PT 153: Therapeutic Exercise 2 THERAPEUTIC EXERCISES TO IMPROVE PROPRIOCEPTION AND KINESTHESIA Kristofferson G. Mendoza, PTRP University of the Philippines Manila College of Allied Medical Professions Department of Physical Therapy

Learning Objectives At the end of the session the learners should be able to: Explain relevant theory, concepts, and principles of kinesthetic and proprioceptive training Describe applications of kinesthetic and proprioceptive training Demonstrate techniques of kinesthetic and proprioceptive training correctly

Kinesthesia and Proprioception Perception of joint and body movement as well as the position of the body, or body segments, in space Spatial orientation of body in space Detects the rate and timing of movements Muscle exertion and how fast a muscle is being stretched Perception of joint and body movement, as well as the spatial orientation of the body and its segments

Kinesthesia and Proprioception Responsible for deep somatosentation Afferent stimuli from: muscles (muscle spindle), tendons, ligaments, fascia, Joint Play an important role in motor control, planning and adaptive behaviors

Kinesthesia and Proprioception Corollary Discharge Motor signals sent to the muscle once an action is planned Important in differentiating between active and passive movement Identifies if the motor activity is appropriate in terms of force and body scheme

Kinesthesia and Proprioception Corollary Discharge Hypothesis Only active joint movement produce an efferent copy (internal correlate or corollary discharge) of a centrally generated motor command Brain compares the movement to a “reference of correctness “ Neuronal model of memory of “how it feels” to move in that way and “what is achieved”

Kinesthesia and Proprioception Feedback mechanism Closed loop mechanism Open loop mechanism Feedforward mechanism

Feedback Schmidt (1998) three types of responses That produce feedback Muscle contraction Change that occurs in the environment Movement of the body parts in space (proprioceptive stimuli)

Closed Loop Response-produced feedback is compared to a reference of correctness The extent of error is determined and correction is made Utilized for precision movements that require sensory feedback (e.g., maintaining balance while sitting on a ball or standing on a balance beam)

Open Loop Muscle commands are pre-programmed and once triggered run their course There is no possibility of correction from sensory feedback Utilized for movements that occur too fast to rely on sensory feedback Utilized for anticipatory aspects of postural control

Feedforward “Internal feedback” Sending of signals in advance of the movement Postulates that a copy of centrally generated motor command signals (corollary discharge) is fed forward and compared to a sensory reference of correctness. Used to correct errors that are detected prior to an action Feedforward, or open loop motor control, is utilized for movements that occur too fast to rely on sensory feedback (e.g., reactive responses) or for anticipatory aspects of postural control. Anticipatory control involves activation of postural muscles in advance of performing skilled movements, such as 26 or planning how to navigate to avoid obstacles in the environment. Closed loop control is utilized for precision movements that require sensory feedback (e.g., maintaining balance while sitting on a ball or standing on a balance beam).

Kinesthesia and Proprioception CNS interprets and integrates proprioceptive and kinesthetic information and then controls individual muscles and joints to produce coordinated muscle activation and both joint stability and joint movement Following injury and subsequent rest and immobilization, the central nervous system “forgets” how to put this information together. CNS interprets and integrates proprioceptive and kinesthetic information and then controls individual muscles and joints to produce coordinated movement. Following injury and subsequent rest and immobilization, the central nervous system “forgets” how to put this information together. Regaining neuromuscular control means regaining the ability to follow some previously established sensory pattern. Strengthening exercise, particularly those that tend to be more functional, are essential for reestablishing neuromuscular control

Kinestetic and Proprioceptive Retraining Restoration of proprioceptive sensibility to retrain altered afferent pathways and enhance the sensation of joint movement Generally, comprised of weight bearing exercises (full weight bearing status or confines of allowed weight bearing)

Kinesthetic and Proprioceptive Retraining Goals Improve proprioceptive awareness of safe posture, safe positioning, and safe movement Improve functional joint stability through improved motor coordination related to proprioceptive awareness Regaining neuromuscular control means regaining the ability to follow some previously established sensory pattern

Stages of Rehabiliation Early training / protection phase Basic training / controlled motion phase Immediate to advanced training / return-to- function phase Kisner and Colby, 2007

Early Training / Protection Awareness of what makes symptoms better or worse Learn neutral spine Pelvic tilt / cervical retraction: passive  active assist  active in comfortable positions Kisner and Colby, 2007

Basic Training/Controlled Motion Active spinal control in supine, quadruped, sitting and standing Dynamic maintenance of pain-free position with activities Kisner and Colby, 2007

Intermediate to Advanced Training/ Return to Function Habitual use of the neutral spine in all functional activities Kisner and Colby, 2007

Kinesthetic and Proprioceptive Retraining Principles Awareness of safe joint positions is of primary importance and should precede other exercises: Supine, side, and prone lying Sitting Standing

