Assessment Of Proprioception Research Articles

Assessing Proprioception in Children: A Review

ABSTRACTProprioception is the subconscious and conscious awareness of the spatial and mechanical status of the musculoskeletal framework. When working with children with motor delays and sensory integrative dysfunction, occupational therapists routinely assess the client's proprioceptive system. However, currently available assessments for occupational therapists are primarily observer-based and concerns have been raised about the reliability of observer-based assessments of sensation. The author's purpose was to review measures of proprioception currently available to occupational therapists and explore direct measures of proprioception from neuroscience and rehabilitation that can be adapted for pediatric clinical use. Observer-based and direct measurements of proprioception assessments complement each other in meeting clinical needs. A better understanding of both types of evaluation will improve proprioceptive evaluation.

Assessment of lumbar proprioception in participants with functional ankle instability: a cross-sectional study

Functional ankle instability (FAI) represents 40–75% of residual disability after acute lateral ankle sprain. FAI has been associated with impaired muscle strength and postural and neuromuscular control. The aim of this study was to investigate the association between FAI and lumbar proprioception. Thirty individuals of both sexes (17 female and 13 male) were selected. The FAI group included 15 participants (nine female and six male) and the control group included 15 normal individuals (eight female and seven male). Lumbar proprioception was assessed using the Biodex system 3 pro isokinetic dynamometer. There was a significant increase in repositioning error in the FAI group compared with the control group (P<0.001). There was an association between FAI and an increase in lumbar reposition error compared with healthy individuals. This effect should be considered in the rehabilitation protocol of patients with FAI.

Internal consistency of a proprioceptive assessment battery for patients with below-knee amputation (BEPAT, by its acronym in Spanish) in Hospital Militar Central

Internal consistency of a proprioceptive assessment battery for patients with below-knee amputation (BEPAT, by its acronym in Spanish) in Hospital Militar Central

Proprioceptive assessment battery for patients with below-knee amputation (BEPAT in Spanish)

Introducción. La amputación trae diversos cambios biomecánicos y estructurales que generan deficiencias en el balance, el equilibrio y la propiocepción. Asimismo, la alteración de la propiocepción afecta el componente corpóreo–espacial, el control postural y demás cualidades físicas, lo cual requiere un manejo específico desde la Fisioterapia. Esta investigación se realizó teniendo en cuenta su función como herramienta adecuada y eficaz dentro de la Fisioterapia, debido a la poca documentación en la literatura de la evaluación propioceptiva en la población escogida. Objetivo. Proponer y validar una batería de evaluación propioceptiva para personas con amputación transtibial, ya protetizadas. Materiales y métodos. Estudio de tipo descriptivo-propositivo que requirió un proceso de recolección de información para proponer una batería de evaluación, basada en la evidencia científica disponible. Resultados. La batería de evaluación de la propiocepción para personas con amputación transtibial ya protetizada (BEPAT), cuenta con alta validez de contenido y constructo según los criterios de Palisano, considerando que los resultados para todos los ítems en la batería se encontraron por encima del 70%. Conclusiones. La creación de la BEPAT permitirá la obtención de información objetiva y cuantitativa sobre las alteraciones funcionales, lo que mejorará la prescripción de prótesis y el tratamiento rehabilitador y fortalecerá los procesos investigativos en el tema.

Effectiveness of Neuromuscular Training Program In Young Athletes Suffering From Lower Lateral Ankle Ligament Injury

The perception and execution of musculoskeletal control and movement are mediated primarily by the central nervous system and involve the integration of 3 main subsystems: somatosensory, vestibular, and visual. Balance performance and its measurement are influenced by these subsystems.This present study was carried out to investigate the effectiveness of, neuromuscular controlled training exercises comprising bosu-ball balance training and conventional physiotherapy exercise training protocols on the level of stability, balance and proprioception in the athletes, diagnosed with lateral ligament injury of ankle joint. The Y Balance test was used as a reliable and valid tool for quantitative balance assessment. Thirteen players (aged between 19 to 26 years, Mean age = 23.2; SD = 2.46) suffering from grade II &amp; grade III lateral ligament injury were recruited from the OPD of the department of Orthopaedics, of the Hosptial of Universiti Sains Malaysia.All of the participants were subjected to pre-intervention or baseline assessments, comprising of Y-balance test and assessment of proprioception employing Biodex 4 Isokinetic Equipment. Thereafter participants were introduced with neuromuscular controlled training program, which was imparted for 12 sessions (30 min/day; 2 days/wk. for 6 wk.). Findings of the study revealed that 6 weeks of neuromuscular exercises training significantly improved the balance and some significant aspects of proprioception observed amongst the young athletes diagnosed with ankle lateral ligament injury.

