What is the ability to use the senses and body parts to perform motor tasks smoothly?

Proprioception Awareness

Depending on symptom presentation and pain severity, effective pain control during the early phase can be achieved via various therapeutic interventions. These interventions may include physical and thermal modalities (e.g., cold pack, moist heat, and electrical stimulation)79; patient education for proper body mechanics to reduce wrist joint overloading80; activity modifications to prevent reinjury81; and regional desensitization methods of the wrist and the hand, incorporating closed-chain active range of motion (AROM) techniques82 as well as various forms of tactile and vibration stimuli83 that enhance the injured body area receptors’ ability to elicit normal proprioceptive sensory feedback for restoration of the normal sense of joint motion and position. An example of an effective closed chain wrist AROM technique is rolling a weighted ball forward or back on a table (Fig. 99.5). This is a safe stress-loading technique, which improves recognition of joint motion and position, enhances active wrist flexion and extension active motions, and improves pain.84 The patient can slowly advance this exercise by moving the wrist toward the end range of its physiological AROM. This method can also be progressed to wall towel wipes, promoting functional AROM improvements of the whole upper extremity kinetic chain (Fig. 99.6). Examples of therapeutic activities that use tactile or vibration stimuli for wrist and hand desensitization include an upper extremity whirlpool; manual or instrument assisted soft tissue mobilization techniques; grasping or manipulating rice, marbles, and small objects of different textures; and the application of a low-frequency vibration stimulus with a mini vibrator over hypersensitive skin or scar regions. Tactile stimulation and vibration techniques are used to enhance wrist and hand kinesthetic and JPS perception by improving the sensory function of cutaneous and musculotendinous receptors (i.e., better muscle spindle activation),14 potentially leading to improved dexterity and wrist joint neuromuscular control for functional activities.

Implementing early wrist AROM methods is clinically important for developing proper proprioceptive awareness and allowing for faster return to function.85 Early functional ROM exercises restore proper awareness for joint position and kinetic control that is required for a multitude of body functions.14 This could become more urgent when the nondominant side is involved. Often, the nondominant side is perceived as less important by patients, thus requiring a longer rehabilitation time for functional recovery after wrist trauma.86 Examples of wrist and hand ROM functional tasks that a patient can readily incorporate in a daily home program consist of grasping a light cylindrical stick, turning a small hammer, grasping and placing marbles in a bucket, rolling a ball on a table, simulating dart-throwing motion (DTM) with the wrist, turning book pages, turning a bottle cap, wiping a table or a wall with a towel, and practicing typing and writing skills. All of these functional exercises promote active wrist ROM by training both conscious and unconscious proprioceptive pathways at the wrist and hand. Performance of these therapeutic activities can produce an influx of visual and tactile sensory feedback from cutaneous and muscle peripheral receptors, which enhance wrist joint position and motion awareness. Improved conscious proprioception senses is considered a precursor for retraining proper neuromuscular joint function, which relies on rapid feed-forward control reflexes.14 Restoring neuromuscular joint control leads to proper anticipatory wrist motor patterns, which are required to produce precise wrist AROM during function.75

Proprioception, or kinesthesia, is the sense that lets us perceive the location, movement, and action of parts of the body. It encompasses a complex of sensations, including perception of joint position and movement, muscle force, and effort. These sensations arise from signals of sensory receptors in the muscle, skin, and joints, and from central signals related to motor output. Proprioception enables us to judge limb movements and positions, force, heaviness, stiffness, and viscosity. It combines with other senses to locate external objects relative to the body and contributes to body image. Proprioception is closely tied to the control of movement.

Reeducation of wrist proprioception.

As stated previously, the muscles are the ultimate carpal stabilizers.35,91 Without their protection, most wrist-stabilizing ligaments would not resist the amount of tension and torque generated in most accidents, and ligament ruptures would be even more common. To remain stable, the wrist does not need powerful muscles, but ones that are able to react quickly to protect the underlying ligaments. Even if some ligaments have failed, however, promptly reacting muscles may succeed in maintaining relatively normal kinematics of mildly unstable joints, avoiding the development of cartilage wear and reactive synovitis. Thus, the immediate goal of proprioception reeducation is not to increase grip strength but to optimize the “latency time” (i.e., the time taken by the stabilizing muscles to react to any potentially damaging force).84

Under axial load, the scaphoid tends to flex andpronate. That tendency can be counteracted by supinating the distal row. Indeed, if the STT capsule and ligaments are intact, a distal row supination will draw the trapezium dorsally, thus preventing the scaphoid from collapsing into flexion and pronation. Laboratory studies have shown ECRL and APL to be distal row supination muscles, while ECU is a pronation muscle.54,92 If properly trained, the former may become effective dynamic scaphoid stabilizers. Isometric contraction of ECU, by contrast, increases scaphoid misalignment and widens the SL gap (seeVideo 13.1). A quick response of the intracarpal supinators (i.e., ECRL and APL), on one side, and avoidance of the ECU, on the other, may explain why many dynamic SL dissociations remain asymptomatic for a long time.

