1. Proprioceptive training
Dr. Ali Abd El-Monsif Thabet

2. Proprioceptive system:
A general term used to cover all those sensory systems that are involved in providing information about position, location, orientation and movement of the body and its parts (sensing position and motion of the body).

3. Fig. 1 Muscle spindle

4. Fig. 2 Golgi tendon organ

5. Fig. 3 a. Ruffini endings b. Pacinian corpuscle

7. Table 1: Summary of articular proprioceptors

8. Cutaneous mechanoreceptors
Cutaneous mechanoreceptors are located in the skin
By morphology
Ruffini's end organ detects sustained pressure.
Meissner's corpuscle detects changes in texture (vibrations around 50 Hz);
Pacinian corpuscle detects deep pressure and rapid vibrations (about Hz).
Merkel's disc detects sustained touch and pressure.
Free nerve endings (touch, pressure, stretch)
Hair follicles receptors are located in hair follicles and sense the position

9. LEVELS OF MOTOR CONTROL
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

10. Purposes of proprioception:
1- Provide awareness of position sense and kinesthesia.
2- Produce coordinated reflex effects on muscle tone and balance.
3- Provide peripheral feedback so the CNS can design and modify effective motor programs

12. Measurement Methods Proprioceptive assessment tests:
1. Tests of angular reproduction (AR)
2.Threshold to detect passive movement (TTDPM)

13. Indications for proprioceptive training 1-Joint sprain or strain 2-Joint instability (shoulder dislocation ,ligament laxity or weakness) 4-Athletic protection against reinjury

14. Proprioceptive Training
Proprioceptive exercises
The objective of kinesthetic and proprioceptive training is to restore the neurosensory properties of injured capsuloligamentous structures and enhance the sensitivity of uninvolved peripheral afferents.
Rehabilitation programs begin with restoration of range of motion, muscular endurance, and muscular strength. These exercises, in a nonspecific fashion, stimulate joint and muscle proprioceptors in the injured extremity
Joint compression is believed to maximally stimulate articular receptors and can be accomplished with closed chain exercises throughout the available ROM. Early joint repositioning tasks enhance conscious proprioceptive and kinesthetic awareness, eventual leading to unconscious appreciation of joint motion and position. Applying elastic bandage can provide additional proprioceptive and kinesthetic formation by stimulating cutaneous receptors

15. Proprioceptive Training
General principles
1- Balance is achieved first, then coordination, then agility ( the ability to control the direction of a body or its parts during rapid movement, it requires flexibility, strength, power, speed, balance, and coordination and involves rapid change of direction and sudden stopping and starting).
2- Exercises progress from simple to complex .
3- Initial exercises are performed slowly and perfomed in controlled situations

16. Proprioceptive Training
4- Advancement is made only after the activity is mastered
5- Progression is to more complex activities and evolves to specific performance activities: 
Make activity more complex
Perform simple activity at a faster pace
Require a more powerful output
Have patient perform more than one task simultaneously
6 - Goal: perform the activity accurately:
Do difficult proprioceptive activities early in exercise session so patient not as fatigued
Repetition

17. 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.

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

20. 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.

21. 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

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

30. Thank you