Galley Proof 13/07/2021; 15:37 File: bmr–1-bmr200361.tex; BOKCTP/ljl p.

Journal of Back and Musculoskeletal Rehabilitation -1 (2021) 1–8 1

DOI 10.3233/BMR-200361
IOS Press

Comparison of the effects of conventional

physiotherapy and proprioception exercises
on pain and ankle proprioception in patients
with lumbar radiculopathy
Deniz Senola , Cumali Erdemb , Mustafa Canbolatc , Seyma Toyd , Turgay Karatasc ,
Rabia Aydogan Baykarab , Davut Ozbagc and Gokcen Akyureke,∗

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a
Department of Anatomy, Faculty of Medicine, Duzce University, Duzce, Turkey
b
Department of Physical Medicine and Rehabilitation, Malatya Training and Research Hospital, Malatya, Turkey

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c
Department of Anatomy, Faculty of Medicine, İnönü University, Malatya, Turkey

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d
Department of Anatomy, Faculty of Medicine, Karabuk University, Karabuk, Turkey
e
Department of Occupational Therapy, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
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Received 19 December 2020

Accepted 2 June 2021
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Abstract.
BACKGROUND: Lumbar radiculopathy is characterized by a significant amount of backache causing loss of workforce and is a
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significant health problem frequently seen in the general population.

OBJECTIVE: The purpose of this study was to compare the effects of conventional physiotherapy (CT) and proprioception
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exercises (PE) on ankle proprioception and lumbar pain between patients with lumbar radiculopathy and a healthy control group.
METHODS: In this randomized clinical trial, 89 patients referred to the Physical Medicine and Rehabilitation outpatient clinic
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were selected through convenience sampling. They were randomly assigned to three groups: CT (n = 27), PE (n = 31), CT&PE
(n = 31). Thirty healthy volunteers were included in the study as the control group. Proprioception measurements were made with
an isokinetic dynamometer at 10◦ dorsiflexion (DF), 11◦ , and 25◦ plantarflexion (PF) angles. Lumbar pain was assessed by using
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the Numerical Pain Rating Scale (NPRS). The data were analyzed by IBM SPSS Statistics version 22.0 via the Kruskal-Wallis and
Mann-Whitney U tests.
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RESULTS: There was a statistically significant difference between the groups in terms of ankle proprioception and NPRS
measurements in post-treatment evaluations (p < 0.05). Statistically significant differences were found between CT and PE groups
and CT&PE and control groups. There was no statistically significant difference in comparing CT and PE groups and CT&PE and
control groups within themselves (p > 0.05).
CONCLUSION: The combined use of CT and PE is an effective method that can be used in the clinic to reduce angular
differences in ankle proprioception which is one of the primary factors of balance and coordination and lumbar pain.

Keywords: Proprioception, physiotherapy, radiculopathy, pain, exercises

1. Introduction 1

∗ Corresponding
Lumbosacral radiculopathy is a term used to describe 2
author: Gokcen Akyurek, Department of Occu-
pational Therapy, Faculty of Health Sciences, Hacettepe Univer-
a pain syndrome caused by compression or irritation of 3

sity, Ankara, Turkey. Tel.: +90 5426136228; E-mail: gkcnakyrk@ nerve roots in the lower back [1]. It can be caused by 4

gmail.com. lumbar disc herniation, degeneration of the spinal verte- 5

ISSN 1053-8127/$35.00
c 2021 – IOS Press. All rights reserved.
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2 D. Senol et al. / Physiotherapy and proprioception exercise

6 bra, and narrowing of the foramen where the nerves exit awareness has emerged about the significance of propri- 57

7 the spinal canal [1,2]. While the literature lacks concise oception, and special rehabilitation programs increasing 58

8 epidemiologic data, most reports estimate about a 3% to proprioception have been added in the treatment proto- 59

9 5% prevalence rate of lumbosacral radiculopathy in pa- cols of locomotor system diseases, especially in sports 60

10 tient populations [3]. Symptoms can include numbness, injuries. In patients with lumbar radiculopathy, dam- 61