The FCR has also been said to have a positive effect on SL stability owing to its ability to close the SL gap by supinating the scaphoid. Indeed, if the dorsal SL ligament is not completely torn, the FCR also may be counted as a dynamic scaphoid stabilizer.91,92

As more research is being published, it appears that avoidance of the ECU's deleterious effects on SL stability, combined with adequate proprioception reeducation of FCR, APL, and ECRL will play an important role in the control of dynamic SL instabilities. What is not known is which of the many protocols being currently tested will prove to be the most useful, and in what circumstances.35 In all cases, adequate evaluation of the extent of ligament damage is a prerequisite for this type of approach.

In recent years, special attention has been drawn to the fact that, during DT motion, the majority of carpal motion occurs at the midcarpal joint, the proximal row remaining relatively stationary. Based on these findings, it has been suggested that, after a SL ligament repair, early dart-throwing mobilization of the midcarpal joint could have a beneficial effect on stiffness, while avoiding tension on the repair. This is not entirely correct, and caution is warranted. Recent studies using dynamic 3D CT of patients with SL dissociations have shown that, once disconnected from the lunate, the scaphoid no longer behaves as a proximal row bone but follows the capitate as if it was a distal row element.30 Certainly, unless the dorsal SL ligament is fully competent, or the repair is protected with additional fixation, DT exercises are not recommended, at least not in the early stages of healing.

I Definition

Proprioception allows individuals to detect joint motion and limb position when their eyes are closed.17 Like most of the simple sensations, proprioception has distinct sense organs and ascending pathways in the spinal cord. Unlike simple sensations, however, full perception requires a healthy contralateral cerebral cortex; in this way it resembles cortical sensations.18,19 (See the section on Cortical Sensations.)

Sir Charles Bell originally called proprioception the “sixth sense.” In 1906, Sherrington introduced the term “proprioception” to describe this sensation.17,20

Theoretical Benefits for Enhanced Proprioception with Rigid Tape Application

Some authors postulate that rigid taping provides a form of proprioceptive biofeedback.35 The rigid tape is applied while the joint or joints are is in the desired positions (Fig. 103.10). Tension is likely created on the skin when the joints move away from the desired positions. Proprioceptive feedback occurs from cutaneous sensory cues when the joints move in a direction outside of the parameters.35 Therefore, rigid tape can provide feedback to the nervous system to promote movement of joints in a desired direction or limit undesired movement patterns (seeAppendix 2).

The mechanical properties of rigid tape for joint support previously discussed may play a role with improved proprioception. It could be argued that the tape provides stimulation to cutaneous receptors or joint mechanoreceptors to improve the protective reflex arc.48 Despite varying opinions on the exact mechanism that contributes to improved proprioception, the rationale for taping is to permit optimal functional movement.

Proprioception

Proprioception is defined as the conscious or unconscious awareness of joint position, whereas neuromuscular control is the efferent motor response to afferent (sensory) information.162 The thrower relies on enhanced proprioception to influence the neuromuscular system to dynamically stabilize the glenohumeral joint because of significant capsular laxity and excessive ROM. Allegrucci et al163 tested shoulder proprioception in 20 healthy athletes participating in various overhead sports. Testing of joint proprioception was performed on a motorized system with the subject attempting to reproduce a specific joint angle. These investigators noted that the dominant shoulder exhibited diminished proprioception in comparison to the nondominant shoulder. They also noted improved proprioception near end ROM in comparison to that at the starting point. Blasier et al164 reported that individuals who have clinically appreciable generalized joint laxity are significantly less sensitive during proprioceptive testing. Wilk et al (unpublished data, 2000) studied the proprioception capability of 120 professional baseball players. They passively positioned the players at a documented point within the players' ER ROM. The athletes were then instructed to actively reposition the shoulder in the same position. The researchers noted no significant difference between the throwing shoulder and nonthrowing shoulder. In addition, Wilk et al (unpublished data, 2000) compared the proprioception ability in 60 professional baseball players with that of 60 non–overhead-throwing athletes. They noted no significant differences between baseball players and non–overhead-throwing athletes. However, baseball players exhibited slightly improved proprioception abilities at ER ROM than did non–overhead-throwing athletes, but these results were not significantly different. See Chapter 24 for an in-depth discussion of proprioception and neuromuscular control.

