Proprioception: Changes with Injury, Disease and Rehabilitation Leslie Russek, PhD, PT, OCS Clarkson University Canton-Potsdam Hospital Clarkson University Master of Physical Therapy Program

Basic Science Questions: What is proprioception? What are the different kinds of proprioception? How is it related to anatomy? I.e., with what tissue or structure is each kind of proprioception associated? Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Clinical Questions: Why think about proprioception with an ankle sprain patient? What exercises and progression of exercises might you use with these patients? Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Sensory Receptors Exteroceptors: sensory receptors that respond to light, sound, smell, touch, pain, etc., to create conscious sensation. Proprioceptors: sensory receptors that respond to joint movement (kinesthesia) and joint position (joint position sense), but do not typically contribute to conscious sensation. Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Sensory receptors mediating prioprioception are found in skin, muscles, joints, ligaments and tendons. Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Mechanoreceptors Freeman MAR, Dean M, Hanhan I. 1965 Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Muscle Spindle Organs Intrafusal muscle fibers include nuclear bag and nuclear chain. Extrafusal mm is the rest of the mm. Small mm for fine control have many more spindle organs than large, ‘power’ mm. Act as a strain gauge (strain is length change due to an applied force) to measure mm length changes. Spindles are in parallel with mm. Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Muscle Spindle Organs Typically 2 nuclear bag fibers and 3-5 nuclear chain fibers per spindle. Able to anticipate length changes: gamma motor neurons can make spindle chain fibers contract. Rapid stretched sensed via Ia fibers, which cause a reflex mm contraction. Example is the ‘tendon’ reflex: tap to patellar tendon causes slight increase in mm length, increased Ia activity causes increased alpha motor neuron activity, which causes mm contraction. Other complex reflexes utilize the spindle: e.g., crossed extension reflex Co-activation of alpha and gamma motor neurons allows the body to anticipate muscle length change so that spindles do not fire if length change is as anticipated. Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Golgi Tendon Organ Found at junction between tendon and muscle. Activated by stretch. Since tendon is much stiffer than muscle, tendon will only be stretched if the muscle is activated and can pull on the tendon, i.e., apply a force. Because they are in series with the muscle, they act as force transducers - or stress gauges. Golgi tendon organs will cause a reflex deactivation of muscle if safe forces exceeded Also able to modify muscle stiffness within the working range. Ref: McMahon: Muscles, Reflexes and Locomotion Clarkson University Master of Physical Therapy Program