11 weakness, and loss of reflexes, radiating pain, and gait aged dermatomal and myotomal fields may cause devi- 62

12 abnormalities [1,2]. Untreated lumbar radiculopathies ations in the ankle proprioception angle [5]. Correcting 63

13 will lead to restriction in movements to avoid pain, re- proprioceptive errors enables patients to gain more use 64

14 sulting in disruption of the spine and lower extremity of the treatment, decrease recurrent traumas and assure 65

15 mechanism and inviting secondary radiculopathy [4]. a quicker return to routine daily activities [15,16]. This 66

16 In this respect, it is thought that exercise and physical study hypothesizes that the methods used in routine 67

17 therapy methods have critical importance in this patient physiotherapy can be effective on ankle proprioception 68

18 population. and pain, which is thought to be affected by lumbar 69

19 A problem in any part of the locomotor system causes radiculopathy and can get patients closer to healthy 70

20 too much load on the muscles and joints, and conse- controls. This study aims to compare the effects of con- 71

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21 quently, agonist-antagonist muscle imbalance and se- ventional physiotherapy (CT), proprioception exercises 72

22 rious injuries occur [5–7]. For example, disturbed pro- (PE), and combined use of conventional physiotherapy 73

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23 prioception leads to altered neuromuscular function, and proprioception exercises (CT&PE) on ankle pro- 74

which, if not corrected, may further exacerbate the in- prioception and lumbar pain in patients with lumbar

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24 75

25 jury and lead to a pattern of reinjury [7]. There are stud- radiculopathy. In addition, we aimed to evaluate the
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26 ies reporting impairment in postural balance in lum- effectiveness of the treatment by comparing the post- 77

27 bar radiculopathy [8–10]. While individuals with lum- treatment outcomes with the control group. 78

bar radiculopathy have broad postural vibration and try

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28

29 to keep the center of gravity in the posterior, it is re-

30 ported that they cannot stand on one foot when their 2. Methods 79
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31 eyes are closed [11]. It is known that this condition is

32 often caused by nerve compression, pain, and the re- The study was conducted at the Malatya Training and 80
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33 sulting tissue damage [12]. Pain causes the inhibition Research Hospital after approval was obtained from 81

34 of the related muscle activity and imbalance of agonist- the Malatya Clinical Researches Ethics Committee (no. 82
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35 antagonist muscles [13,14]. This instability causes an 2018/68). Eighty-nine out of 115 patients between the 83

36 increase in loads of muscles or joints, which causes ages of 25–65 who were referred to the Malatya Train- 84
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37 them not to fulfill their functions correctly and thus to ing and Research Hospital Physical Medicine and Re- 85

38 get injured. Some studies have shown that injuries and habilitation outpatient clinic and who were diagnosed 86
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39 instability in joints decrease proprioception [15,16]. with lumbar radiculopathy with magnetic resonance 87

40 For good posture, the nervous system and the mus- imaging by a specialist physician were included in the 88
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41 cles and joints should work in harmony and make the study. Twenty-six patients who did not meet the inclu- 89

42 movements fit for purpose [17]. While the nervous sys- sion criteria and delayed the treatment days were not 90

43 tem makes the muscles, an active element of the loco- included in the study. The patients were distributed into 91

44 motor system, work through the sent impulses, it also groups in a randomized controlled manner, as 27 re- 92

45 receives messages from specialized mechanoreceptors ceiving CT, 31 receiving PE, and 31 receiving CT&PE. 93

46 in joints, tendons, ligaments, and the skin [17]. This The flowchart of the study is presented in Fig. 1. 94

47 sense is called proprioception, and it is accepted as one There were no sensory and motor deficits in 30 95

48 of the parameters that ensure the protection of postu- healthy volunteers who were included in the study as 96

49 ral control and balance [18]. The messages originating the control group. Age, height, weight, dominant side, 97

50 from mechanoreceptors and the visual-vestibular sys- pre-treatment, and post-treatment measurements of all 98

51 tem are gathered together; thus, we have information participants included in the study were recorded. 99

52 about the position of our bodies in space [19]. All patients had a full body examination, including 100