Kinesthetic and Proprioceptive Retraining Principles Practice of safe movements (basic body mechanics) should follow, in: Rolling Supine to sit Sit to stand Walking forward and in reverse

Kinesthetic and Proprioceptive Retraining Principles Awareness of safe joint positions and observance of safe movements should be integrated into work-specific activities, recreation-specific activities, and sport-specific activities

Kinesthetic and Proprioceptive Retraining Principles Patient education is always a must: Active, informed patient involvement Self-management and safe progression of treatments Injury prevention through task and environmental modification

Phases of Training Static stabilization exercises with closed chain loading and unloading (weight shifting) Transitional stabilization exercises Dynamic stabilization exercises Voight, 2000

Static Stabilization Isometric exercises around the involved joint on solid and even surfaces, then to unstable surfaces Initiated with controlled balance training and joint repositioning Tools: mini-trampoline, balance board, swiss ball, wobble board Voight, 2000

Static Stabilization DOUBLE LIMB SUPPORT SINGLE LIMB SUPPORT SINGLE WITH TASK- OR SPORT- SPECIFIC SKILL

Static Stabilization Taping Use of weighing scale to check weightbearing Force platform

Static Stabilization

Static Stabilization

Transitional Stabilization Involves conscious control of motion without impact Replaces isometric exercises with controlled concentric and eccentric exercises Stimulates dynamic postural response Increases “muscle stiffness” which in turn increases dynamic stabilization around the joint by resisting and absorbing joint load Voight, 2000

Transitional Stabilization Step-up 90% of the foot should be on the box Push through the heel and midfoot Do not let the other foot touch the box

Transitional Stabilization One-leg Box Squat Stand on a box and attempt to squat to a position with thigh parallel to the floor Keep the weight on the heel to minimize movement at the ankle and to keep the knee from moving beyond the big toe in the bottom position It is important to begin by bending at the knee and not by the ankle

Transitional Stabilization Lunges Back tight and arched, and the upper body straight Length of step should be approximately as long as the height of the athlete Movement ends by pushing back so the feet are back together

Transitional Stabilization SMALL RANGE LARGE RANGE

Dynamic Stabilization Includes unconscious loading of the joint Involves both ballistic and impact exercises Muscle strength, endurance and flexibility and NM control to achieve stability and mobility Mediated by articular mechanoreceptors Voight, 2000

Dynamic Stabilization Side Plank Bridge Prone bridge Lateral bridge Supine bridge Plank

Dynamic Stabilization Hip Lift Lie on back with feet flat on the floor Pull one knee to the chest and hold in place Push the foot on the floor and extend the hip while keeping the other leg in place against the ribs

Dynamic Stabilization OPEN CHAIN PLYOMETRIC EXERCISES CCK IN PAIN FREE RANGE TO IMPROVE STABILITY ALTERATIONS IN JOINT POSITIONING RHYTHMIC STABILIZATION/ CO- CONTRACTION

Dynamic Stabilization

Sample Proprioceptive Exercises Standing and leaning against treatment table Rocking forward and backward in quadruped Maintenance of kneeling Weight-shifting in a push-up position Maintenance of sitting on v.ball while alternately moving limbs Standing on one leg on BAPS board

Techniques for the Pediatric Population Slow stretch or alternate compression Rhythmic vibration and stretch Joint approximation Joint pounding Joint distraction Joint moblization

Techniques for the Geriatric Population The approach is functional and task-oriented Stimulate heavy work patterns Give many opportunity to enhance sensory-motor activity to cause the brain to have a clear “body map”

Techniques for the Geriatric Population Use of weights in the form of vests Promoting reaching, stretching, elongation of muscles Task modification to allow pushing, pulling, sliding, carrying, lifting Maintenance of quiet standing Hopping in a trampoline

Techniques for the Geriatric Population: Precautions Spinal and skeletal deformities Severe osteoporosis Weak grip Bilateral neglect Poor depth perceptions Poor stabilization Low tone and slack joints Painful joints Poorly articulated joints

References Dutton, M. (2004). Orthopaedic Examination, Evaluation & Intervention. NY: McGraw-Hill. Kisner, C. & Colby, L. A. (2002). Therapeutic Exercise: Foundations and Techniques (4th ed.) PA: F.A. Davis Company O’ Sullivan, S.B. and Schmitz, T.Z. (2002) Physical rehabilitation: Assessment and Treatment (4th ed.) PA: F.A. Davis Company Tiongson C. and Julio Veloso JM. Lecture Slides on Evidence Based Approach to Assessment and Treatment of ACL Rupture. Lopez, L. (2007). Lecture Slides on Kinesthetic and Proprioceptive Training. Encabo, M. (2008). Lecture Slides on Kinesthetic and Proprioceptive Training.

Thank You