Manual Therapy 15 (2010) 445e450

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

Original article

Head movement kinematics during rapid aiming task performance in healthy and
neck-pain participants: The importance of optimal task difculty
Martin Descarreaux a, *, Steven R. Passmore b, c, Vincent Cantin d
a
Universite du Quebec a Trois-Rivieres, Titulaire de la Chaire de Recherche en Chiropratique FRCQ e Systeme Platinum,
Departement de Chiropratique 3613 Pavillon de Chiropratique, Trois-Rivieres, QC, Canada G9A 5H7
b
McMaster University, Hamilton, Ontario, Canada
c
New York Chiropractic College, Seneca Falls, NY, USA
d
Dpartement des sciences de l'activit physique, Universit du Qubec Trois-Rivires, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: Head repositioning tasks have been used in different experimental and clinical contexts but
Received 29 October 2009 have yet to offer insight as to the task performance strategy. The purpose of this study was to explore the
Received in revised form kinematics from a head aiming task that encompasses a Fitts' task in neck pain patients and healthy control
16 February 2010
subjects.
Accepted 23 February 2010
Methods: Chronic neck pain patients and healthy individuals were compared in a head aiming task.
Participants were asked to move their head as quickly, and precisely as possible to a target under 4
Keywords:
different experimental conditions. Dependent variables included movement time, movement time vari-
Fitts' task
Neck pain
ability, acceleration phase duration, deceleration phase duration and absolute positioning error.
Head repositioning Results: The chronic neck pain patients, when compared to healthy participants showed a signicant
Motor control increase in movement time and deceleration phase duration for the small target/large movement ampli-
tude condition. No group difference was observed for movement time variability, acceleration phase
duration and absolute positioning errors.
Conclusions: Decreased motor performance was observed in chronic neck pain patients during the most
challenging cervical pointing task condition. These results may imply that in order for a performance
based outcome measure to yield observable differences conditions that meet or exceed the optimum
challenge point of the population tested should be employed.
2010 Elsevier Ltd. All rights reserved.

1. Introduction Numerous approaches to measure head-repositioning have been

Neck pain intensity is not easily quantiable in subclinical or
intermittent pain populations (Lee et al., 2008). In the measurement
of neck pain beyond the use of goniometry, and self reported
disability indices, there is an interest in the pursuit of developing
more objective quantitative measures of functional assessment
(Sjolander et al., 2008; Passmore et al., 2010). Jerk index is a way of
measuring the smoothness of movement; it's calculation normalizes
jerk cost related to angular excursion and movement time (Kitazawa
et al, 1993). Jerk index, and range of motion variability have been
identied as potential techniques to differentiate neck pain patients
from asymptomatic participants (Sjolander et al., 2008) as has head
repositioning accuracy (Revel et al., 1991; Kristjansson et al., 2003).
* Corresponding author.
E-mail address: martin.descarreaux@uqtr.ca (M. Descarreaux).
applied to populations with neck pain. Revel's Approach, (Revel et al.,
1991) is an active head repositioning technique utilizing visual
measurement of error in degrees when attempting to return the head
to neutral following rotation. When Revel's approach was compared
with the use of three-dimensional ultrasound for head repositioning,
it was determined that both of these techniques while unique, are
efcient at discriminating participants with neck pain, from asymp-
tomatic individuals (Roren et al., 2009). Absolute error calculated
from position data of movements into exion, or bilateral rotation
yielded signicant differences in ability to return to a predened
neutral head posture in populations with neck pain when move-
ments were recorded by an ultrasound-based motion analysis system
(Lee et al., 2008). In addition, more frequent episodes (weekly as
opposed to monthly) of neck pain lead to signicantly greater head
repositioning errors (Lee et al., 2008). While these approaches can
differentiate between the presence or absence of pain, they have so
far offered incomplete insight as to the task performance strategy, or
difculty in application when utilized to assess cervical spine