Robot-assisted assessment of wrist proprioception: does wrist proprioceptive acuity follow Weber's law?

Proprioception is essential for planning and controlling limb posture and movement. In our recent work, we introduced a standardized robot-aided method for measuring proprioceptive discrimination thresholds at the wrist to obtain reliable and accurate measures of proprioceptive acuity. Weber's law defines discrimination thresholds as a constant ratio between the just noticeable difference and the reference or standard stimulus. Reporting Weber's fractions thus provides the possibility of comparing results with the reports of others collected worldwide. This work aims to determine that Weber's Law holds for proprioceptive discrimination thresholds and to provide Weber's fraction for wrist joint proprioception. To this end, eight healthy subjects experienced two passive wrist movements of different amplitude and verbally indicated which was larger. An adaptive psychophysical procedure established the amplitude of the largest stimulus according to participants' responses. This comparison stimulus was then compared to a standard stimulus amplitude of 10°, 20°, 30° or 40°. The discrimination thresholds for each standard stimulus were established at the 75% correct response level. The obtained thresholds followed Weber's Law indicating that larger amplitudes were associated with higher discrimination thresholds. Based on a linear regression function the overall Weber's fraction, defined as the slope of the line, was computed to be 0.09. This result expands the present limited knowledge on wrist proprioception showing that its proprioceptive acuity follows Weber's law.

A preliminary study for quantitative assessment of upper limb proprioception.

Proprioception, or sense of position and movement of the body, strongly correlates with motor recovery of the hemiplegic arm. The evaluation of the awareness of the location of joints in space involves measuring the accuracy of joint-angle replication. Robotic devices allow an accurate manipulation of joint movements necessary to assess proprioceptive status. This study evaluated the proprioceptive performance of healthy subjects by mean of the H-Man, a planar robot designed for upper-limb rehabilitation to gather preliminary normative data for neurorehabilitation applications. Twelve participants were equally divided into Aged and Young groups and were asked to indicate when their dominant hand position matched a predefined target in the contralateral, sagittal and ipsilateral direction. Results indicated a better performance for movements towards the contralateral target in terms of both absolute and signed error while there was not a significant effect of age group. Error variability was not affected by the target location and participants' age. The present study established preliminary proprioceptive metrics that could assist in providing information about the normal range of proprioceptive acuity of healthy subjects of different age.

Reliable and Rapid Robotic Assessment of Wrist Proprioception Using a Gauge Position Matching Paradigm.

Quantitative assessments of position sense are essential for the investigation of proprioception, as well as for diagnosis, prognosis and treatment planning for patients with somatosensory deficits. Despite the development and use of various paradigms and robotic tools, their clinimetric properties are often poorly evaluated and reported. A proper evaluation of the latter is essential to compare results between different studies and to identify the influence of possible confounds on outcome measures. The aim of the present study was to perform a comprehensive evaluation of a rapid robotic assessment of wrist proprioception using a passive gauge position matching task. Thirty-two healthy subjects undertook six test-retests of proprioception of the right wrist on two different days. The constant error (CE) was 0.87°, the absolute error (AE) was 5.87°, the variable error (VE) was 4.59° and the total variability (E) was 6.83° in average for the angles presented in the range from 10° to 30°. The intraclass correlation analysis provided an excellent reliability for CE (0.75), good reliability for AE (0.68) and E (0.68), and fair reliability for VE (0.54). Tripling the assessment length had negligible effects on the reliabilities. Additional analysis revealed significant trends of larger overestimation (constant errors), as well as larger absolute and variable errors with increased flexion angles. No proprioceptive learning occurred, despite increased familiarity with the task, which was reflected in significantly decreased assessment duration by 30%. In conclusion, the proposed automated assessment can provide sensitive and reliable information on proprioceptive function of the wrist with an administration time of around 2.5 min, demonstrating the potential for its application in research or clinical settings. Moreover, this study highlights the importance of reporting the complete set of errors (CE, AE, VE, and E) in a matching experiment for the identification of trends and subsequent interpretation of results.

