, patients with soft tissue cervicothoracic pain and restricted mobility have increased fall frequency and fear of falling, independent of other fall risk factors and should undergo complete fall risk appraisal.

The relationship of cervicothoracic mobility restrictions to fall risk and fear of falling in ankylosing spondylitis

“…Both acute and chronic neck pain cause imbalance through the disruption of cervical proprioceptive signals ( 15 – 17 ). Patients with chronic soft tissue pain and stiffness involving the neck, shoulders, and upper thorax are at increased risk for falls ( 18 ). Similar restrictions in the head and neck movements are seen in AS and are thought to result from cervical muscle hypertonicity occurring early in the course of the disease and underlying disease initiation and progression ( 2 ).…”

“…Physiologically, chronic cervical immobility prolongs vestibulo-ocular reflex suppression during eye–head movements causing diminished gaze accuracy ( 19 ), potentially impairing navigation through complex visual environments where it is essential to accurately redirect gaze to novel targets. Practically, diminished neck rotation amplitudes double the risk of falling and contribute to increased fear of falling ( 18 ). Static axial deformities can also cause imbalance ( 20 – 22 ) but do not cause falls ( 18 ); rather thoracic kyphoscoliosis heightens fear of falling likely related to the impairment of trunk muscle co-activation needed to modulate gait-induced oscillations when walking ( 23 ).…”

“…Practically, diminished neck rotation amplitudes double the risk of falling and contribute to increased fear of falling ( 18 ). Static axial deformities can also cause imbalance ( 20 – 22 ) but do not cause falls ( 18 ); rather thoracic kyphoscoliosis heightens fear of falling likely related to the impairment of trunk muscle co-activation needed to modulate gait-induced oscillations when walking ( 23 ).…”