Proprioceptive Rehabilitation Research Articles

A preliminary study of test reliabilty in quantitative proprioception measurement

Objective To study the test-retest reliability in quantitative measurement of proprioception using Tecnobody rehabilitation system. Methods Nine healthy volunteers [4 males,5 females,averaged age (22.8 ±0.68) years] participated in three consecutive measurements on both feet by using Tecnobody rehabilitation system for computerized proprioceptive assessment.Standard of measurement(SEM),correlation coefficient and intraclass correlation coefficient(ICC) obtained from the three consecutive measurements were used to analyze the Timeused in each measuring session,and the average track error (ATE) of the measurements. Results SEM values of Time in left foot and right foot were 3.07 ～ 3.83 and 6.65 ～ 8.44 respectively.ATE values in left foot and right foot were 1.33 ～ 1.97 and 1.39 ～ 1.91 respectively.The Time and correlation coefficients of left foot / right foot were 0.919/0.6 and 0.808/0.831,respectively.The Time ICC values were 0.893/0.639 for left foot / right foot,respectively ; and the ATE ICC values were 0.716/0.734 for left foot / right foot,respectively. Conclusion The Tecnobody rehabilitation system provided a fairly good reliability in both relative and absolute values in quantitative evaluation of proprioception in the feet.These data in a larger amount may be useful for setting up variables and the standard values of the local population for reference in proprioceptive rehabilitation. Key words: Proprioception; Quantitative assessment; Reliability; Average track

Assessment of the impact of proprioceptive exercises on balance and proprioception in patients with advanced knee osteoarthritis

Impaired proprioceptive perception and the balance function are known to associate with knee osteoarthritis. The previous publications have reported the beneficial effects of proprioceptive exercises on mild or moderate knee osteoarthritis. Scientific data in the literature regarding their effects in advanced stages of knee osteoarthritis are lacking. The objective of this study is to investigate the impact of the proprioceptive exercises on balance, proprioceptive perception and clinical findings in advanced-stage knee osteoarthritis. Fifty-four patients diagnosed as having knee osteoarthritis according to the American Collage of Rheumatology criteria with grade of 3 or higher according to the Kellgren-Lawrence scale were enrolled in the study. Patients were allocated randomly into two groups. The study group included 30 patients, and the control group included 24 patients. The proprioceptive perception was assessed by the ability to reproduce the knee position. The balance function was assessed by stabilometric evaluation in static and dynamic patterns. The clinical evaluation was made by using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Patients were reevaluated after the three-week proprioceptive rehabilitation program. The improvement in the scores of static balance was significant statistically. No significant improvement in the dynamic balance scores was obtained. Although the measurements of proprioceptive perception showed a tendency toward improvement, the difference was not significant statistically. The WOMAC scores showed better improvements in the study group. As conclusion, in further stages of knee osteoarthritis, proprioceptive exercises have beneficial effects on static balance and to some extent on proprioceptive accuracy. In the treatment for advanced knee osteoarthritis, adding exercises specifically targeting the proprioceptive and balance dysfunction might be useful.

Le réentraînement proprioceptif chez les patients opérés d’une ligamentoplastie du LCA : quels effets sur le contrôle de l’équilibre ?

In order to show the effects of proprioceptive rehabilitation on postural control, 14 patients with postoperative anterior cruciate ligament reconstruction have been tested according to one-leg and two-leg standing tasks. Patients have been tested before and after the proprioceptive protocol on a force platform for three trials lasting 32 seconds, without shoes, eyes open. They were required to stay motionless as much as possible during the test. The data were then analyzed through classical parameters including mean positions, surface, variances and mean velocity of the center of pressure displacements and modeled as fractional Brownian motion (fBm). No statistically significant effect was observed during one-leg standing, whereas significant effects were reported during two-leg standing. More precisely, the strategies used to limit the antero-posterior body motions are changed and the asymmetries between the two legs, initially observed, tended to disappear. Thus, the proprioceptive rehabilitation protocol interferes with postural control, but in different ways according to the condition. Two-leg standing appears therefore as a more objective way to assess the proprioceptive rehabilitation effects and its measure may be used as benchmarks during rehabilitation.