1356-689X/$ e see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2010.02.009
446 M. Descarreaux et al. / Manual Therapy 15 (2010) 445e450
movement (Roren et al., 2009). As a further cautionary note, Grip et al.
(2007), have stated they found only modest differences comparing
participants with non-traumatic neck pain, and whiplash associated
disorders to a control group through a head repositioning protocol. As
a result they suggest that for the most accurate result such techniques
should be utilized in tandem with additional objective measures.
To extend our understanding of functional cervical spine
performance the use of goal oriented, established, motor control
paradigms have been applied to measuring movement parameters.
In using a self selected target in a recent head repositioning study
Lee et al. (2008) attempted to integrate a phase where participants
were required to move to a self selected target, (that bisected their
neutral head posture and maximum range of motion). Their results
for absolute error comparing the self selected angle to the angle
observed including movements into exion, extension, and bilat-
eral rotation did not attain signicance. In this study participants
had been asked to move slowly, which may have had ramications
on their results. In a similar study, when age was taken into
consideration and a group of young adults, was compared to older
adults in their ability to perform a head repositioning task,
a statistically signicant error score was noted into rotation with
a self selected target that was larger in the older population
(Teng et al., 2007).
By rigidly predening a uniform movement amplitude across
participants, and altering target width performance details may be
isolated. Specically the applications of Fitts' Law to head move-
ment tasks that can replicate the paradigm have been employed
successfully, in non-pathologic populations, across a spectrum of
ages (Passmore et al., 2007). A Fitts' task has an alterable index of
difculty (ID), which is attained by manipulation of one or both the
amplitude of the movement, and/or the size of the target location
one aims to as quickly and accurately as possible and movement
time (MT) is measured (Fitts, 1954). Specically for a Fitts' task the
index of difculty (ID), is measured in bits, as the log2(2A/W). The
letter A denotes of the movement amplitude from home position to
target, and W denotes target width. According to Bootsma and
colleagues (2004), in the fty years since the formulation of Fitts'
Law, the relationship between ID and MT is considered one of the
most robust in terms of being resistant to changes in context, and
remains one of the most popular and powerful paradigms in the
eld of experimental psychology. It is possible that through the
application of a Fitts' task, to a population with neck pain, mean-
ingful functional measurement may be attained. Through dissect-
ing the kinematic, and kinetic details from this goal oriented
movement task it may be possible to illuminate aspects relating to
the functional disability of people with non-traumatic neck pain.
Proprioceptive and motor control decits may serve as better tools
to dene impairment related to cervical spine pain, than attempt-
ing to measure pain itself in isolation (Michaelson et al., 2003;
Sjolander et al., 2008).
The purpose of the current study was to apply kinematic, and
endpoint measures derived from a head reorientation task that
encompasses a Fitts' task and thus also includes measures of
movement time. This task was applied to a population with non-
traumatic neck pain and compared their performance to a healthy
control group. Interpretation of kinematic data, addresses the
shortcomings described not only in the (Lee et al., 2008; Roren et al.,
2009) head repositioning work, but also in the Passmore et al. (2010),
and Passmore et al. (2007) studies. This kinematic approach to Fitts'
task may be used to measure both the quantity of motor perfor-
mance (end result), but also the quality of performance (how the end
result was attained). In extension to the Passmore et al. (2010), and
Passmore et al. (2007) work the present study utilizes the applica-
tion of a head performed Fitts' task to a clinically symptomatic
population.
2. Methods
2.1. Participants
A total of 39 participants were recruited for this study. The chronic
neck pain group (n 19) included individuals with non-traumatic
chronic neck pain. Inclusion criteria consisted of having experienced
at least one episode of neck pain in the last 6 months, suffering from
neck pain on a persistent or recurrent basis and having no history of
trauma or accident involving the cervical or upper thoracic spinal
regions basis (Nachemson and Jonsson, 2000). The exclusion criteria
included rheumatoid arthritis, presence of upper limb neurological
signs or symptoms or any history of pathology or surgery involving
the cervical spine. Twenty healthy participants without any prior or
current experience of spinal pain, cervicobrachial pain or other
diffuse pain conditions were included in the study to form the control
group. All participants were recruited from the university outpatient
clinic and the broader university community. After an initial
screening, subjects provided written informed consent prior to
laboratory testing as approved by the local ethic committee. Neck
pain patients were asked to score their pain level prior to the
experimental session using a 100 mm visual analog scale (VAS). A
VAS score was also obtained after the experimental task to evaluate if
any pain developed or changed during the experimental session. VAS
pain scoring is commonly used and has been shown to exhibit very
high testeretest correlations (Rosier et al., 2002). The Neck disability
index (NDI) (Vernon and Mior, 1991; Hains et al., 1998; Riddle and
Stratford, 1998) and the fear avoidance belief questionnaire (FABQ)
(Waddell et al., 1993; Chaory et al., 2004) were used to respectively
quantify neck disability and fear avoidance behaviour related to work
and physical activities. Both NDI and FABQ French versions have been
validated (Wlodyka-Demaille et al., 2002). Cervical ranges of motion
were also quantied using a cervical range of motion (CROM) goni-
ometer (Youdas et al., 1992; de Koning et al., 2008). Ranges of motion
in all planes were measured twice and the mean value was recorded.
The examiner was previously trained to the use of the CROM device
and precautions were taken to avoid any movement outside the
measured movement plane. Participants' characteristics, anthropo-
metric data, pain, disability, fear avoidance scores as well as cervical
range of motion are presented in Table 1.
2.2. Aiming task
A custom made experimental set-up was developed to assess
cervical kinesthetic performance using a Fitts' task. A laser pointer
mounted on a helmet (approx. 200 g) was secured to the head and
tightened enough to avoid extra movement yet still be comfortable
for the participants. In a quiet and dimly lit room, subjects were
seated in front of a black semi-circular board (radius 1.75 m). The
seat height was adjusted so that subjects had their eyes level with
the targets. Subjects were instructed rst to close their eyes and to
produce 3e4 non-maximal exion, extension and rotation head
movements and then assume a neutral nal position. This position
was used as the neutral head position and the laser pointer was
oriented in the center of the board. The instructions provided at this
point were standardized and always given in the same order for all
participants. Participants were told to move as quickly, and
precisely as possible to the target then back to the neutral head
position as soon as they heard a computerized audible signal; both
speed and accuracy were considered equally important. In order to
limit the use of sensory feedback, participants were requested not
to correct the movement once it was initiated. A target was then
placed on the board and the participant was asked to practice
movements 3e5 times. Four different ID conditions were repre-
sented by two target sizes (4 cm and 8 cm diameter), and two
 M. Descarreaux et al. / Manual Therapy 15 (2010) 445e450 447

