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.

Clarkson University Master of Physical Therapy Program

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

Clarkson University Master of Physical Therapy Program

Muscle Spindle Organs

Clarkson University Master of Physical Therapy Program

Muscle Spindle Organs

Clarkson University Master of Physical Therapy Program

Golgi Tendon Organ

Clarkson University Master of Physical Therapy Program

More Mechanoreceptors

Ruffini ending

Pacinian corpuscle

Clarkson University Master of Physical Therapy Program

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)
Clarkson University Master of Physical Therapy Program

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)

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

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

Clarkson University Master of Physical Therapy Program

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

Clarkson University Master of Physical Therapy Program

Exercises and Progressions:

Ankle:
Appropriate Patients
Recurrent ankle sprain
Other?

Clarkson University Master of Physical Therapy Program

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
Clarkson University Master of Physical Therapy Program

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
Clarkson University Master of Physical Therapy Program

Clinical Implications
What other joints, disorders or patient
populations might benefit?

Osteoarthritis
Aged
Sedentary
Temporomandibular disorder (TMD)
Hypermobility syndrome
Vestibular disorder
Other?
Clarkson University Master of Physical Therapy Program

Besides
Proprioception exercises are fun!

Clarkson University Master of Physical Therapy Program