53 Although a study on the lumbar region has examined the locomotor system. The patients who had an in- 101

54 the spine’s stability [4], the number of studies evaluat- fectious, inflammatory, tumoral, and metabolic pathol- 102

55 ing the proprioception status, including lower extremity ogy that could cause pain, patients with a history of 103

56 muscles and joints, is quite limited. Recently, a serious spinal surgery, patients who had a spinal instability 104
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D. Senol et al. / Physiotherapy and proprioception exercise 3

three weeks in total by applying 5-minute long warm-up 135

and cooling before and after exercise [21,22]. 136

Both protocols were applied to the CT&PE group 137

five days a week, three weeks in total, by the same 138

physiotherapist. 139

2.3. Ankle proprioception measurement 140

Ankle proprioception measurements were conducted 141

on the affected sides of all patients included in the study. 142

Pre-treatment and post-treatment scores were recorded 143

by using a baseline digital inclinometer (Model: 12- 144

1057, Fabrication Enterprises, Inc., White Plains, NY, 145

USA). The ankle proprioception was assessed in EO 146

and EC position at 10◦ dorsiflexion (DF), 11◦ and 25◦ 147

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Fig. 1. Flowchart of the study.
plantarflexion (PF) positions by using an active repro- 148

duction test. Joint position sense was assessed by re- 149

problem, osteoporosis, patients with a body mass index

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105
peating positioning actively and passively. First, the 150
106 (BMI) higher than 30 kg/m2 , severe cardiovascular or
extremity on which the inclinometer was fastened was

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151
107 metabolic disease, pregnant women and those who had
brought to the targeted angle, and the subject was kept 152
108 received physiotherapy and medical treatment for the
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in that position for a minimum of 10 seconds to re- 153
109 lumbar region within the last six months were not in-
member this position. Then, the extremity was taken 154
110 cluded in the study. The healthy volunteers included in
to the initial position. The participant was asked to ac-
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155
111 the control group were examined by a specialist. The
tively bring the extremity to the target angle or indicate 156
112 control group did not have any known systemic, loco-
when s/he reached the predetermined angle passively. 157
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113 motor system, and cognitive problems. All patients and

The deviation amount from the targeted angle (angular 158
114 controls who participated in the study were informed
error) was recorded. Active positioning (the ability to 159
about the study and signed informed consent forms.
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115
bring the extremity actively to the predetermined an- 160

gle) measures the ability of the muscle and capsular 161

2.1. Conventional physiotherapy protocol
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116
receptors, whereas passive positioning primarily mea- 162

sures the capability of the capsular receptors [23,24]. 163

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117 Conventional physiotherapy agents were as follows: This study evaluated the proprioceptive function as a 164
118 Transcunatenus Electrical Nerve Stimulation (TENS) whole in line with the literature. Following a trial test, 165
was applied on the lumbar region in all patients 20 min-
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119
the subjects were asked to move their ankles to target 166
120 utes a day, five days a week for three weeks with Com- angles three times, and the mean value was recorded as 167
pex Theta MI Pro. In addition, 20 minutes of hot pack
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121
well as the measured average distance. A medical doc- 168
122 application was used as a superficial heat agent. Ul- tor performed the ankle proprioception measurements. 169
123 trasound (US) was used as a deep heat agent and was All of the evaluation methods were conducted on the 170
124 applied with a frequency of 1 MHz and 1.5 watts/cm2 dominant side [25]. 171
125 intensity for 10 minutes [20]. CT agents were applied
126 by the same physiotherapist for five days a week, three 2.4. Pain analysis 172
127 weeks in total.
Pain analysis was evaluated by the Numerical Pain 173

128 2.2. Proprioception exercises Rating Scale (NPRS). The NPRS is a measure of pain 174

intensity in adults. Although various scales exist, the 175

129 Exercises for the PE group (balance on one foot with most commonly used is the 11-item NPRS. It is a seg- 176

130 arms open on sides in line with the chest, dorsiflexion- mented numeric version of the visual analog scale in 177

131 plantar flexion, inversion-eversion exercises on the bal- which a respondent selects a whole number (0–10). 178