NT-3 promotes proprioceptive axon regeneration when combined with activation of the mTor intrinsic growth pathway but not with reduction of myelin extrinsic inhibitors

Although previous studies have identified several strategies to stimulate regeneration of CNS axons, extensive regeneration and functional recovery have remained a major challenge, particularly for large diameter myelinated axons. Within the CNS, myelin is thought to inhibit axon regeneration, while modulating activity of the mTOR pathway promotes regeneration of injured axons. In this study, we examined NT-3 mediated regeneration of sensory axons through the dorsal root entry zone in a triple knockout of myelin inhibitory proteins or after activation of mTOR using a constitutively active (ca) Rheb in DRG neurons to determine the influence of environmental inhibitory or activation of intrinsic growth pathways could enhance NT-3-mediate regeneration. Loss of myelin inhibitory proteins showed modest enhancement of sensory axon regeneration. In mTOR studies, we found a dramatic age related decrease in the mTOR activation as determined by phosphorylation of the downstream marker S6 ribosomal subunit. Expression of caRheb within adult DRG neurons in vitro increased S6 phosphorylation and doubled the overall length of neurite outgrowth, which was reversed in the presence of rapamycin. In adult female rats, combined expression of caRheb in DRG neurons and NT-3 within the spinal cord increased regeneration of sensory axons almost 3 fold when compared to NT-3 alone. Proprioceptive assessment using a grid runway indicates functionally significant regeneration of large-diameter myelinated sensory afferents. Our results indicate that caRheb-induced increase in mTOR activation enhances neurotrophin-3 induced regeneration of large-diameter myelinated axons.

Ankle proprioceptive acuity is associated with objective as well as self-report measures of balance, mobility, and physical function.

Ankle proprioceptive information is integrated by the central nervous system to generate and modulate muscle contractions for maintaining standing balance. This study evaluated the association of ankle joint proprioception with objective and self-report measures of balance, mobility, and physical function across the adult life span. Seven hundred and ninety participants (age range 24-97years, 362 women) who completed ankle proprioception assessment between 2010 and 2014 were included in the present study from the population-based cohort of the Baltimore Longitudinal Study of Aging (BLSA), USA. Outcome measures included ankle joint proprioception measured as threshold for perception of passive movement (TPPM); single leg stance time; perceived difficulty for standing balance; usual, fastest, and narrow-path gait speed; walking index; short physical performance battery score; and self-reported activity restriction due to fear of falling. Descriptive variables included age, sex, body mass index, education, strength, and cognition. Analyses of covariance (ANCOVA) in general linear model (GLM) or multinomial logistic regression analyses were performed, as appropriate, to test the hypothesis that balance, mobility, and physical function were significantly different according to TPPM quintiles even after adjusting for relevant covariates. Those with TPPM >2.2° consistently demonstrated poor balance, mobility, and physical function. However, with increase in challenge (single leg stance, fastest walking speed, and SPPB), TPPM >1.4° was associated with significantly worse performance. In conclusion, ankle proprioceptive acuity has an overall graded relationship with objective and self-report measures of balance, mobility, and physical function. However, the cutoff proprioceptive acuity associated with substantial decline or inability to perform could depend on the challenge induced.

Age-related differences in EEG beta activity during an assessment of ankle proprioception

The aim of this work was to compare cortical beta oscillatory activity between young (YA) and older (OA) adults during the assessment of ankle proprioception. We analyzed the response time (RT) to kinesthetic perception and beta event-related desynchronization/synchronization (ERD/ERS) in response to passive ankle movement applied at a slow speed, 0.5°/s. The relationship between ERD/ERS and RT was investigated by classifying the signals into fast-, medium-, and slow-RT. The results showed a temporal relationship between beta oscillation changes and RT for both groups, i.e., earlier ERD and ERS were obtained for trials with faster response time. ERD was larger and delayed in OA compared to the YA, and beta ERS was present only for OA. These findings suggest that a less efficient proprioceptive signaling reaching the brain of OA requires a higher level of brain processing and hence the differences in ERD potentials between YA and OA. Furthermore, the occurrence of ERS in OA might represent a compensatory strategy of active cortical resetting for adequate sensorimotor behavior due to the age-related reduced peripheral input and neuromuscular impairments. Altered balance between excitatory and inhibitory intracortical activity in older adults presumably explains the changes in beta oscillations.

