Propioceptive Training PDF

PROPRIOCEPTIVE TRAINING DR. Sherine Omar El-Sherif Lecturer of Biomechanics Objectives By the end of this lecture you will be able to understand: Know proper definition of proprioception Be familiar with different types of receptors Be aware about the clinical significance of propriocept...

PROPRIOCEPTIVE TRAINING DR. Sherine Omar El-Sherif Lecturer of Biomechanics Objectives By the end of this lecture you will be able to understand: Know proper definition of proprioception Be familiar with different types of receptors Be aware about the clinical significance of proprioceptive exercises Determine target population who will benefit from exercises Assess individuals with proprioceptive deficits Concepts of proprioceptive training Introduction One of the current trends in the field of sports training concerns the integration into training programs of exercises defined as "proprioceptive", which also include balance exercises, used to optimize performance, prevention or recovery from injuries.  Introduction Until recently, proprioceptive training was used almost exclusively for patients in post-trauma rehabilitation, specifically, to reactivate the functionality of muscle and joint receptors. However, according to recent evidence in the literature state that proprioceptive exercises can be prescribed for athletes, patients and even in healthy individuals. It has been shown that increasing the quality of reception using the proprioceptive system leads to tangible improvements in terms of the rapidity and precision of the central nervous system response. It can therefore be deduced that proprioceptive training may also be able to enhance performance of athletic and health persons specifically; the proprioception of the foot-ankle complex seems to play a particularly important as it is often the only part of the body in contact with the ground. History of proprioception Julius Caesar was the first person who described the position- movement sensation as a “sense of locomotion” in 1557. History of proprioception After centuries in 1826, Charles Bell proposed that frequent signals and information were sent to brain called “muscle sense “. History of proprioception In 1880, Henry Charlton suggested another term as “kinesthesia” instead of “muscle sense” to point out that afferent information was originating not only from muscles but also from joints, tendons, ligaments, capsules and skin. History of proprioception Finally in 1906, Charles Scott introduced the terms “proprioception, interoception, and exteroception. What is Proprioception Proprioception, literally the “sense of self” (from Latin “proprius” = “own”), is the group of sensory modalities that allow us to know the positions of our limbs in space, to detect and assess the magnitudes of movements and forces without vision. What is Proprioception Proprioception also known as kinesthesia that can be defined as individual’s ability to integrate the sensory signals from specialized sensors inside tissues which are named mechanoreceptor to determine body segment positions and movements in space. Having this kinesthetic awareness is important for day-to-day living and vital for sports performance. What is Proprioception In other words, proprioception is not merely a physiological property, but rather, it has both physiological (hardware) and (software) aspects. To be specific, proprioception is the perception of movement, action, and location in three-dimensional space i.e overall proprioceptive performance is determined by the quality of both the available proprioceptive information and an individual's proprioceptive ability. Thus, the hardware (peripheral mechanoreceptors) provides proprioceptive information to (the brain) for the software and central processing to integrate and use. What is Proprioception For example, you experience proprioception when you’re hiking on a dirt path and detect small deviations, such as holes or rocks, in the path. To prevent injury, your body adjusts, stabilizing your foot and ankle in response to the feedback picked up by your lower limb proprioceptors. Without proprioception, you wouldn’t be able to move without thinking about your next step. Proprioception allows you to walk without consciously thinking about where to place your foot next. The Anatomy of Proprioception Proprioception classically subserved by a special type of somatosensory receptors located in skin, joints, ligaments, tendons, capsules called mechanoreceptors. It responds to any mechanical pressure or distortion then convert this extracellular stimulus to intracellular electric signal toward central nervous system for processing and perception. The external stimuli are usually in the form of touch, pressure, stretching, and motion. Mechanoreceptors are present in the superficial as well as the deeper layer of skin and near bone. The Anatomy of Proprioception There are five major categories of tactile mechanoreceptors or what we called (conscious proprioceptors) each shaped according to its function as follow: Merkel’s disks respond to sustained pressure. Meissner’s corpuscles respond to light touch and adapt rapidly to changes in texture (vibrations around 50 Hz). Ruffini end organ respond to deep tension in the skin and fascia. Pacinian corpuscles respond to rapid vibrations (of about 200–300 Hz). Free nerve ending respond to nociceptive stimulation. The Anatomy of Proprioception On the other side, muscle spindle and Golgi tendon organ are considered stretch receptors inside skeletal muscles called (unconscious proprioceptors) that provide and maintain constant length and tension inside skeletal muscles. These proprioceptive signals are transmitted to the system which organize and analyze these senses, forming a response for keeping joints in the safest possible position during functional tasks. The Anatomy of Proprioception Also, all proprioceptive afferents are integrated with information from other sensory systems, such as the visual system and the vestibular system, to create an overall representation of body position, movement, and acceleration in addition to stabilizing body posture and coordinating body movement. Benefits and clinical significance of proprioceptive exercises Regenerate the relationship between mechanoreceptors and central nervous system and tries to compensate the proprioceptive deficit resulted from injury Preparing dynamic stabilizers for any unexpected joint motion or overload with subconscious muscular activation to achieve joint stabilization in broad joint motion, keeping the joint safe and prevent further injuries. Enhancing neuromuscular control through improving motor function as there is increasing empirical evidence documenting that a training focusing on improving specific aspects of proprioception (e.g., position sense) improves the trained motor function Benefits and clinical significance of proprioceptive exercises Creating smooth voluntary control and coordination on movements and error correction during movements for providing postural stabilization and balance control. Balance control improvement is one of the most important goals in sports and exercise, wherefore superior balance ability is strongly and positively associated with enhanced athletic performance to achieve the highest competitive level and negatively associated with lower limb sports injuries. Proprioception plays an essential role in stability control through improved joint position sense and function. Indications Proprioceptive sensory impairment can develop with different neurological disorders such as patients with: o Multiple sclerosis o Chronic inflammatory demyelinating polyneuropathy (CIDP) o Parkinson Also various proprioceptive damage caused by orthopedic disorders and sport injuries such as: o Direct swelling, o Ligaments sprain and tear like ACL of knee, lateral collateral ligament of ankle joint. o Shoulder instability. o Knee osteoarthritis. o Idiopathic neck pain. o Inflammation. Indications orthopedic disorders also lead to loss of proprioception in chronic diseases which affects soft tissue such as rheumatoid arthritis and complex regional pain syndrome or neuropathic problems such as diabetes. There are significant decreases in the proprioception due to changes in the central and peripheral nervous system along with progressive aging as seen in geriatrics. Fortunately, adding proprioception training exercises to routine exercise program under supervision of experienced well-trained physiotherapists can significantly lower risk of injury and improve postural control. Focus on evidence Proprioception is crucial in all sports and fitness activities. For example, it allows an athlete to dribble a soccer ball and run without looking down or thinking through each step. It also allows a volleyball player to know where the ball is in the air to spike it In fact, a 6-year study in European basketball players who participated in a proprioceptive training program observed an 81% decrease in ankle sprains and a 75.5% decrease in missed games and practices. Another study showed greater proprioception is highly correlated with athletic abilities, with elite athletes demonstrating the greatest levels of proprioception in the ankles, shoulder, and spine. Recent systematic review 2022, revealed that Proprioceptive training can lead to significant improvements in motor function across wide range of healthy populations Contraindications Although improving proprioception helps reduce the risk of injury, there are instances when it may actually cause more harmful effects such as: o Acute inflammation and o Postoperative conditions o Joint instability. Assessment Techniques of Proprioception Proprioceptive measurements are performed to assess the quality of the proprioceptive function. Measurements are usually based on testing the quality of CNS in perception different deep senses in a various ways using different tests. 1. Threshold to detection of passive motion (TTDPM) participants are seated or lying down. The body site being tested is isolated by strapping the adjacent body segments, such as the upper body. Other peripheral information, such as tactile, visual, and aural information, is usually occluded by using air cushions, blindfolds, and headphones. the body segment under investigation is passively moved in a predetermined direction. Participants are instructed to press a stop-button as soon as they perceive the movement and direction. They then report the perceived direction of movement of their limb. If the reported direction is wrong, the trial is discarded, and testing proceeds until three to five correct judgments are achieved. 