4.6.7 Unstable Surface Training (Proprioception Training)

Proprioception comes from a Latin word meaning unconscious perception of movement. It allows the body to control its position for optimal locomotion. It is carried out by internal sensors such as the muscle spindle stretch receptor and Golgi tendon organ. The vestibular system in the brain is a key component in proprioception and also in maintaining static, mixed, or dynamic balance. Proprioception training improves balancing, movement sensing, and, naturally, proprioception.

Proprioception is present in every muscle movement, therefore proprioception training may be misleading. Unstable surface training is a more expressive name for this type of method. Proprioception is extremely important in motor learning, smooth motor learning, and preventing injury (Verhagen et al., 2004). The latter observation made unstable surface training very popular, where movements are carried out in a position that needs constant balancing. Exercises on a wobble board improve ankle and knee functional stability and prevent injuries (Cloak et al., 2013; Sparkes and Behm, 2010). A balance board or unstable straps push-up exercises used for shoulder joint training give different EMG signals compared to push-ups executed on a stable surface. On a stable surface, an EMG indicates lower muscle activity (Snarr and Esco, 2013). Unstable surface training is recommended for injury prevention, rehabilitation, and improving physical performance.

10.20.4.1 Proprioception

Proprioception not only allows humans to detect position and motion of limbs and joints (Lephart et al., 1998; Lord et al., 2003; Sturnieks et al., 2004), but also provides sensation of force generation to allow for better regulation of force output (Baker et al., 2002; Hurley and Scott, 1998; Williams et al., 2001). Furthermore, Hurley et al. (1997), Hurley and Scott (1998), and Sharma (1999) have reported that proprioception is closely related to functional performance and walking speed. We have demonstrated that non-weight-bearing proprioception training (Figures 19 and 20) and strength training exercise interventions were effective in improving pain, function, walking speed on different terrains, and knee strength in patients with knee OA. Proprioception training was found to be superior to enhance neuromuscular function, most notably joint reposition sense and walking speed on a spongy surface. As well documented in the literature, the integrity and control of sensorimotor systems, including those involved in proprioception and muscle action, are essential for the maintenance of balance and production of a smooth stable gait. As thus proprioception training should be more emphasized in our physiotherapy practice to maximize the treatment effect (Lin et al., 2009). As thus proprioception training shoulder should be stressed in our day-to-day practice of orthopedic physiotherapy.

Background to proprioceptive training

Proprioception has been defined as a specialized variation of touch encompassing the sensations of both joint movement and joint position (Lephart and Fu, 1995). Practically, it is the ability of the body to use position sense and respond (consciously or unconsciously) to stresses imposed on the body by altering posture and movement (Houglum, 2001).

Definition

Proprioception is the awareness of the body in space. It is the use of joint position sense and joint motion sense to respond to stresses placed upon the body by alteration of posture and movement.

Proprioception encompasses three aspects, known as the ‘ABC of proprioception’. These are: agility, balance and coordination. Agility is the capacity to control the direction of the body or body part during rapid movements, while balance is the ability to maintain equilibrium by keeping the line of gravity of the body within the body's base of support. Coordination is the smoothness of an activity. This is produced by a combination of muscles acting together with appropriate intensity and timing (Houglum, 2001).

Proprioceptive exercise is progressed in terms of skill and complexity rather than pure overload. The aim is to perform gradually more challenging actions while maintaining movement accuracy. The emphasis therefore is on quality of motion rather than quantity (volume) of muscle work.

4.05.1 Abstract

Proprioception relies on mechanoreceptors located in deep tissues such as muscles and tendons. However, low-threshold mechanoreceptors located in the skin and hair follicles may also contribute to proprioception, in addition to touch. An outstanding issue is the extent to which putative cutaneous proprioceptive activity indeed represents “signal” (i.e. a source of information utilized by the nervous system for perception and/or motor control) rather than “noise” (i.e. activity that must be subtracted out to support cutaneous sensing of external objects). Here, we review evidence for such a role.