Impaired Joint Proprioception at Higher Shoulder Elevations in Chronic Rotator Cuff Pathology

Anderson VB, Wee E. Impaired joint proprioception at higher shoulder elevations in chronic rotator cuff pathology. Objectives To assess the degree of impairment of shoulder proprioceptive acuity in individuals with chronic rotator cuff pathology (CRCP), and to examine the effect of impingement-related shoulder pain on acuity using a reliable laboratory technique. Design Case-control study. Setting University human movement laboratory. Participants A volunteer sample of individuals with CRCP (n=26) were recruited and screened, and compared with age-, sex-, and limb dominance–matched individuals (n=30) who acted as controls. Ten participants with CRCP underwent repeat assessment after 2 days to determine the intrarater reliability of proprioceptive measurement. Interventions Not applicable. Main Outcome Measures Each participant underwent assessment of joint position sense at 40° and 100° of scapular plane abduction using an active position-matching task. Movements were recorded with reflective skin markers and a multidimensional motion analysis system. Self-reported pain intensity associated with the procedure was recorded with a visual analog scale. Results Intraclass correlation coefficients (model 3,5) between repeat assessments ranged from .54 to .99. On average, those with CRCP demonstrated reduced acuity at 40° and 100° test angles. In comparison with the control group, proprioceptive acuity was significantly impaired ( P<.01) at the 100° test angle, where the pain intensity was significantly greater ( P<.01). Conclusions This study demonstrated impairment of shoulder joint position sense in CRCP. The degree of proprioceptive impairment was greatest at higher elevations in the setting of increased shoulder impingement and pain, which may serve to perpetuate the pathology. These findings provide a theoretic rationale for the continued implementation of proprioceptive rehabilitation programs in managing CRCP.

Role of Kabat physical rehabilitation in Bell's palsy: A randomized trial

Conclusion: When applied at an early stage, Kabat's rehabilitation was shown to provide a better and faster recovery rate in comparison with non-rehabilitated patients. Objective: To assess the validity of an early rehabilitative approach to Bell's palsy patients. Patients and methods: A randomized study involved 20 consecutive patients (10 males, 10 females; aged 35–42 years) affected by Bell's palsy, classified according to the House-Brackmann (HB) grading system and grouped on the basis of undergoing or not early physical rehabilitation according to Kabat, i.e. a proprioceptive neuromuscular rehabilitation. The evaluation was carried out by measuring the amplitude of the compound motor action potential (CMAP), as well as by observing the initial and final HB grade, at days 4, 7 and 15 after onset of facial palsy. Results: Patients belonging to the rehabilitation group clearly showed an overall improvement of clinical stage at the planned final observation, i.e. 15 days after onset of facial palsy, without presenting greater values of CMAP.

Effect of Proprioceptive Rehabilitation on Postural Control Following Anterior Cruciate Ligament Reconstruction

[Purpose] The aim of this study was to determine the functional level of activity and postural control after rehabilitation of anterior cruciate ligament reconstructed knees and compare them with non-operated limbs and healthy limbs in control subjects. [Subjects] Twenty-seven patients participated in the study: 17 had undergone reconstruction with a bone-patellar tendon-bone and 10 with a semitendinosus graft technique. The same rehabilitation protocol was used for all of the patients. Besides the patients, 18 healthy volunteers participated as a control group. [Methods] Both groups were tested for one-leg standing (eyes open and closed), static (eyes open and closed) and dynamic postural control on The Kinesthetic Ability Trainer-KAT 2000 (OWM Medical, Carlsbad, California, USA) at the 3, 6 and 12 month post-operation. Functional outcomes of the rehabilitation were evaluated by Lysholm scoring. [Results] There were no significant differences for the eyes open static stabilometry test between operated and non-operated limbs of the patients. On the other hand, there were statistically significant differences for the closed eyes static balance test between the operated and non-operated limbs at 3 and 6 months after surgery. There were significant differences for the eyes open static balance test between the 3rd and 6th, and 6th and 12th months and for the eyes closed test of non-operated limbs between the same months as well. No statistically significant differences were noted in the dynamic balance tests between the patients and the control group. Lysholm scores of the patients obtained at 6 and 12th months after surgery were significantly better than those at 3 months after surgery. Different operation techniques revealed no significant differences in any test performed at any time. [Conclusions] Performing a postoperative sportive rehabilitation including specific proprioceptive training sessions has positive effects both on clinical status and postural control of the patients.

How far do patients with sensory ataxia benefit from so-called “proprioceptive rehabilitation”?

A rehabilitation program including foot sensory stimulation, balance and gait training with limited vision was performed in 24 patients with clinically defined sensory ataxia. There were 15 patients with bilateral somatosensory loss related to chronic neuropathy and nine patients with unilateral loss-related to multiple sclerosis. After training, balance control assessed using the Berg Balance Test improved similarly in both groups, and Romberg's sign disappeared in some patients, suggesting an improvement in dynamic balance and in the proprioceptive contribution. Conversely, balance assessed on a static force platform remained similar in the open-eyes condition and improved in the closed-eyes condition only in patients with unilateral sensory loss. These results show that ataxic patients can improve their balance with better results in dynamic conditions and that the relative contribution of proprioceptive and visual inputs may depend on the extent of somatosensory loss.