2. Joint position reproduction (JPR) In contrast to the TTDPM method where passive movement is used, the JPR testing method is conducted under either passive or active conditions, and may involve either ipsilateral or contralateral limb. There are three types of JPR tasks described in the assessment of proprioception: ipsilateral JPR (IJPR); and two contralateral JPR (CJPR) approaches. 2. Joint position reproduction (JPR) For IJPR testing, a predetermined target joint position is passively or actively presented to the participant for a few seconds. Thereafter, the joint is returned to the initial start position, either passively by the therapist or actively by the participant. Participants are then required to reproduce the target joint position previously experienced by either indicating the target position by pressing a stop-button when the joint is passively moved into the same range, or by actively moving the joint to the target position. That is, participants need to remember the target position and reproduce the position using the same limb. 2. Joint position reproduction (JPR) a. For the two CJPR tests, one procedure is identical to the method for IJPR testing in terms of experiencing the target joint position, but differs in that the participant is asked to reproduce the joint position by using the contralateral limb. That is, participants need to remember the target joint position and use the opposite limb to reproduce the position. b. The second CJPR test differs in that once one joint is moved to the target position, it remains in that position and the contralateral limb is required to reproduce the target joint position. That is, the test does not require a memory of the target position. 3. Active movement extent discrimination apparatus (AMEDA) The Active Movement Extent Discrimination Apparatus (AMEDA) was designed to measure proprioception under more ecologically valid conditions than these other proprioception metrics. Specifically, for the ankle AMEDA device, testing is conducted in a weight bearing unconstrained stance that mimics conditions that would be encountered outside the laboratory. The apparatus allows the experimenter to control the angle of inversion of a plate on which a participant’s foot is placed, thus changing the extent of inversion at the ankle. Participants are then asked to identify the angle at which the plate is displaced from the horizontal. 4. Thumb localization Test The therapist moves patient affected hand in a different certain position. With his eyes closed, patient instructed to touch the thumb of one hand with fingers and thumb of the other hand. 5. Distal Proprioception Test The therapist moves patient’s big toe up and down with open eyes then patient try to duplicate this movement and detect its direction with eyes closed. 6. Sequential Finger Touching From closed eyes starts with your thumb and fingers straight. Touch the tip of your thumb to the tip of each finger in turn, making an 'O' shape. Return to the starting position between making each 'O'. Repeat these 3 more times. Repeat with the other hand. 7. Romberg test The patient is asked to remove his shoes and stand with his two feet together. The arms are held beside the body or crossed in front of the body. The therapist asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance for 30 seconds. Proprioceptive Training When planning proprioception exercises for a particular client, it is just as important to consider the client’s baseline level of skill as it is when designing a flexibility, strength or endurance program. There is a proper progression to follow, starting with static balance activities, progressing to dynamic balance activities and finally advancing to coordination and agility training. Equipments for proprioceptive training More equipments designed to improve proprioception is on the market today than ever before. There are balance boards, stability trainers, Bongo Boards, Thera band and BOSU Balance Trainers. BOSU an acronym for “both sides utilized,” describes the function and purpose of its balance training and core strengthening products. Essentially an inflated half ball on a flat rigid platform, BOSU products are excellent for physical therapy as well as general exercise. Equipments for proprioceptive training Proprioceptive training for lower body Ankle Alphabet exercise Sit on chair, with as big movements as possible, draw the letter A with your toes, Follow this with the letter B and so on and Continue through the letters as advised. Proprioceptive training for lower body Proprioception Alphabet Stand on one leg (injured leg) with your knee straight with support.Have the opposite leg move forwards and draws the letters of the alphabet in the air, trying to keep your balance on the stance leg.Increase the difficulty by slightly bending the stance leg. Proprioceptive training for lower body Tandem stance Stand on a firm surface, Place one foot directly in front of the other, Maintain your upright posture, Switch feet and repeat, Progress by standing on a folded towel or a pillow. Proprioceptive training for lower body Leg swing and Stork stance Fig (A) Stand on your left leg and raise the right leg 3-6 inches off the floor. With arms at your hips, swing your right leg forward and backward, touching