132 ance board with eyes open and eyes closed (EO, EC), 0 represents no pain, and 10 represents severe pain 179

133 walking training on an uneven surface) were performed (“as bad as you can imagine” and “worst pain imagin- 180

134 with the same physiotherapist for five days a week, able”) [26]. 181
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4 D. Senol et al. / Physiotherapy and proprioception exercise

Table 1
The median (min-max) values of age, weight, height and BMI variables of CT, PE, CT&PE and control groups
Sex Parameter CT PE CT&PE Control p
Male Age (year) 43 (26–62) 44.1 (24–65) 46.5 (22–64) 46.6 (22–63) 0.141
Weight (kg) 83.5 (69–93) 86.2 (65–97) 80 (65–99) 81.1 (73–91.9) 0.138
Height (cm) 176 (168–187) 180 (170–191) 175 (168–191) 177 (167–190) 0.092
BMI (kg/m2 ) 25.1 (22.3–28.6) 24 (21.1–28.3) 26.4 (22–29.6) 25.6 (21.5–27.9) 0.296
Female Age (year) 48 (23–64) 47 (23–60) 47 (24–65) 50 (25–63) 0.091
Weight (kg) 75 (47–91) 71.5 (47–98) 73 (45–101) 74 (44.5–96) 0.123
Height (cm) 160 (148–178) 163 (151–178) 163 (150–183) 162 (151–177) 0.236
BMI (kg/m2 ) 24 (22–27.5) 25.2 (23.2–29) 25.3 (21–28.7) 26.1 (23.1–28.9) 0.178
CT: Conventional physiotherapy, PE: Proprioception exercises, CT&PE: Combined use of conventional physiotherapy
and proprioception exercises, BMI: Body mass index.

Table 2 Table 3
Median (min-max) values and Wilcoxon test analysis results of pre- Median (min-max) values and Wilcoxon test analysis results of pre-
treatment post-treatment ankle proprioception and NPRS measure- treatment post-treatment ankle proprioception and NPRS measure-
ments of male and female patients in the CT group ments of male and female patients in the PE group

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Sex Variables Pre-treatment Post-treatment p Sex Variables Pre-treatment Post-treatment p
Male EO10◦ DF 4.9 (1–8.1) 4.2 (0–7.7) 0.112 Male EO10◦ DF 4.9 (1–7.2) 4.7 (1–6.7) 0.200

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EO11◦ PF 8.8 (1–12.3) 7.3 (0–11.1) 0.048 EO11◦ PF 8.9 (1–14) 6.9 (0–12) 0.033
EO25◦ PF 7.9 (1–13.4) 6.1 (0–11.3) 0.040 EO25◦ PF 8.2 (1–13.9) 6.4 (0–13.1) 0.016

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EC10◦ DF 5.5 (1.5–10.4) 5.4 (0–10) 0.232 EC10◦ DF 6 (1–9.2) 5.5 (0–10.1) 0.172
EC11◦ PF 8.3 (2.8–13.7) 6.3 (1.1–10.7) 0.034 EC11◦ PF 8.9 (1.5–12.3) 6.5 (0–11.7) < 0.001
EC25◦ PF EC25◦ PF 10.2 (1.2–15)
9.2 (1–16.8) 7 (0–13.2) < 0.001
fv 6.8 (0–12.4) < 0.001
NPRS 7 (5–9) 4 (2–7) < 0.001 NPRS 8 (4–10) 4 (0–8) < 0.001
Female EO10◦ DF 5.1 (1–10.2) 4.8 (0–11) 0.098 Female EO10◦ DF 6 (1–9.9) 5.3 (0.5–12) 0.123
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EO11◦ PF 7.2 (1.5–12.1) 6.1 (0–10.3) 0.047 EO11◦ PF 8 (1–11.2) 5.9 (0–9.5) < 0.001
EO25◦ PF 7.5 (2.4–13) 6.2 (0–13.7) 0.440 EO25◦ PF 7.1 (1.5–11) 6 (0–13.7) 0.310
EC10◦ DF 6.3 (3–12.6) 6.3 (0.5–13.4) 0.261 EC10◦ DF 6.4 (2–11) 6 (0–12.3) 0.203
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EC11◦ PF 7.7 (0.5–10.7) 6.7 (0–11.5) 0.038 EC11◦ PF 8.7 (1–11.5) 6.5 (0–13) 0.001
EC25◦ PF 9.7 (2–14.2) 7.7 (1–12) 0.022 EC25◦ PF 9.4 (1–13) 7.2 (0–11.5) 0.005
NPRS 7 (4–9) 4 (1–9) 0.029 NPRS 7 (4–10) 4 (0–10) < 0.001
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DF: Dorsiflexion, EO: Eyes Open, EC: Eyes Close, PF: Plantarflex- DF: Dorsiflexion, EO: Eyes Open, EC: Eyes Close, PF: Plantarflex-
ion, NPRS: Numerical Pain Rating Scale. ion, NPRS: Numerical Pain Rating Scale.
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182 2.5. Statistical analysis Table 4