More Mechanoreceptors Ruffini ending Pacinian corpuscle Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program AFFERENT INPUT LEVELS OF MOTOR CONTROL Peripheral afferents joint muscle skin Spinal reflexes Cognitive programming CNS MUSCLE Visual receptors Brain Stem balance Different forms of sensory input are integrated in the central nervous system (CNS). When one type of input is missing or inadequate, other forms can sometimes compensate. The output is a combination of cognitive (deliberate), subconscious (e.g., balance), and reflex motor activity. Vestibular receptors From Lephart SM, Henry TJ. 1996 Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Changes with Injury Traumatic, recurrent shoulder instability causes deficits in kinesthesia (Smith et al, 1989) ACL deficiency causes decrease in reflex hamstring activity (Beard et al, 1994) and joint position/motion sense (Borsa et al, 1997) Ankle sprains result in decreased ankle kinesthesia and joint position (Glencross et al, 1981; Leanderson et al, 1996) (This is well past “nice to know” and probably into “don’t worry about it.”) Shoulder dislocation increased angle of reproduction to2.75º from normal values of 1.08-1.5º; increased threshold-to-sensation-of-movement to 2.58º from .91-1.18º; increased end-range-reproduction to 3.00º from .98-1.4º. Forwell and Carnahan, 1996, found additional proprioceptive deficits when vibration present. ACL deficient knee has decreased motion detection which is greater near end-range extension (15 º) than in mid-range (45º) and decreased motion sensitivity moving into extension than into flexion. (Borsa et al, 1997) Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Changes with Disease Knee joint position sense decreased in osteoarthritis (Barrett et al, 1991) Knee proprioception decreased in people with OA - even uninvolved knee and compared to age-matched controls (Sharma et al, 1997) Knee and PIP proprioception decreased in hypermobility syndrome (Hall et al, 1995; Mallick et al, 1994) In hypermobility syndrome (HMS), errors greatest near end range. Subjects perceived PIP joint to be less displaced than it actually was. (Mallik et al, 1994) Normal subjects had increased acuity of knee proprioception at end ranges; this increased acuity was not seen in HMS. (Hall et al, 1995) Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Changes with Age Decreased knee joint position sense with age (Barrett et al, 1991; Petrella et al, 1997) Decreased ankle joint position sense with age - appears to be due to decreased plantar tactile sensitivity (Robbins et al, 1995) Activity partially countered the loss of joint position sense with age (Petrella et al, 1997) Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Changes with Fatigue Muscle fatigue decreases shoulder proprioception (Voight et al, 1996) Maximum effort eccentric activity of forearm flexors decreased force and position proprioception for 5 days following exercise (Saxton et al, 1995) Eccentric exercise caused more deficit than concentrice exercise (Brockett et al, 1997) (more “don’t need to know” unless you are curious) Eccentric exercise study looked at position proprioception, believed to be mediated by muscle spindles and force proprioception, believed to be mediated by golgi tendon organs. (Saxton et al) Eccentric exercise was damage-inducing, documented by appropriate biochemical correlates. It also caused tremor for 1-2 days post exercise. (Saxton et al) Eccentrically exercised arm caused errors in angle reproduction into extension - i.e. the subject thought the arm was more flexed than it was. In force-matching, eccentric arm undershot - i.e. thought there was less force being applied than there was.(Brockett et al) Clarkson University Master of Physical Therapy Program

Changes Due to Other Causes Use of an elastic bandage improved position sense in subjects with impaired position sense due to OA and after total knee replacement, but not in normal individuals (Barrett et al, 1991) Use of elastic sleeve knee ‘brace’ improved proprioception in normal individuals (McNair et al, 1996) Clarkson University Master of Physical Therapy Program

Changes Due to Other Causes Ankle taping improves joint position sense (Robbins et al, 1995a) Footwear decreases (closed kinetic chain) proprioception at the ankle (Robbins et al, 1995a; Robbins et al, 1995b) and taping decreases impairment due to footwear (Robbins et al, 1995a) Clarkson University Master of Physical Therapy Program

Changes Due to Other Causes Chronic effusion decreased accuracy of passive positioning, but not of active repositioning; aspiration temporarily improved passive repositioning (Guido et al, 1997) Injection of saline into the knee joint does not cause changes in proprioception (McNair et al, 1995) Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Changes with Surgery ACL reconstruction improves kinesthesia (Barrack et al, 1989; Lephart et al, 1992) Total knee replacement improves position sense (Barrett et al, 1991) Capsulolabral reconstruction partially restores shoulder proprioception (Lephart et al, 1994) Improved kinesthesia is primarily in midrange: around 45º. A longer threshold until motion was detected remained at 15º. (Barrack, 1989) With TKR, semi-constrained replacements had greater improvement in joint position sense than hinged replacement. (Barrett, 1991) Capsular shift appears to work by recreating appropriate tension on the capsule. (Lephart et al, 1994) Clarkson University Master of Physical Therapy Program