Table 1
Descriptive characteristics of the chronic neck pain patients and healthy participants.

n F:M Age (years) Mean (SD) Weight (kg) Mean (SD) Height (m) Mean (SD) Pain duration (years) Mean (SD)
Neck pain 19 16:3 38.7 (10.7) 67.4 (16.3) 164.6 (9.1) 8.9 (6.5)
Control 20 13:7 32.5 (8.8) 74.8 (11.6) 170.3 (9.7) e

VAS Mean (SD) NDI Mean (SD) FABQ (PA) Mean (SD) FABQ (Work) Mean (SD)

Pre Post
Neck pain 23 (20) 30 (26) 9.5 (5.6) 6.6 (6.4) 8.9 (7.6)
Control e e e e e

VAS: Visual analogue scale (/100 mm scale).

NDI: Neck Disability Index questionnaire (/100).
FABQ: Fear-Avoidance Belief questionnaire; work (/42) and physical activity component (/24).

rotation amplitude distances (15 and 40 from the neutral head
position). To avoid any upsurge of neck pain or discomfort, partic-
ipants went through all conditions on only one side (random
attribution). Indexes of difculty for each condition are presented
in Table 2.
All conditions were conducted in a random order to avoid
a sequence effect and participants were cautioned to limit errors (not
stopping on the target) to no more than 20% of the trials. Blocks of 10
trials were executed for each condition and the block results were
retained for analysis if the success rate was 80 percent or higher.
A successful trial was dened as one with the laser beam pointing in
the target limits. High resolution slow-motion video footage of the
laser beam pointing on the target was used to validate successful
trials. If the desired success rate was not achieved, the block of trials
was rejected and performed again at the end of the experiment. Only
the successful blocks of trials were used for the analysis.
Kinematic data was collected using an active marker motion
analysis system (Optotrak Certus, Northern Digital, Waterloo, ON,
Canada). Four light-emitting diodes were positioned on a rigid body
xed on the helmet and were used to calculate head movement.
Kinematic data was collected at 100 Hz, and was lowpass ltered
using a dual-pass, fourth-order Butterworth lter with a cut-off
frequency set at 5 Hz.
2.3. Data analysis
T-tests for independent samples were used to evaluate mean
differences in baseline characteristics and cervical range of motion
between the groups. Dependent variables included [1] movement
time, [2] movement time variability, [3] acceleration phase dura-
tion, [4] deceleration phase duration and [5] absolute positioning
error dened as the positive difference between the reached
angular position and the target for a particular trial. All dependant
variables were compared across all the different experimental
conditions by 2  2  2 (group  width  amplitude) repeated-
measures ANOVA models with repeated measures on the last two
factors. Whenever a signicant interaction was observed, post hoc
comparisons were made using Tukey's test. For all analyses,
statistical signicance was set at p < 0.05.
3. Results
Age, weight and height were similar between the two groups
(p > 0.05). Cervical range of motion in exion/extension, left and
right rotation as well as in left and right lateral exion were similar in
both groups (ps > 0.05). The values recorded for cervical range of
motion in the various movement planes were similar to the age-
dependent values reported in the literature (Youdas et al., 1992) and
are presented in Table 3.
In agreement with Fitts' law speed-accuracy tradeoff principles,
increasing index of difculty yielded longer movement times in both
groups. Signicant target size and movement amplitude effects were
observed for movement time (Size: F(1, 37) 30.82; p < 0.001 and
Amplitude: F(1, 37) 271.87; p < 0.001), and movement time
variability (Size: F(1, 37) 9.33; p 0.004 and Amplitude: F