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Median (min-max) values and Wilcoxon test analysis results of pre-

183 The normality distribution of the data was tested with treatment post-treatment proprioception and NPRS measurements of
the Kolmogorov-Smirnov test, and it was found that the male and female patients in the CT&PE group
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184

185 data were not normally distributed. Kruskal-Wallis test Sex Variables Pre-treatment Post-treatment p
186 was applied to the groups to compare the age, weight, Male EO10◦ DF 5.9 (1–10.1) 3.5 (0–9.2) 0.047
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187 height, BMI, and post-treatment measurement results EO11◦ PF 6.5 (2–12.5) 4.5 (0–11.1) < 0.001
188 of the groups. Wilcoxon matched-pairs test was applied EO25◦ PF 7.4 (0.5–12.5) 3.5 (0–10.8) < 0.001
EC10◦ DF 6.5 (1.2–12) 3.2 (0–9.7) < 0.001
189 on the data to compare pre-treatment, post-treatment EC11◦ PF 6.7 (1–10.9) 5.1 (0–10.5) 0.040
190 proprioception measurements, and NPRS values. The EC25◦ PF 6.6 (0–11.9) 5.1 (1.2–13.4) 0.043
191 Mann-Whitney U test was applied as a post hoc test, NPRS 7 (4–10) 1 (0–5) < 0.001
192 and adjusted p values were given. The data with ab- Female EO10◦ DF 6.3 (2–12.3) 4.1 (0–9.4) < 0.001
EO11◦ PF 6.9 (0–10.2) 5 (0–11.2) 0.027
193 normal distribution were expressed with median and EO25◦ PF 7.2 (1–14) 4.7 (1.9–10.8) < 0.001
194 minimum (min) and maximum (max) values. A p-value EC10◦ DF 6.4 (0–11.5) 5.1 (0.7–10.5) 0.028
195 of < 0.05 was accepted as statistically significant. IBM EC11◦ PF 7.4 (0–13.7) 5.2 (1.1–10.3) < 0.001
196 SPSS Statistics 22.0 for Windows program was used EC25◦ PF 8.2 (1.3–13.5) 5.2 (0.4–12.4) < 0.001
NPRS 7 (3–10) 1 (0–6) < 0.001
197 for statistical analysis.
DF: Dorsiflexion, EO: Eyes Open, EC: Eyes Close, PF: Plantarflex-
ion, NPRS: Numerical Pain Rating Scale.
198 3. Results
(year), weight (kg), height (cm), and BMI (kg/m2 ) 200

199 Table 1 shows median (min-max) values of age of male and female patients in different groups and 201
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D. Senol et al. / Physiotherapy and proprioception exercise 5

