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Clarkson University Master of Physical Therapy Program Leslie Russek, PhD, PT, OCS Clarkson University Canton-Potsdam Hospital Proprioception: Changes.

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Presentation on theme: "Clarkson University Master of Physical Therapy Program Leslie Russek, PhD, PT, OCS Clarkson University Canton-Potsdam Hospital Proprioception: Changes."— Presentation transcript:

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2 Clarkson University Master of Physical Therapy Program Leslie Russek, PhD, PT, OCS Clarkson University Canton-Potsdam Hospital Proprioception: Changes with Injury, Disease and Rehabilitation

3 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?

4 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?

5 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.

6 Clarkson University Master of Physical Therapy Program Sensory receptors mediating prioprioception are found in skin, muscles, joints, ligaments and tendons.

7 Clarkson University Master of Physical Therapy Program Mechanoreceptors Freeman MAR, Dean M, Hanhan I. 1965

8 Clarkson University Master of Physical Therapy Program Muscle Spindle Organs

9 Clarkson University Master of Physical Therapy Program Muscle Spindle Organs

10 Clarkson University Master of Physical Therapy Program Golgi Tendon Organ

11 Clarkson University Master of Physical Therapy Program Ruffini ending Pacinian corpuscle More Mechanoreceptors

12 Clarkson University Master of Physical Therapy Program AFFERENT INPUT Peripheral afferents joint muscle skin Visual receptors Vestibular receptors CNS LEVELS OF MOTOR CONTROL Spinal reflexes Cognitive programming Brain Stem balance MUSCLE From Lephart SM, Henry TJ. 1996

13 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)

14 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)

15 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)

16 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)

17 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)

18 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)

19 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)

20 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)

21 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)

22 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)

23 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?

24 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?

25 Clarkson University Master of Physical Therapy Program Exercises and Progressions: Shoulder Appropriate patients:Types of exercises:

26 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

27 Clarkson University Master of Physical Therapy Program Exercises and Progressions: Knee Appropriate PatientsTypes of exercises

28 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

29 Clarkson University Master of Physical Therapy Program Exercises and Progressions: Ankle: Appropriate Patients –Recurrent ankle sprain –Other?

30 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

31 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, sports- specific exercises

32 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?

33 Clarkson University Master of Physical Therapy Program Besides… Proprioception exercises are fun!


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