(1, 37) 5.27; p 0.027). Although the slope of the linear rela-
tionship between movement time and index of difculty was not
signicantly different between the two groups, the statistical anal-
ysis yielded a signicant group  size  amplitude interaction effect
for the movement time (F(1, 37) 4.85; p 0.034) and the decel-
eration phase duration (F(1, 37) 6.95; p 0.012) variables.
A decomposition of the interaction (Tukey's test) showed that, when
compared to the control subjects, the chronic neck pain patients
showed a signicant increase in movement time (0.83  0.04 s ms vs
0.75  0.04 s) and deceleration phase duration (0.62  0.04 s vs
0.55  0.04 s) for the small target/large movement amplitude
condition. No group difference was observed for movement time
variability, acceleration phase duration and absolute positioning
errors (ps>0.05). Figs. 1 and 2 respectively illustrate the movement
time and deceleration phase duration, for both groups, across the
different experimental conditions.
4. Discussion
The objective of the present study was to quantify the motor
performance of chronic neck pain patients and healthy participants
using the Fitts' law paradigm. This paradigm has been used previ-
ously to assess motor performance of healthy subjects in a cervical
spine movement head aiming task (Passmore et al., 2007, 2010) and

Table 3
Cervical range of motion in the various movement planes: current study and
Table 2
normative values.
Fitts index of difculty calculation for each target.
Mean (SD) of Normative data for 30e39
Target diameter (cm) Amplitude ( )a
the 2 groups year old subjects
15 40 Flexion 58.3 (9.7) 47.3 (9.5)
4 4.52 6.10 Extension 71.5 (14.3) 73.1 (13.3)
8 3.52 5.10 Right rotation 63.0 (8.7) 69.4 (6.6)
a Left rotation 65.1 (9.1) 65.8 (8.6)
The index of difculty was calculated using the following formula: [log2(2A/W)];
Right lateral exion 46.0 (8.3) 44.7 (8.5)
where A movement amplitude, and W target width. The arc length corre-
Left lateral exion 46.9 (8.7) 42.4 (9.1)
sponding to the axial rotation motion was calculated to obtain the index of difculty.
448 M. Descarreaux et al. / Manual Therapy 15 (2010) 445e450

Fig. 1. Movement time across the different size and amplitude aiming for both groups.

we believe it could be a useful tool to identify the presence of
neuromuscular system impairments related to cervical spine
movement, and function.
The index of difculty and movement time relationship during the
cervical spine aiming task employed in the present study adheres to
the previously described a linear speed-accuracy tradeoff observed in
previous Fitts' task work (Fitts, 1954; Passmore et al., 2007, 2010).
The main ndings of this study not only demonstrate signi-
cantly decreased motor performance in chronic neck pain patients
during the most challenging cervical pointing task condition, but
also that this decreased motor performance was observed in
a group of participants tested while their level of pain and disability
ranged from low to moderate. Therefore, one can argue that rapid
cervical aiming tasks and potentially other challenging sensori-
motor tasks may be useful to assess functional changes present
even in subclinical conditions (changes we were not able to identify
using a standard goniometer range of motion evaluation). It has
been suggested that sensorimotor decits in chronic pain condi-
tions could either be explained by changes in the central motor
command (adaptation to pain) or modications in the regional
neuromuscular system caused by persistent articular pain and
degeneration (Holm et al., 2002).
Interestingly, chronic neck pain patients were able to produce
head and neck movement as accurately as the healthy participants.