Table 5
Median (min-max) values of post-treatment measurements of ankle proprioception and NPRS in CT,
PE, CT&PE and control groups and Kruskall-Wallis test analysis results
Sex Variables CT PE CT&PE Control p
Male EO10◦ DF 4.2 (0–7.7) 4.7 (1–6.7) 3.5 (0–9.2) 3.1 (0–5) 0.055
EO11◦ PF 7.3 (0–11.1) 6.9 (0–12) 4.5 (0–11.1) 3.4 (0–10) 0.031
EO25◦ PF 6.1 (0–11.3) 6.4 (0–13.1) 3.5 (0–10.8) 3.2 (0–8.3) < 0.001
EC10◦ DF 5.4 (0–10) 5.5 (0–10.1) 3.2 (0–9.7) 3.1 (0–7.1) 0.040
EC11◦ PF 6.3 (1.1–10.7) 6.5 (0–11.7) 5.1 (0–10.5) 4.1 (2–8.7) < 0.001
EC25◦ PF 7 (0–13.2) 6.8 (0–12.4) 5.1 (1.2–13.4) 4 (0–11) < 0.001
NPRS 4 (2–7) 4 (0–8) 1 (0–5) 0 < 0.001
Female EO10◦ DF 4.8 (0–11) 5.3 (0.5–12) 4.1 (0–9.4) 3.3 (0–6.5) 0.051
EO11◦ PF 6.1 (0–10.3) 5.9 (0–9.5) 5 (0–11.2) 3.7 (0–9.5) 0.011
EO25◦ PF 6.2 (0–13.7) 6 (0–13.7) 4.7 (1.9–10.8) 3.9 (0–10.3) < 0.001
EC10◦ DF 6.3 (0.5–13.4) 6 (0–12.3) 5.1 (0.7–10.5) 4.4 (0–8.8) 0.023
EC11◦ PF 6.7 (0–11.5) 6.5 (0–13) 5.2 (1.1–10.3) 5 (1–10) 0.036
EC25◦ PF 7.7 (1–12) 7.2 (0–11.5) 5.2 (0.4–12.4) 4.9 (0–9.9) < 0.001
NPRS 4 (1–9) 4 (0–10) 1 (0–6) 0 < 0.001

on
CT: Conventional physiotherapy, CT&PE: Combined use of conventional physiotherapy and propriocep-
tion exercises, DF: Dorsiflexion, EO: Eyes Open, EC: Eyes Close, PF: Plantarflexion, PE: Proprioception
exercises, NPRS: Numerical Pain Rating Scale.

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EO10◦ DF, EO11◦ PF, EO25◦ PF, EC10◦ DF, EC11◦

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202 Kruskal-Wallis test analysis results. According to the 235

203 results of the analysis, it was found that there were PF, EC25◦ PF, and NPRS values of female and male 236
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patients (p < 0.05). It was found that the angular dif-
204 no statistically significant differences between the age, 237

205 weight, height, and BMI variables of the groups (p > ferences in post-treatment proprioception scores and 238
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206 0.05) (Table 1). pain decreased in both male and female patients in the 239

207 Table 2 shows median (min-max) values of pre- CT&PE group (Table 4). 240

treatment and post-treatment proprioception measure- Table 5 shows median (min-max) values of post-
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208 241

209 ments and NPRS of the individuals in the CT group in treatment proprioception measurements and NPRS val- 242

210 addition to Wilcoxon test analysis results. According to ues of the individuals in CT, PE, CT&PE, and control 243
ed

211 the analysis results, a statistically significant difference groups and Kruskal-Wallis test analysis results. Ac- 244

212 was found between pre-treatment and post-treatment cording to the analysis results, a statistically significant 245

difference was present between groups in EO11◦ PF,

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213 EO11◦ PF, EO25◦ PF, EC11◦ PF, EC25◦ PF, and NPRS 246

values of female and male patients (p < 0.05). It was EO25◦ PF, EC10◦ DF, EC11◦ PF, EC25◦ PF, and NPRS 247
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214

215 seen that the angular differences in post-treatment pro- parameters of both men and women (p < 0.05). It was 248

216 prioception scores and pain decreased in both male and found that both men and women in CT&PE and control 249

groups had lower angular differences in post-treatment

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250
217 female patients in the CT group (Table 2).
218 Table 3 shows median (min-max) values of pre- proprioception scores and pain scores than men and 251

women in CT and PE groups (Table 5).