Influence de stimulations nociceptives sur le sens de repositionnement céphalique

The goal of this study was to evaluate the impact of nociceptive stimuli upon the cervical proprioception ability. MethodThirty healthy young subjects performed a cervicocephalic relocation test (CRT) in two random conditions: the first one was based on a nociceptive electric stimulation called condition “pain”, whereas the second one was targeting a painless electric condition called condition “control”. The CRT consisted of repositioning the head on the trunk, after an active transversal movement of the head in the transverse field with closed eyes. The pointing was recorded at the beginning and at the end of each rotation using a custom video acquisition system. ResultsThe average mean of error repositioning was worth 3.98±0.99° (average mean, standard deviation) in the condition “pain”, and 1.75±0.37° in the condition “control” (p<0.01). ConclusionAcute pain provokes a disturbance of the cervical proprioception ability without damaging the anatomic structure. This observation suggests the interest of an early follow-up of the pain to avoid sensory disturbances, as well as the establishment of a cervical proprioceptive rehabilitation program after an algic event.

Proprioception of the knee joint in patellofemoral pain syndrome

The importance of proprioception in the etiology, treatment, and prevention of sports injuries and joint diseases has become increasingly clear. The purpose of this study was to investigate knee proprioception in patients with patellofemoral pain syndrome (PFPS). The study included 28 patients (18 females, 10 males; mean age 28 years; range 16 to 48 years) with a clinical diagnosis of unilateral PFPS and 27 normal volunteers (13 females, 14 males; mean age 26 years; range 19 to 32 years) without any complaint related to the knee. The mean duration of complaints was 35.8 weeks (range 2 weeks to 3 years). In both patient and control groups, proprioception of the knee was measured by means of active joint position sense at four different target angles (15 degrees , 30 degrees , 45 degrees , 60 degrees ) with the use of a digital goniometer and the results were compared. Proprioceptive errors were greater at all target angles in the affected knees compared to those measured in the contralateral knees and both knees of the controls. Differences between affected knees and contralateral knees ranged from 1.01+/-0.25 degrees to 1.65+/-0.43 degrees and were significant at three target angles (15 degrees , 30 degrees , 60 degrees ; p<0.05). Comparisons between the affected knees and both knees of the controls also showed significant differences at all target angles ranging from 2.48+/-0.92 degrees to 3.87+/-2.46 degrees (p<0.001). Errors obtained in the normal knees of the patients were also significantly greater compared to those seen in both knees of the controls, exceeding 2.7 degrees at some target angles (p<0.001). Our results show that patients with PFPS have impaired proprioception in the affected knee accompanied by significant losses in the proprioception of the contralateral normal knee. Based on these findings, proprioceptive rehabilitation techniques should be incorporated into the treatment of PFPS.

Exercise training for patients with cardiovascular disease

This review surveys effort training, a validated and recommended therapy, in patients with atheromatous cardiovascular disease. This true therapy reduces mortality by 25–35%, reduces clinical manifestations and complications (rhythm problems, thrombosis) and improves physical capacity, reintegration and quality of life. The effects are essentially linked to improved metabolic performance of muscles and reduced endothelial dysfunction, insulin resistance and neurohormonal abnormalities. Training also has an impact on the evolution of major risk factors, especially diabetes and arterial hypertension. The risks are limited as long as the contraindications are respected and the programmes supervised. The indications (stable angina, chronic heart failure, peripheral arterial disease) should be described more precisely by taking into account functional criteria: physical deconditioning, exclusion, compliance, mood swings, and seriousness of risk factors. The training programme should be tailor made and based on evaluation of the patient's adaptation to effort, in terms of frequency, intensity and duration of the exercises. Various types of exercise include overall or segmental physical training; concentric, eccentric, even isokinetic muscle contraction exercises; and proprioceptive rehabilitation. However, knowledge is lacking about the molecular mechanisms of the effects of training, the most effective intensity of effort, and strategies to develop physical activity in this ever-growing population for both primary and secondary prevention.

