1. 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

2. 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

3. 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

4. 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

5. 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

6. 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”

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

8. 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)

9. 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)

10. 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

11. 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).

12. 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

13. 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)

14. 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

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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

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

24. 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

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

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

27. Static Stabilization

28. Static Stabilization

29. 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

30. 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

31. 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

32. 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

33. Transitional Stabilization
SMALL
RANGE
LARGE
RANGE

34. 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

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

36. 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

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

38. Dynamic Stabilization

39. 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

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

41. 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”

42. 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

43. 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

44. 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.

45. Thank You