Proprioceptive Training for upper Extremities Types of exercises used for upper extremity proprioceptive training: 1- Balance training. One major category of proprioceptive exercise is balance training. These exercises help to train the proprioceptive system in a mostly static activity. Activities or exercises in weight bearing using unstable supporting surface, profitter, swiss ball, balance board are example of balance training in the upper extremity.

Figure 8 : Left, Eyes open, Fitter balance in push-up position with platform rocking in the frontal plane. Right, Fitter balance in push up position with platform rocking in the sagittal plane.

Figure 9 : Eyes open, Gymnastic ball balance feet-elevated position

2. Kinetic chain exercises 2. Kinetic chain exercises . Open-chain manual resistance exercises with rhythmic stabilization (Figure 6) are also considered proprioceptively enriched. In either case, resistance can be modified, depending on pain, as the patient progresses

Figure10: Rhythmic stabilization (A physical therapist provides resistance in all planes of movement for upper extremity strengthening. These maneuvers activate mechanoreceptors in multiple planes, stimulating proprioceptive pathways, and are especially helpful in treating rotator cuff tendonitis.)

Quadruped stabilization on a balance board(Figure 11) Four closed-chain exercises have been described to stimulate co-activation in the shoulder: push­ups, horizontal abduction on a slide board, and tracing circular motions on a slide board with the dominant and nondominant arms (Figure 12). These exercises ac­commodate for the individual's tolerance to joint loads by progressing from a quadruped to a push-up position

Figure 11 : Dynamic shoulder stabilization in all four position but with one hand on a wobble board and the other hand held off the floor. The shoulder girdle is challenged as the patient tries to keep the edge of the wobble board from touching the floor.

Fig. 12 Dynamic stabilization exercises for the upper extremity Fig. 12 Dynamic stabilization exercises for the upper extremity. A, Push-ups. B, Horizontal abduction on a slide board

Wall push-ups (Figure 13)are also useful and can be proprioceptively enhanced by having a physical therapist or resistance band provide resistance to the patient's back.

3- Sport-specific maneuvers 3- Sport-specific maneuvers. Rehabilitation is incomplete until maneuvers specific to the sport and the athlete's position in the sport can be performed maximally and without pain or loss of function. Starting sport-specific maneuvers with weighted resistance (eg, swinging a weighted tennis racket or baseball bat), Functional positions, "such as over­head throwing, should be incorporated and are more sport-specific (Figure 14).

Fig. 14 Active and passive repositioning activities should be performed in functional positions specific to individual sports.  

4. PNF (Proprioceptive neuromuscular facilitation): These techniques may be defined as methods of promoting or hastening the response of the neuromuscular mechanism through stimulation of the proprioceptors. Emphasis is placed on the application of maximal resistance through out the range of motion, using many combinations of motions in a pattern format. Motion is first performed in the strongest part of the range, with progression toward the weaker parts of the range of motion. The patterns used are spiral and diagonal in character and closely resemble the movements used in sports and in occupational activities. (Figure 15 and Figure 16)

Figure 15: Extension adduction internal rotation pattern of PNF : Left or right shoulder exercise. Patient is in a supine position. With the therapist standing at left or right side of patient. (A) The exercise should start on the right side. The arm should be entirely straight throughout the patterns, keeping the elbow stiff. The patient's hand is grasped with your right hand when you are standing on the right side. Your left hand should support the patients elbow. (B) You can start with either the upward or downward diagonal. As the patient moves the arm into extension internal rotation, the guideline should be anterior iliac crest. As the patient moves the arm up and out (flexion external rotation), the diagonal angle should be maintained in the opposite direction from the anterior iliac crest. It should be noted that the adduction can be added to the extension internal rotation pattern and that the abduction can be added to the flexion external rotation pattern. This exercise is repeated 10 times, with some resistance in both diagonal directions.

Figure 16: Flexion adduction external rotation pattern of PNF : Left or right shoulder exercise. Patient is in a supine position. (A) Starting on the right side, you should keep the patient's elbow stiff. With your right hand, you grasp the patient's hand. With your left hand, you support the elbow. Our landmark will be the nose and its opposite diagonal. (B) Exercise is begun either up and in- or down and out. When going up and in toward the nose (flexion external rotation adduction), you must remember to keep the elbow stiff. When going down and out (extension abduction and internal rotation), you can follow the opposite diagonal from the nose. The pattern and rhythm should be kept. This exercise is repeated 10 times in each direction with some resistance. (It is important to always be careful not to administer too much resistance, only what each individual can handle through the fullest range.)