Test-retest reliability of assessing cervical proprioception using cervical range of motion device

Background: Cervical proprioception plays an important role in the stability and optimal functional of the cervical spine and assessment of cervical proprioception is integral in the assessment and management of cervical spine dysfunction. Cervical range of motion (CROM) device is an effective tool, simple and cost effective tool to assess cervical proprioception. The objective of the study was to establish the test-retest reliability of a CROM in assessing cervical proprioception in asymptomatic individuals. Methods: Twenty healthy adults (mean age 37±8 years) were recruited and test retest reliability of CROM device in assessing cervical proprioception was assessed. Cervico-cephalic kinaesthetic sensibility tests - Neutral Head Positioning (NHP) and Target head Positioning (THP) tests were used to assess cervical proprioception. The test retest reliability was assessed in 2 sessions each session is separated with the other by 48 hours. Results: The test-retest reliability of measurements made with the CROM was verified with ICC values for all cervical measurements ranging between 0.66 (CI: 0.1, 0.8) for Target Head Position – rotation right to 0.93 (0.8, 0.9) (CI: 0.8-0.9) for THP – Rotation right. The correlation analysis found there are high and significant correlations between the test and retest results indicating that the reliability of the test can be established (positive correlation coefficients ranging from 0.524 – 0.863). Conclusion: CROM device can be used to quantify cervical proprioception errors with acceptable level of reliability in asymptomatic individuals.

Measurement of force sense reproduction in the knee joint: application of a new dynamometric device

[Purpose] The aim of this study was to determine the reliability of a newly designed dynamometric device for use in frequent force producing/reproducing tasks on the knee joint. [Subjects and Methods] In this cross-sectional study (Development & Reliability), 30 young healthy males and females (age 23.4 ± 2.48 years) were selected among students of Tabriz University of Medical Sciences by simple randomized selection. The study instrument was designed to measure any isometric contraction force exerted by the knee joint flexor/extensor muscles, known as the ipsilateral and contralateral methods. Participant knees were fixed in 60° flexion, and each participant completed the entire set of measurements twice, 72 hours apart. [Results] The findings showed a good intraclass correlation coefficient of 0.73 to 0.81 for all muscle groups. The standard error of measurement and smallest detectable difference for flexor muscle groups were 0.37 and 1.02, respectively, while the values increased to standard error of measurement=0.38 and smallest detectable difference=1.05 for extensor muscle groups. [Conclusion] The device designed could quantify the forces producing/reproducing tasks on the knee joint with a high rate of reliability, and can probably be applied for outcome measurements in proprioceptive assessment of the knee joint.

The Right Supramarginal Gyrus Is Important for Proprioception in Healthy and Stroke-Affected Participants: A Functional MRI Study.

Human proprioception is essential for motor control, yet its central processing is still debated. Previous studies of passive movements and illusory vibration have reported inconsistent activation patterns related to proprioception, particularly in high-order sensorimotor cortices. We investigated brain activation specific to proprioception, its laterality, and changes following stroke. Twelve healthy and three stroke-affected individuals with proprioceptive deficits participated. Proprioception was assessed clinically with the Wrist Position Sense Test, and participants underwent functional magnetic resonance imaging scanning. An event-related study design was used, where each proprioceptive stimulus of passive wrist movement was followed by a motor response of mirror ­copying with the other wrist. Left (LWP) and right (RWP) wrist proprioception were tested separately. Laterality indices (LIs) were calculated for the main cortical regions activated during proprioception. We found proprioception-related brain activation in high-order sensorimotor cortices in healthy participants especially in the supramarginal gyrus (SMG LWP z = 4.51, RWP z = 4.24) and the dorsal premotor cortex (PMd LWP z = 4.10, RWP z = 3.93). Right hemispheric dominance was observed in the SMG (LI LWP mean 0.41, SD 0.22; RWP 0.29, SD 0.20), and to a lesser degree in the PMd (LI LWP 0.34, SD 0.17; RWP 0.13, SD 0.25). In stroke-affected participants, the main difference in proprioception-related brain activation was reduced laterality in the right SMG. Our findings indicate that the SMG and PMd play a key role in proprioception probably due to their role in spatial processing and motor control, respectively. The findings from stroke-­affected individuals suggest that decreased right SMG function may be associated with decreased proprioception. We recommend that clinicians pay particular attention to the assessment and rehabilitation of proprioception following right hemispheric lesions.

