Proprioception: Changes with Injury, Disease and Rehabilitation

1. Leslie Russek, PhD, PT, OCS Clarkson University Canton-Potsdam Hospital Proprioception: Changes with Injury, Disease and Rehabilitation

2. 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?

3. Clinical Questions: • Why think about proprioception with an ankle sprain patient? • What exercises and progression of exercises might you use with these patients?

4. 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.

5. Sensory receptors mediating prioprioception are found in skin, muscles, joints, ligaments and tendons.

6. Mechanoreceptors Freeman MAR, Dean M, Hanhan I. 1965

7. Muscle Spindle Organs

8. Muscle Spindle Organs

9. Golgi Tendon Organ

10. More Mechanoreceptors Ruffini ending Pacinian corpuscle

11. AFFERENT INPUT LEVELS OF MOTOR CONTROL • Peripheral afferents • joint • muscle • skin Spinal reflexes Cognitive programming CNS MUSCLE Visual receptors Brain Stem balance Vestibular receptors From Lephart SM, Henry TJ. 1996

12. 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)

13. 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)

14. 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)

15. 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)

16. 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)

17. 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)

18. 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)

19. 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)

20. 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)

21. 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)

22. Clinical Implications • What kind of patients, injuries or diseases might respond to proprioceptive training? • What exercises are appropriate or effective?

23. Clinical Implications • What kind of patients, injuries or diseases might respond to proprioceptive training? • What exercises are appropriate or effective?

24. Appropriate patients: Types of exercises: Exercises and Progressions:Shoulder

25. Appropriate patients: Instability Impingement? Other? Types of exercises: PNF closed chain stabilization/balance ballistic/plyometrics functional activities Exercises and Progressions:Shoulder

26. Appropriate Patients Types of exercises Exercises and Progressions:Knee

27. 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 Exercises and Progressions:Knee

28. Appropriate Patients Recurrent ankle sprain Other? Exercises and Progressions:Ankle:

29. 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

30. 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

31. Clinical Implications • What other joints, disorders or patient populations might benefit? • Osteoarthritis • Aged • Sedentary • Temporomandibular disorder (TMD) • Hypermobility syndrome • Vestibular disorder • Other?

32. Besides…Proprioception exercises are fun!