Transcript Proprioception changes with injury

Proprioception:
Changes with Injury,
Disease and Rehabilitation
Leslie Russek, PhD, PT, OCS
Clarkson University
Canton-Potsdam Hospital
Clarkson University Master of Physical Therapy Program
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?
Clarkson University Master of Physical Therapy Program
Clinical Questions:
• Why think about proprioception with an
ankle sprain patient?
• What exercises and progression of exercises
might you use with these patients?
Clarkson University Master of Physical Therapy Program
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.
Clarkson University Master of Physical Therapy Program
Sensory receptors mediating
prioprioception are found in skin,
muscles, joints, ligaments and
tendons.
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Mechanoreceptors
Receptor
Location
Adaptation Function
Ruffini ending Joint capsule
and ligaments
Slow
Joint pressure
Pacinian
Corpuscle
Joint capsule
Quick
High frequency
vibration
Golgi tendon
organ
Tendon
Slow
Reflex
Muscle
spindle
Muscle
Slow
Stretch reflex
Unmyelinated
free nerve
ending
Ligaments and
related muscles
Slow
Joint pain
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
CNS
Visual receptors
Vestibular receptors
Cognitive
programming
MUSCLE
Brain Stem
balance
From Lephart SM, Henry TJ. 1996
Clarkson University Master of Physical Therapy Program
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)
Clarkson University Master of Physical Therapy Program
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)
Clarkson University Master of Physical Therapy Program
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)
Clarkson University Master of Physical Therapy Program
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)
Clarkson University Master of Physical Therapy Program
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)
Clarkson University Master of Physical Therapy Program
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)
Clarkson University Master of Physical Therapy Program
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)
Clarkson University Master of Physical Therapy Program
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)
Clarkson University Master of Physical Therapy Program
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?
Clarkson University Master of Physical Therapy Program
Clinical Implications
• What kind of patients, injuries or diseases
might respond to proprioceptive training?
• What exercises are appropriate or effective?
Clarkson University Master of Physical Therapy Program
Exercises and Progressions:
Shoulder
• Appropriate patients:
• Types of exercises:
Clarkson University Master of Physical Therapy Program
Exercises and Progressions:
Shoulder
• Appropriate patients:
– Instability
– Impingement?
– Other?
• Types of exercises:
– PNF
– closed chain
stabilization/balance
– ballistic/plyometrics
– functional activities
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Exercises and Progressions:
Knee
• Appropriate Patients
• Types of exercises
Clarkson University Master of Physical Therapy Program
Exercises and Progressions:
Knee
• 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 Progressions:
Ankle:
• 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, sportsspecific exercises
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Clinical Implications
• What other joints, disorders or patient
populations might benefit?
–
–
–
–
–
–
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Osteoarthritis
Aged
Sedentary
Temporomandibular disorder (TMD)
Hypermobility syndrome
Vestibular disorder
Other?
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Besides…
Proprioception exercises are fun!
Clarkson University Master of Physical Therapy Program