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252
219 treatment and post-treatment proprioception measure-
220 ments and NPRS of the individuals in the PE group The Mann-Whitney U test was applied to the data 253

as a post hoc test to examine intergroup differences 254

221 with Wilcoxon test analysis results. According to the
and adjusted p values. The results are presented in Ta- 255
222 analysis results, a statistically significant difference was
ble 6. According to the analysis results, statistically 256
223 found between pre-treatment and post-treatment EO11◦
significant differences were present between CT and 257
224 PF, EO25◦ PF, EC11◦ PF, EC25◦ PF, and NPRS values
PE groups and between CT&PE and Control groups re- 258
225 of female and male patients (p < 0.05). It was seen that
garding the evaluated parameters. There were no statis- 259
226 the angular differences in post-treatment propriocep-
tically significant differences in the comparison of CT 260
227 tion scores and pain decreased in both male and female and PE groups and CT&PE and Control groups within 261
228 patients in the PE group (Table 3). themselves (p > 0.05) (Table 6). 262
229 Table 4 shows median (min-max) values of pre-
230 treatment and post-treatment proprioception measure-
231 ments and NPRS of the individuals in the CT&PE 4. Discussion 263
232 group and Wilcoxon test analysis results. According to
233 the analysis results, a statistically significant difference Lumbar radiculopathy, characterized by a signifi- 264

234 was found between pre-treatment and post-treatment cant amount of backache that can cause loss of work- 265
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6 D. Senol et al. / Physiotherapy and proprioception exercise

Table 6
Adjusted p values of Mann-Whitney U test applied as post hoc test
Binary
Sex EO11◦ PF EO25◦ PF EC10◦ DF EC11◦ PF EC25◦ PF NPRS
comparison
Male CT-PE 0.125 0.231 0.229 0.315 0.214 0.398
CT-CT&PE < 0.001 < 0.001 0.045 < 0.001 < 0.001 < 0.001
CT-Control < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
PE- CT&PE < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
PE-Control < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
CT&PE-Control 0.288 0.119 0.099 0.375 0.087 0.093
Female CT-PE 0.199 0.214 0.202 0.207 0.096 0.121
CT-CT&PE < 0.001 < 0.001 0.038 < 0.001 < 0.001 < 0.001
CT-Control < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
PE-CT&PE 0.023 < 0.001 0.034 < 0.001 < 0.001 < 0.001
PE-Control < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
CT&PE-Control 0.176 0.312 0.276 0.121 0.067 0.073
CT: Conventional physiotherapy, CT&PE: Combined use of conventional physiotherapy and proprioception
exercises, DF: Dorsiflexion, EO: Eyes Open, EC: Eyes Close, PF: Plantarflexion, PE: Proprioception exercises,

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NPRS: Numerical Pain Rating Scale.

force, is a significant health problem frequently seen provides significant improvement in ankle EO11◦ PF,

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266 300

267 in the general population [27]. A considerable num- EO25◦ PF, EC11◦ PF, EC25◦ PF, and NPRS in indi- 301

er
268 ber of patients with lumbar radiculopathy evaluated in viduals with lumbar radiculopathy, it was not found to 302

269 the present study were randomly allocated to treatment have an advantage over CT&PE. 303
fv
270 groups. At the end of the study, the groups were com- In our daily lives, the localization and proprioception 304

271 pared with the control group. According to the analysis of the lower extremity, and thus the ankle, gain impor- 305
oo

272 results, when pre-treatment and post-treatment mea- tance in providing and maintaining balance while walk- 306

273 surements were compared between male and female ing and standing. Proprioceptive mechanisms appear 307
pr

274 patients in CT and PE groups, EO11◦ PF, EO25◦ PF, to play a role in joint stabilization and may serve as a 308

275 EC11◦ PF, EC25◦ PF angular differences and NPRS means for interplay between static stabilizers and dy- 309
ed

276 scores were found to decrease. When pre-treatment and namic muscular restraints [32]. Malliou et al. reported 310

277 post-treatment measurements in male and female pa- that exercise in the group receiving proprioceptive exer- 311

tients in the CT&PE group were compared, EO10◦ DF, cise had a major improvement effect on proprioception
ct