Changes in joint position sense after conservatively treated chronic lateral ankle instability

Improvement of ankle proprioception through physiotherapy (a.k.a. proprioceptive training) is a widely accepted conservative treatment modality of chronic functional lateral ankle instability. Clinical studies provided controversial data on its proprioceptive effect. Aim of this study was to gain evidence on the efficacy of proprioceptive training on ankle joint position sense. Ten patients (five males and five females, aged 23.3+/-5.4 years) were treated conservatively for chronic lateral ankle instability with a special training programme over 6 weeks. For the assessment of joint position sense we used the slope-box test, first applied and described by Robbins et al. (Br J Sports Med 29:242-247, 1995). The test was performed before the start and after the end of the training programme, measuring joint position sense on 11 different slope amplitudes in four directions (anterior, posterior, lateral and medial) in random order each on both ankles. Comparisons were made between pre- and post-training results as well as versus a control-group of ten healthy athletes. Overall the proprioceptive sensory function of the studied group has improved, but this improvement was not significant in all directions. Only two patients have shown significant improvement of joint position sense in all directions (mean estimate error improvement: 2.47 degrees ), while conservative treatment was partially successful in five others (mean estimate error improvement: 0.73 degrees ). The follow-up results of these seven patients were comparable with the values measured in the control-group. Three patients did not show any improvements (mean estimate error improvement: -0.55 degrees ) (overall difference between improving and non-improving patients: P<0.0001). Mean absolute estimate error profiles of the seven improving patients became similar to the profiles of healthy athletes, while these changes could not be observed in the case of the three non-improving participants. Proprioceptive rehabilitation programme can be an effective method in order to improve impaired joint position sense function. After 6 weeks non-responding patients can be well identified, and considered for other treatment modalities. The determination of the effective length of the programme however needs further evaluation. Still, changes in the proprioceptive sensory function of the ankle plantarflectors indicate the preventive effect of the training programme. Furthermore, our results support the theory of simultaneous function of different mechanoreceptor-systems.

Does Proprioceptive Training During Knee and Ankle Rehabilitation Improve Outcome?

Although much research has been conducted on the measurement and quantification of knee and ankle proprioception, there are few studies on results of targeted proprioceptive training during rehabilitation in knee and ankle injuries. Proprioceptive training has been hypothesized to increase joint stability through a variety of mechanisms, including muscle strength, kinesthesia, and muscle tone. The purpose of this paper is to comprehensively review and critically appraise the available literature from 1966 to January 2001 in order to examine the evidence concerning the efficacy of proprioceptive training during knee and ankle rehabilitation. Medline was searched using MeSH and textwords for English language articles related to proprioceptive training during knee and ankle rehabilitation published since 1966. Additional references were reviewed from the bibliographies of the retrieved articles. The total number of articles reviewed was 9 and 8 for the knee and ankle, respectively. In reviewing the literature, particular attention was paid to the relative strengths of the different study designs. From these data, the factors associated with effectiveness and the beneficial results of proprioceptive training were examined. For the knee, five of the nine studies evaluated a proprioceptive rehabilitation programme for anterior cruciate ligament (ACL) deficient patients, three studied a training programme in healthy subjects and athletes involved in soccer and gymnastics and one study was on patients suffering from knee pain. The duration of proprioceptive training ranged from 1–52 weeks. Eight studies showed the beneficial effects of proprioceptive training during a knee exercise programme; one study showed that joint position sense in the ACL deficient knees with muscular and proprioceptive training remained unchanged. For the ankle, three studies evaluated patients with functionally instability in the ankle joint. The authors found that improvements in balance performance following a 6-week, 8-week, and 10-week training period appeared to be greater in individuals with previously reported ankle sprains as compared with uninjured participants. Three papers investigated the significance of postural stability in healthy subjects receiving a proprioceptive training programme; one studied joint position sense in gymnasts, and one study looked at postural stability in dancers. Eight studies have been published on the benefits of proprioceptive training during a knee exercise programme and the role of proprioception in the knee joint. Increased joint proprioceptive sense, muscle strength, knee kinesthesia, muscle tone and the decreased risk of ACL injury have suggested that dynamic joint control training may improve stability by improving joint position sense in healthy and injured-knees. The effects of proprioceptive training on muscle reaction times and postural stability have increased during ankle rehabilitation after several weeks. Ankle proprioceptive training has been shown to decrease functional instabilities of the ankle and to decrease the incidence of re-injury. Specific neuromuscular co-ordination training such as dynamic joint control and kinesthetic awareness may be indicated at 3–4 months following rehabilitation.

The assessment of knee joint position sense as a predictor of injuries/reinjuries

The relationship between joint sense and sports injuries has rarely been investigated, and the methods of testing have usually been passive. Since sport involves active postures and movement , it is argued that JPS testing should be active. Problems of accuracy and reliability in previous studies have been here addressed by using computer-aided analysis of videotaped tests and responses. The retention of substantial JPS in ligament-injured knees may be because normal position sense is largely mediated by muscle receptors, or because muscle receptors compensate for lost joint receptor activity. Although normal JPS does not guarantee injury-free sport, it remains unclear as to what if any level of JPS provides some measure of protection against injury, or what level of specific proprioceptive training and rehabilitation is justified. The procedures used in the present study provide the opportunity to further investigate these and related questions.