the floor for balance then don’t touch, while keeping your torso erect. Switch legs and repeat. Proprioceptive training for lower body Leg swing and Stork stance Fig (B) in stork stance bring your arms out to your sides so they are nearly parallel with your shoulders. Raise your non- standing leg backwards until it is parallel with your horizontal upper body. Maintain for at least 30 seconds then repeat other leg. Proprioceptive training for lower body Single leg stance on firm and foam surface Try to stand on one leg firstly on firm surface then upgrading to stability trainer “foam surface” with double leg then single leg from open then closed eyes Proprioceptive training for lower body Single Leg Stance Clock Stand on one leg and lightly tap the floor on an imaginary clock around you. Bend your support knee slightly. Start with tapping forward and continue your way to 1, 2, 3, 4, 5 and 6. Keep your balance. Proprioceptive training for lower body Single leg Deadlift Standing upright on one leg, tip the body forward, hinging at the hips and keeping the back straight. Pick up ball from the floor and use hamstring to lift you back to the starting position. Proprioceptive training for lower body Banded triplanar toe taps For beginners, try this move without the loop band. Place a TheraBand around your ankles and stand with your feet hip- width apart. Shift your weight to your left foot and lower into a quarter squat. Using the loop band as resistance, tap your right toe in front of you, to the side, and behind. Do this 10 times and switch sides. Proprioceptive training for lower body Bird dogs exercises From quadruped position, first athlete support on mat and try to raise one arm forward then one leg then right arm with left leg at same time and vice versa from open and closed eyes while instructed to maintain balance and don’t fall. For upgrading, the same exercise was done on swiss ball then on wobble board. Proprioceptive training for lower body Medicine ball catch While standing on BOSU balance board try to throw and catch ball keeping your balance as much as you can Proprioceptive training for lower body Sitting on swiss ball Steady yourself on the swiss ball, then steady your injured leg on the floor before raising the opposite leg while catching ball on hand and keep your balance. Proprioceptive training for lower body Reverse Lung Stand with your feet hip-width apart and your hands on your hips. Shift your weight to your left foot and take a large step back with your right foot. With the ball of your right foot touching the ground and heel up, lower your right leg until your thigh is perpendicular to the ground and your right knee is at a 90-degree angle. Your left knee should also be bent 90-degrees. Push into your heel and squeeze your glutes to lift your body back to starting position. Repeat this 8–12 times. Proprioceptive training for lower body Wobble balance board exercises Balance board workout starting easy and getting harder 1. Sitting down place the wobble board under the feet and slowly rotate it a number of times in each direction. This is good for improving ankle range of motion and control. 2. Stand on the wobble board, feet shoulder width apart. Hold on to a chair for support if needed and rock the board forwards and backwards, then side to side. Do this for 2 to 3 minutes. 3. Stand on the wobble board, feet shoulder width apart. Rotate the wobble board round so that the edge of the board is in contact with the floor at all times. Again try this for 2 to 3 minutes. 4. Balance on the wobble board for as long as you can without the edges touching the floor. Aim for over 2 minutes without touching the floor. Proprioceptive training for lower body Wobble balance board exercises Balance board workout starting easy and getting harder 5. Rotate the wobble board in a circle but do not allow the edge of the board to touch the floor. Aim for 2 minutes. 6. Balancing on the board with both feet, perform small knee bends to challenge your balance. Gradually bend your knees further into a squat. 7. Again balancing with both feet, reach both arms out in front of you. Rotate your upper body around slowly from side to side. 8. Balancing with both feet, throw a ball against a wall and catch it on its return. You can also do this with a partner. 9. Do all of the above exercises with your eyes closed! This will make them considerably harder! Proprioceptive training for lower body Wobble balance board exercises Balance board workout starting easy and getting harder 10. Stand on the wobble board with one leg. Rock the board from front to back for 1 minute and then side to side for 1 minute. 11. Again stand on the wobble board with one leg only. Rotate the board in a circular motion in one direction for 1 minute then repeat in the other direction. 12. Balancing on one foot, perform small knee bends to challenge your balance. 