5- Plyometrics. It is a quick powerful movement involving pre-stretching of a muscle, followed by a shortening cycle. The stretch shortening cycle occurs when elastic loading, through a quick eccentric muscular contraction, is followed by a burst of concentric muscular contraction. (Figure 17)

Fig. 17 Plyometric exercises

6- Ballistic stretching uses the momentum of a moving body or a limb in an attempt to force it beyond its normal range of motion. This is stretching, or "warming up", by bouncing into (or out of) a stretched position, using the stretched muscles as a spring which pulls you out of the stretched position, (Fig. 18)

Proprioceptive Training for Lower Extremities Proprioceptive training improves a patient's static and dynamic equilibrium. The static proprioceptive re-education is begun when patients proceed to weight bearing without crutches and consists of six stages: 1-Recovery of sense of body position muscle contraction and joint movement. 2-Transition from bilateral to unilateral activities 3-Transition from eyes-open to eyes-closed activities. 4-Transition from activities on a stable support, such as the ground, to unstable surfaces, such as a soft mattress, a trampoline and Freeman's boards, or more modern equipment, such as the kinesthetic ability trainer 5-Throwing and catching a football to take the patient's mind off active control of his balance. 6-Balance recovery exercises are carried out different joint positions to evoke different responses from the tendon and muscle receptors.

An unstable platform promotes reactive muscle activity when an athlete attempts to balance and a clinician manually perturbs the platform. These exercises can facilitate adaptations to reflex pathways mediated by peripheral afferents, resulting in reactive muscle activation.

Proprioceptive exercise on the kinesthetic ability trainer

"Kickers" use an elastic band fixed to the distal aspect of the involved or uninvolved limb. The athlete attempts to balance while executing short kicks with either knee extension or hip flexion. This exercise is most difficult when performed on unstable surfaces.

The dynamic proprioceptive re-education The dynamic proprioceptive re-education is indicated for patients needing to resume sports that involve running, jumping, landing, sudden changes of direction and twisting movements. During such sports, athletes are obviously able to lose and then regain balance, and avoid falls and accidents that might occur by adjusting their posture so as to execute harmonious movements in a necessarily brief space of time

Early dynamic joint stabilization exercises begin with balance training and partial weight bearing on stable surfaces, progressing to partial weight bearing on unstable surfaces. Balancing on unstable surfaces is initiated once full weight bearing is achieved. Exercises such as "kickers" also require balance and can begin on stable surfaces, progressing to unstable platforms.

Eccentric loading is accomplished by activities such as forward and backward stair climbing or backward downhill walking. Strength and balance exercises can be combined and executed with light external forces to increase the level of difficulty.

Plyometric activities such as low-impact hopping may commence once weight bearing is achieved Double-leg bounding is an effective intermediate exercise, because the uninvolved limb can be used for assistance. Stretch-shortening exercises are a necessary component for conditioning the neuromuscular apparatus to respond more quickly and forcefully, permitting eccentric deceleration then developing explosive concentric contractions.

The dynamic proprioceptive re-education consists of seven stages:- 1- Slow exercises followed by quicker movement 2- Exercise with limited effort followed by exercises requiring greater strength 3- Exercises requiring volition, followed by exercises done freely 4- Progress from walking to jogging 5- Running and sprinting 6- Jumping and changes of direction 7- Twirling and twisting around the injured or operated knee

Balance and control proprioceptive exercises 1.    Stand on one leg.      2.    Stand on one leg with eyes closed.      3.    Stand on one leg – throw and catch a ball.      4.    Stand on one leg – bend and straighten knee     

5.    Stand on one leg- pick up item from floor.    6.    Hold knee dip – throw and catch a ball. 7.    Stand on one leg – move other leg to side, front and back.   8.    Push up onto toes (2 legs) and hold.   9.   Push up onto toes with eyes closed.    10.   Push back onto heels, balance and hold. 11.   Push up on toes on one leg.     

Walking proprioceptive exercises 13.    Walk forward along a straight line.  14.    Walk on tip toes along straight line.   15.    Walk backwards along straight line. 16.    Side step along straight line.   17.    Walk sideways crossing one foot over other (Cariocas).   18.    Walk fast in one direction, quickly changing direction at intervals.

Running proprioceptive exercises 19.    Run fast in one direction.      20.    Run backwards and do sidesteps.      21.    Fast crossovers (Cariocas).      22.    Run in figure of eight – make it smaller and smaller.     

23.    Hopping on spot.      24.    Hop forwards and backwards – stop between hops.      25.    Hop in zigzags.      26.    Hop on and off step.      27.    Do triple jump - run, hop, jump and land.

Balance and strength exercises are combined by incorporating light external forces and increasing the level of difficulty for balancing while strengthening the muscles required for dynamic stabilization

Figure 16 The Fitter is useful for weight shifting

Plyometrics begin with low-impact hopping, progressing to double-leg bounding, and finally single-leg hopping.