Does Proprioceptive Loss Influence Recovery of the Upper Extremity After Stroke?

Stroke patients with motor paralysis and proprioceptive deficits are considered to have a worse functional outcome than those with pure motor paralysis, but the mechanism of this detrimental effect is not clear. In order to clarify it, we compared the motor and functional recovery of the affected upper extremity in stroke patients having pure motor paralysis with that of such patients with both motor and proprioceptive deficits. Forty patients undergoing stroke rehabilitation were studied: 20 with pure motor deficits and 20 also with proprioceptive deficits. They were assessed on four occasions during the first six weeks of rehabilitation. Motor impairment was assessed with the Fugl-Meyer subscale of the upper extremity, disability with the Frenchay Arm Test, and proprio ception by the Thumb Localization Test. Significant within-group improvement of the motor and functional abilities was demonstrated in both groups, between admission to six weeks later (p &lt; 0.001, either group). However, no significant difference was found between the two groups, although pure motor patients had a slightly better outcome. It was concluded that the proprioception deficit did not influence limb recovery in the first six weeks of rehabilitation. Therefore, the upper extremity of all patients should be treated and given a similar chance because significant improvement can be expected in all cases. Key Words: Upper Extremity—Stroke—Proprioception—Rehabilitation.

The Role of Ankle Strength in Functional Ankle Instability

The purpose of this study was to determine if there were any differences in ankle range of motion, strength, or work between persons with normal ankles (Normal,n= 14), those with functional ankle instability (FAI,n= 15), and those with a history of FAI who have been through formal proprioceptive rehabilitation (Rehab,n= 14). A second puipose was to determine normative values for ankle strength and work measurements using the Biodex® isokinetic system. There were no significant differences between groups for ankle range of motion or for any strength or work measurements. The overall strength/work averages were 11.75/3.42 for plantar flexion, 339/1.48 for dorsiflexion, 3.30/2.40 for inversion, and 2.62/1.79 for eversion. Dorsiflexion torque overall was 31.43% of plantar flexion, and the evertors produced 75.42% of the torque produced by the invertors. It is recommended that clinicians continue to rehabilitate ankles with strength and proprioceptive exercises but do not rely on ankle strength/work testing as the only criteria for determining an athlete's readiness to return to full activity.

Functional Assessment and Rehabilitation of Shoulder Proprioception for Glenohumeral Instability

Following injury to the articular ligaments, disruption of mechanoreceptors results in partial deafferentation of the joint. This has been shown to inhibit normal neuromuscular joint stabilization, and it contributes to repetitive injuries and the progressive decline of the joint. Assessment of proprioception is valuable in identification of proprioceptive deficits and subsequent planning of the rehabilitation program. A shoulder rehabilitation program must address both the mechanical and sensory functions of articular structures by incorporating a proprioceptive training element within the normal protocol. The objective of proprioception rehabilitation is to enhance cognitive appreciation of the respective joint relative to position and movement, and to enhance muscular stabilization of the joint in the absence of structural restraints. If these objectives are properly addressed, the restoration of the proprioceptive mechanism will prevent further disability of the shoulder joint.

The modified broström procedure for acute and chronic ankle instability

The modified Bröstrom repair for chronic lateral ankle instability is a relatively simple procedure that is indicated when clinical instability persists in spite of peroneal strengthening and proprioceptive rehabilitation. It is especially useful in patients who require a full range of motion in their ankle with preservation of peroneal function, such as dancers, gymnasts, and ice skaters. Bröstrom's original operation involved shortening the attenuated lateral ligaments to their normal length and suturing them to their anatomic locations on the distal fibula. Gould's modification uses the lateral portion of the extensor retinaculum to reinforce the repair, limit inversion, and help correct the subtalar component of the instability.

Cervicocephalic kinesthetic sensibility in patients with cervical pain.

Head orientation in space makes use of multiple sensory afferents, among which the cervical proprioceptive cues could play a predominant role. To quantify the alteration of neck proprioception in patients with cervical pathology, we proposed a test for the clinical evaluation of the ability to relocate the head on the trunk after an active head movement, for 30 healthy subjects and 30 patients with cervical pain. The data demonstrated that this ability was significantly poorer in the patient group, indicating an alteration in neck proprioception. This test permits a discriminant classification of healthy and sick subjects, justifies proprioceptive rehabilitation programs, and allows a quantitative evaluation of their results.