Clarkson University Master of Physical Therapy Program Changes with Training Improved proprioception with exercise makes physiological sense (Lephart et al, 1996) Function (hop and figure-8 run) improves but joint position sense does not (Carter et al, 1997) Dancers are more sensitive to small threshold movement, but less accurate in position (Barrack et al, 1984) Joint position sense measured through passive motion is not a comprehensive measure of proprioception (does not include muscle spindles, Golgi tendon organs, some skinn receptors). Dancers had generalized hypermobility, so had more than just training to differentiate them from controls. Dancers’ errors in joint position sense had significantly more errors of overshoot than controls; I.e., dancers allowed too much movement. (Barrack) Only male dancers showed decreased postural sway compared to controls, not female dancers. Both showed significantly less postural sway on left foot versus right foot. (Leanderson) Ankle disk training decreased muscle reaction time in simulated ankle sprain. (Sheth et al, 1997) Clarkson University Master of Physical Therapy Program

Relationship to Function Functional hop and figure 8 run not correlated to passive joint position sense (Carter et al, 1997) Functional hop test highly correlated to threshold to detect motion test at the knee (Borsa et al, 1997) Clarkson University Master of Physical Therapy Program

Clinical Implications What kind of patients, injuries or diseases might respond to proprioceptive training? What exercises are appropriate or effective? Clarkson University Master of Physical Therapy Program

Clinical Implications What kind of patients, injuries or diseases might respond to proprioceptive training? What exercises are appropriate or effective? Clarkson University Master of Physical Therapy Program

Exercises and Progressions: Shoulder Appropriate patients: Types of exercises: PNF stabilization, PNF patterns closed chain rocking, progress to balance on Swiss ball, single arm stand, dynamic walking on hands Ballistic: medicine balls progressing into positions of instability Function: sport specific simulation or actual Underarm ‘squeeze’ Clarkson University Master of Physical Therapy Program

Exercises and Progressions: Shoulder Appropriate patients: Instability Impingement? Other? Types of exercises: PNF closed chain stabilization/balance ballistic/plyometrics functional activities PNF stabilization, PNF patterns closed chain rocking, progress to balance on Swiss ball, single arm stand, dynamic walking on hands Ballistic: medicine balls progressing into positions of instability Function: sport specific simulation or actual Underarm ‘squeeze’ Clarkson University Master of Physical Therapy Program

Exercises and Progressions: Knee Appropriate Patients Types of exercises BAPS board or wobble board Fitter board SportsCord Mini-tramp: jog, jump-jump-stick, double and single leg jumps, side-to-side jumping Clarkson University Master of Physical Therapy Program

Exercises and Progressions: Knee Appropriate Patients ACL deficiency Generalized internal derangement Patellofemoral instability Other? Types of exercises single leg balance soft/unstable surfaces eyes closed dynamic balance plyometrics functional activities BAPS board or wobble board Fitter board SportsCord Mini-tramp: jog, jump-jump-stick, double and single leg jumps, side-to-side jumping Clarkson University Master of Physical Therapy Program

Exercises and Progressions: Ankle: Appropriate Patients Recurrent ankle sprain Other? BAPS board or wobble board Fitter board Sidestepping kariokas Sportscord jumping Clarkson University Master of Physical Therapy Program

Ankle Proprioception Exercises Early active assisted range of motion (AAROM) into: dorsiflexion/plantarflexion (DF/PF) inversion/eversion (inv/ev) active range of motion (AROM) into: DF/PF, inv/ev, circles alphabet with foot BAPS board, partial weight bearing Clarkson University Master of Physical Therapy Program

Ankle Proprioception Exercises Advanced BAPS board single leg balance start on stable surface, progress to: soft/unstable surfaces (e.g., trampoline) eyes closed dynamic balance (e.g., while throwing ball) plyometrics (jumping) functional activities: running, cutting, sports-specific exercises Clarkson University Master of Physical Therapy Program

Clinical Implications What other joints, disorders or patient populations might benefit? Osteoarthritis Aged Sedentary Temporomandibular disorder (TMD) Hypermobility syndrome Vestibular disorder Other? Clarkson University Master of Physical Therapy Program

Besides… Proprioception exercises are fun! Clarkson University Master of Physical Therapy Program