The Hemi-Castaing ligamentoplasty for chronic lateral ankle instability does not modify proprioceptive, muscular and posturographic parameters.

The Hemi-Castaing ligamentoplasty uses a powerful dynamic stabilizer of the ankle which is the peroneus brevis tendon. To our knowledge, there is no study available evaluating the effects of this type of surgery on proprioceptive, muscular and posturographic parameters. This case-control study included 39 subjects divided into two groups: the operated (n = 24) and the control group (n = 15). All subjects underwent a clinical, proprioceptive and isokinetic assessment using a CON-TREX dynamometer, and a postural evaluation using the Win-Posturo force platform. At a mean period of 23 (SD 5.4) post-operative months, the Karlsson ankle functional score was 84.2 (SD 23.8) and the AOFAS score was 88.1 (SD 16.2). The mean ankle joint position error for operated ankles was from 1.9° (SD 0.9) at 10° of inversion range of motion to 2.5° (SD 1.7) at 20°. It was similar to that achieved in the control group ranging from 2.2° (SD 1) at 10° to 2.3° (SD 1.3) at 20°. No significant loss of ankle eversion strength could be observed after ligamentoplasty. Ankle eversion/inversion ratio when tested under all velocities and contraction modes failed to reveal any statistical difference between the operated and healthy ankles in the patient group, neither between the patient and control groups. This surgical technique achieved excellent functional outcomes. It did not impair the agonist/antagonist balance of ankle muscles, and use of half the peroneus brevis tendon did not lessen the eversion strength. Case-control study, Level III.

Measuring ankle proprioception DURING walking using a robotized ankle-foot orthosis: Towards a quantitative method to assess clinical populations

Evaluation of lower limb proprioception is usually done under static conditions. Sensory inputs are partially gated during movements, however. This gating might explain the lack of correlation between static proprioceptive testing and motor performance in clinical populations. The goal of the present study was therefore to determine if proprioception could reliably be estimated during actual walking. Twenty healthy subjects walked on a treadmill while wearing a robotized ankle-foot orthosis (see Noel et al., 2008; 2 visits within 2–7 days). Short-duration force perturbations (150 ms; n = 96) of graded amplitude (1–7 Nm; producing ankle deviations of 1–12°) were applied during the swing phase of gait, once every 5–10 strides. Participants pressed a hand-held button each time they felt a perturbation. To determine proprioceptive threshold, % detection was then plotted as a function of ankle deviations. A sigmoidal curve was fitted to individual subject data. Proprioceptive threshold was defined as the ankle deviation at which subjects detected 50% of the perturbations. Intraclass correlation coefficient (ICC) were then calculated to determine the test-retest reliability. Median proprioceptive threshold was 5.25° (range 1.04°–9.14°; n = 20). The ICC was 0.792, indicating a good reliability. This pilot study suggests that a threshold for movement error detection can be reliably obtained during walking in healthy subjects. This proprioceptive threshold is higher than what is reported during static tasks, likely reflecting the sensory gating occurring during movement, and emphasizing the need to perform this assessment during walking. Further studies are now underway to determine if this method can be used as a tool for proprioception assessment in clinical populations.

Adaptive Staircase Measurement of Hand Proprioception.

Clinicians and researchers often need to measure proprioception (position sense), for example to monitor the progress of disease, to identify the cause of movement or balance problems, or to ascertain the effects of an intervention. While researchers can use sophisticated equipment to estimate proprioceptive acuity with good precision, clinicians lack this option and must rely on the subjective and imprecise methods currently available in the clinic. Here we describe a novel technique that applies psychometric adaptive staircase procedures to hand proprioception with a simple tablet-style apparatus that could easily be adapted for the clinic. We report test-retest reliability, inter-rater reliability, and construct validity of the adaptive staircase method vs. two other methods that are commonly used in clinical settings: passive motion direction discrimination (PMDD) and matching. As a first step, we focus on healthy adults. Subjects ages 18–82 had their proprioception measured with each of the three techniques, at the metacarpophalangeal joint in the second finger of the right hand. A subset completed a second session in which the measures were repeated, to assess test-retest reliability. Another subset had the measurements done by two different testers to assess inter-rater reliability. Construct validity was assessed using stepwise regression on age and activity level, and correlations calculated across the three methods. Results suggest that of the three methods, the adaptive staircase method yields the best test-retest reliability, inter-rater reliability, and construct validity. The adaptive staircase method may prove to be a valuable clinical tool where more accurate assessment of proprioception is needed.