Fig. 2. Deceleration time across the different size and amplitude conditions for both groups.
 M. Descarreaux et al. / Manual Therapy 15 (2010) 445e450
To achieve such a level of accuracy, chronic neck pain patients used
an alternative control strategy. Specically, they increased their
movement time by increasing the duration of the deceleration
phase. Similar results have also been reported in isometric force
reproduction tasks and pointing task in chronic low back pain
populations (Descarreaux et al., 2004, 2005). In the present experi-
ment, chronic neck pain patients may have increased movement
time during the most challenging condition in order to reduce
response variability and be as accurate and consistent as possible in
their performance.
The development of performance based outcome measures
requires that like all diagnostic tests they should be sensitive and
specic in order to derive meaningful information from them
(Altman and Bland, 1994). In order to assess the sensitivity of
a performance based test, or in some instances the lack of sensi-
tivity in a motor performance task, one can look to the challenge
point framework for interpretation (Guadagnoli and Lee, 2004).
Guadagnoli and Lee (2004) suggest that as task difculty increases
the predicted success will decrease, and that the rate of decrement
in performance will relate to the skill level of the performer. As
demonstrated in their previous work, if a task is too easy for
a skilled performer, or is too difcult for a novice performer, their
performance will appear to remain at a plateau. When the envi-
ronmental sensory information the performer is able to interpret
is appropriately related to the functional difculty of a task, the
optimal challenge point is determined. Manipulation of index of
difculty (Fitts, 1954) is a way of altering the functional level of
a task. Based on the results of the present study, we suggest that
task difculty may be affected not only by the level of a skill of
a performer, but also by the level of disability and perhaps
symptom chronicity of a performer. This interpretation may have
a tremendous impact in the creation of functional outcome
measures in clinical populations. Our results indicate that for both
movement time, and the length of the deceleration phase when
approaching a target, at all levels of difculty no differences are
noted between a group with neck pain and a healthy group until
the task demanded performance at the highest index of difculty
used in the study (the most challenging). Based on the movement
performance demonstrated (Figs. 1 and 2), it can be noted that the
optimal challenge point of the neck pain group specically was
exceeded, and this is reected in the decrement observed in their
performance while the healthy group remained less affected. In
the design of future performance based outcome measures the
optimal challenge point in both healthy and pathological pop-
ulations should be determined so that task difculty may be set
appropriately to ensure adequate outcome measure sensitivity. If
the challenge point of one of the groups is not appropriately met,
or exceeded, differences between groups may not be observed,
which suggests a type 2 error, an error of omission may be
committed.
4.1. Limitations and future research
In the current study, participants were tested while their level
of pain and disability ranged from low to moderate and this may
explain the lack of differences observed in kinematic variables.
However, similar ndings have been reported before and showed
that cervical range of motion and neck movement precision of
healthy individuals are similar to those measured in a group of
whiplash patients (Armstrong et al., 2005) or non-traumatic neck
pain patients (Rix and Bagust, 2001). Higher levels of pain and
disability may lead to different sensorimotor adaptations. Future
studies to be carried out should focus on non-traumatic and
traumatic neck pain with higher level of pain and related disability.
As proprioceptive decits may be similar in both populations, Fitts
449
like protocols could be useful in assessing such decits in whiplash
patients. Future studies should also investigate the relation
between changes in proprioceptive variables and clinical
outcomes.
5. Conclusion
On the basis of the data in this study, we conclude that indi-
viduals with non-traumatic neck pain perform with longer move-
ment times then healthy control participants during a rapid head
movement aiming task when task conditions are adequately chal-
lenging. This increase in movement time, when broken down into
kinematic components is attributed to the increased length of the
deceleration phase when aiming the head to a challenging target.
Thus, these results may imply that in order for a performance based
outcome measure to yield observable differences conditions that
meet or exceed the optimum challenge point of the population
tested should be employed. Additionally, these types of goal
oriented performance based outcome measures may yield
measurable differences where other functional tests including
range-of-motion are not adequately sensitive.
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