Leslie Russek, PhD, PT, OCS

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Proprioception Changes with Injury, Disease and
Rehabilitation

• Leslie Russek, PhD, PT, OCS
• Clarkson University
• Canton-Potsdam Hospital

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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?

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Clinical Questions

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

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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.

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Sensory receptors mediating prioprioception are
found in skin, muscles, joints, ligaments and
tendons.
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Mechanoreceptors
Freeman MAR, Dean M, Hanhan I. 1965
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Muscle Spindle Organs
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Muscle Spindle Organs
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Golgi Tendon Organ
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More Mechanoreceptors
Ruffini ending
Pacinian corpuscle
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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
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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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Clinical Implications

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

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Clinical Implications

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

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Exercises and ProgressionsShoulder

• Appropriate patients

• Types of exercises

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Exercises and ProgressionsShoulder

• Appropriate patients
• Instability
• Impingement?
• Other?

• Types of exercises
• PNF
• closed chain stabilization/balance
• ballistic/plyometrics
• functional activities

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Exercises and ProgressionsKnee

• Appropriate Patients

• Types of exercises

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Exercises and ProgressionsKnee

• 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

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Exercises and ProgressionsAnkle

• Appropriate Patients
• Recurrent ankle sprain
• Other?

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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

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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

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Clinical Implications

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

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BesidesProprioception exercises are fun!