Robot-aided assessment of wrist proprioception.

Impaired proprioception severely affects the control of gross and fine motor function. However, clinical assessment of proprioceptive deficits and its impact on motor function has been difficult to elucidate. Recent advances in haptic robotic interfaces designed for sensorimotor rehabilitation enabled the use of such devices for the assessment of proprioceptive function. This study evaluated the feasibility of a wrist robot system to determine proprioceptive discrimination thresholds for two different DoFs of the wrist. Specifically, we sought to accomplish three aims: first, to establish data validity; second, to show that the system is sensitive to detect small differences in acuity; third, to establish test-retest reliability over repeated testing. Eleven healthy adult subjects experienced two passive wrist movements and had to verbally indicate which movement had the larger amplitude. Based on a subject's response data, a psychometric function was fitted and the wrist acuity threshold was established at the 75% correct response level. A subset of five subjects repeated the experimentation three times (T1, T2, and T3) to determine the test-retest reliability. Mean threshold for wrist flexion was 2.15°± 0.43° and 1.52°± 0.36° for abduction. Encoder resolutions were 0.0075°(flexion-extension) and 0.0032°(abduction-adduction). Motor resolutions were 0.2°(flexion-extension) and 0.3°(abduction-adduction). Reliability coefficients were r T2-T1 = 0.986 and r T3-T2 = 0.971. We currently lack established norm data on the proprioceptive acuity of the wrist to establish direct validity. However, the magnitude of our reported thresholds is physiological, plausible, and well in line with available threshold data obtained at the elbow joint. Moreover, system has high resolution and is sensitive enough to detect small differences in acuity. Finally, the system produces reliable data over repeated testing.

Methods for the assessment of neuromotor capacity in non-specific low back pain: Validity and applicability in everyday clinical practice.

Physiotherapists and clinicians require methods that can be used in everyday practice for measuring proprioception of the trunk in individuals with non-specific low back pain (NSLBP). Our objective was to conduct a systematic literature review of methods used for assessment of proprioception of the trunk in individuals with non-specific low back pain. Data were obtained from MEDLINE, CINAHL, Embase, PEDro and CENTRAL databases from their inception to December 2011. Reference lists of the selected reviews were hand searched for other potentially relevant studies. Randomized and nonrandomized controlled studies proprioception of the trunk in individuals with low back pain were selected. Thirty-six studies satisfied the selection criteria and were included in this review. Two reviewers independently selected the studies, conducted the quality assessment, and extracted data from each study. The Strobe scale was used to evaluate the scientific rigor of each selected study. This systematic review covered all the relevant literature, but none of the included studies offered a valid, reliable and feasible method to assess neuromotor capacity in everyday physiotherapy clinical practice.

Proprioception in musculoskeletal rehabilitation. Part 1: Basic science and principles of assessment and clinical interventions

IntroductionImpaired proprioception has been reported as a feature in a number of musculoskeletal disorders of various body parts, from the cervical spine to the ankle. Proprioception deficits can occur as a result of traumatic damage, e.g., to ligaments and muscles, but can also occur in association with painful disorders of a gradual-onset nature. Muscle fatigue can also adversely affect proprioception and this has implications for both symptomatic and asymptomatic individuals. Due to the importance of proprioception for sensorimotor control, specific methods for assessment and training of proprioception have been developed for both the spine and the extremities. PurposeThe aim of this first part of a two part series on proprioception in musculoskeletal rehabilitation is to present a theory based overview of the role of proprioception in sensorimotor control, assessment, causes and findings of altered proprioception in musculoskeletal disorders and general principles of interventions targeting proprioception. ImplicationsAn understanding of the basic science of proprioception, consequences of disturbances and theories behind assessment and interventions is vital for the clinical management of musculoskeletal disorders. Part one of this series supplies a theoretical base for part two which is more practically and clinically orientated, covering specific examples of methods for clinical assessment and interventions to improve proprioception in the spine and the extremities.