278 312

279 EO11◦ PF, EO25◦ PF, EC10◦ DF, EC11◦ PF, EC25◦ PF and reduced lower extremity injuries due to radiculopa- 313
rre

280 angular differences and NPRS scores were decreased. thy [33]. Lu et al. assessed the efficiency of propriocep- 314

281 In post-treatment assessments, statistically significant tive exercises in patients with LDH and reported a sig- 315

differences were present in both men and women in nificant increase in the post-treatment spinal stabiliza-
co

282 316

283 EO11◦ PF, EO25◦ PF, EC10◦ DF, EC11◦ PF, EC25◦ tions of the exercise group [34]. Lin and Lin reported 317

PF, and NPRS parameters between groups. Statistically that older patients with lumbar nerve root compression
un

284 318

285 significant differences were found between CT and PE had weaker leg muscle strength and poorer balance con- 319

286 groups and CT&PE and control groups. In the com- trol than healthy older adults [35]. As a result of this 320

287 parison of CT and PE groups and CT&PE and control study, it was concluded that there were statistically sig- 321

288 groups within themselves, no statistically significant nificant improvements in EO11◦ PF, EO25◦ PF, EC11◦ 322

289 differences were found. PF, EC25◦ PF, and NPRS results of individuals with 323

290 Although lumbar radiculopathy has many alterna- lumbar radiculopathy in the PE group; however, this 324

291 tive treatments such as CT, acupuncture, chiroprac- was not an advantage over the CT&PE group. 325

292 tic manipulation, exercises, traction, epidural injection, Exercises aiming at paraspinal muscle strength, 326

293 and surgery, CT and exercise therapies stand out be- which are frequently applied in routine treatment, pro- 327

294 cause they are easily accessible and non-invasive meth- vide endurance and recovery in spinal mobility. This 328

295 ods [28,29]. The literature remarks that CT is used type of exercise provides the centralization of the nu- 329

296 frequently in the treatment of individuals with low cleus pulposus and ensures the regression of symptoms 330

297 back pain. Statistically significant improvement in ki- in the presence of herniated nucleus pulposus, espe- 331

298 nesiophobia, disability, and pain is reported after treat- cially after the acute phase [36]. Although this situation 332

299 ment [30,31]. In this study, while it was found that CT causes regression in pain and thus positive results in 333
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D. Senol et al. / Physiotherapy and proprioception exercise 7

334 proprioceptive input, proprioceptive exercises applied for physiotherapists, physiatrists, neurosurgeons, spine 382

335 in this study are very valuable in providing a quick surgeons, and clinicians and provide a basis for other 383

336 transformation of the required proprioceptive input for studies to be conducted. 384

337 coordination and proprioception in the ankle.

338 Sipko et al. reported that patients with LDH had
339 difficulty in their postural control, and especially the EC Author contributions 385

340 proprioception sensation would be adversely affected.

341 They stated that the EO postural performance of patients DŞ, ŞT, CE, and RAB: Conceptualization; data 386

342 with LDH was the same as the healthy individuals and curation, methodology, validation, visualization; and 387

343 that postoperative controls showed improvement after writing-original draft. TK, GA, MC: Validation, for- 388

344 surgery [37]. mal analysis, resources; and writing-review and editing. 389

345 When situations such as pain or paraesthesia result- DŞ and DÖ: Conceptualization, methodology, valida- 390

346 ing from radiculopathy regress, the individual can show tion, visualization; writing-review and editing; fund- 391

347 his/her actual motor performance. Although the mech- ing acquisition and supervision. All authors read and 392

348 anism of the association between the increase in mo- approved the final manuscript. 393

on
349 tor strength and the development obtained in the pro-
350 prioception is not completely known, it is stated that
Conflict of interest

si
394
351 strengthening the motor component of the sensorimo-
tor system can cause the motor response to be faster

er
352
The authors declare that there is no conflict of inter- 395
353 and more suitable. However, sensory stimulation does est.
fv 396
354 not change [38]. Studies conducted in the literature on
355 low back pain show that patients were reported to have
higher angular deviations than healthy individuals in
oo
356
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