13. Still on one foot, point your arms out in front of you and rotate the upper body from side to side. 14. Balancing with one foot, throw a ball against a wall and catch it on its return. You can also do this with a partner. If you can master all of these exercises then your proprioception and balance are good! If not, keep working at it and you should soon see improvements. Proprioceptive training for upper body Proprioception Alphabet with weight Lie on your back with your knees bent and your back flat on the floor. Extend your arm in front of you holding a weight in your hand. Slowly draw out the letters of the alphabet with the arm, keeping your body, shoulder blades and head stable. Proprioceptive training for upper body Alphabet on wall with a ball Stand with your arm extended in front of you at shoulder height, holding a ball against a wall keeping it moving. Pull the tip of your shoulder backwards and slowly draw out the letters of the alphabet with the arm, keeping the shoulder blade stable and chin tucked-in. Relax and repeat. Proprioceptive training for upper body Prone Ball Toss Lie down on the edge of a bed or table. Pull your shoulder blade toward the middle of your back and lift your arm up and out from your body. Bend your elbow so your palm faces down toward the floor. Hold a small weighted ball in your hand in this position (can start with a unweighted ball ex, tennis ball) Release and then catch the ball repeatedly, allowing it to barely fall from your hand. Maintain the position of your arm and shoulder blade throughout the ball tosses. Proprioceptive training for upper body Squatting while throwing and catching ball While standing on BOSU try to throw and catch the ball from squatting position keeping your balance as much as you can Proprioceptive training for upper body Push up and plank on ball and wobble board From push up or plank position try maintain your balance while supporting on half ball “BOSU” or small rigid ball from open then closed eyes Special Considerations When designing any proprioception training program, you need to consider the client’s age, physical condition, body weight, level of competition and footwear: 1. During proprioceptive activities, children under the age of 16 are at a higher risk of injury than adults because their central nervous systems are not fully developed; information is not transmitted quickly enough to provide the necessary safeguards against excessive body stresses. Older adults have a similar problem because message transmissions to and from the central nervous system tend to slow with age. Both children and geriatrics are also more prone to injuries during proprioception training because they tend to have less muscular strength than adults. Special Considerations 2. Body weight is another concern, especially when implementing dynamic balance activities. The more a client weighs, the less he may be able to do. The stress placed on joints during some dynamic balance or agility/coordination movements may be too much for some clients. For example, a client who weighs 250 pounds may be able to perform a vertical jump only five times in 30 seconds, whereas a 120-pound client may be able to do 20 jumps in the same amount of time. The intensity and progression of more advanced activities must be based on each client’s unique abilities. Special Considerations 3. When choosing how to progress proprioception activities, you also need to address the level at which a client participates in a given sport. For example, the goals of a competitive runner will be very different from the goals of a recreational runner. And, of course, you would not expect a 55-year-old novice exerciser to be at the same fitness level as an 18-year- old gymnast. 4. Footwear worn during proprioception training is also important. To prevent injuries, ensure that each client wears the appropriate amount of support and cushion for the activity being performed. Although a client should be barefoot for exercises like the stork stance, proper footwear is crucial for advanced activities such as running and jumping. Proper footwear means shoes are in good condition , not excessively worn, are laced correctly fit properly, offer appropriate support and cushioning Teaching Technique Correct technique is essential when performing all of the proprioceptive exercises. Clients must maintain good postural alignment during each movement and should not be allowed to compensate using other parts of the body. For example, when a client is performing the stork stance, ensure that she is standing up straight and not leaning to either side. Teaching Technique When teaching proper landing technique during jumping movements, stress the need to land on the midfoot, not on the heels or toes. If at any time a client cannot perform an activity using proper technique, you must immediately reduce the difficulty of the activity until you reach a level he can perform correctly. Allowing a client to continue with improper form will increase his chance of injury and decrease his chance of succeeding with the overall training program. Ideal time of proprioceptive exercise during session: It is recommended to include proprioception exercises at the beginning of the client’s training session, before fatigue has set in. The time to perform these exercises is after the warm-up, but before cardio and/or strength training. As fatigue increases, so does the risk of injury—especially when you are intensifying the level of difficulty. That said, it is acceptable to include a few simple static balance exercises, such as the stork stance, during the cool-down period. However, dynamic balance and agility/coordination activities should not be performed that late in the training session. Thank You