Learn why proprioception is important for effective musculoskeletal rehabilitation
Proprioception is “sensing the motion and position of the body”.1 There are several independent yet interrelated mechanisms to sense and provide this necessary information. Specialized nerve endings are present in the soft tissues of the musculoskeletal system that interact with the central nervous system to coordinate body movements, postural alignment, and balance.
Some proprioceptive sensory organs are located in muscles and tendons, while others are within the connective tissues of joints. There is a constant flow of information regarding the status and function of the musculoskeletal system from these structures to the spinal cord, cerebellum, and brain. If any of these sensors begins to transmit false or incorrect information, there is a decrease in movement efficiency, which can have a damaging effect on joints and muscles. There is the potential for postural coordination problems that can be annoying or even painful.
Proprioceptive Input Problems
Post-whiplash headaches and vertigo. Twenty years ago, researchers demonstrated the involvement of spinal (especially upper cervical) proprioceptors in the various symptom patterns found in post-whiplash patients.2 Complaints associated with problems of position sensors include tension headaches, disequilibrium and vertigo, and persisting muscle tension and myofascial pain.3 Treatment methods that address the proprioception system must be included for recovery.
Chronic postural problems. Position receptors in the feet, spine, and especially in the neck (head-righting reflexes) must coordinate smoothly in order to maintain postural equilibrium. Difficulty in achieving or keeping optimal postural alignment, or problems with excessive postural sway are frequently caused by inaccurate information sent by spindle sensors in chronically strained muscles or by joint mechanoreceptors.
Figure 1: Balance exercise progression (eyes open and closed). a) Raise up on bilateral toes; b) Raise up on toes unilaterally; c) Torso flexion standing on one leg; d) One-leg balance on raised platform; e) Pivot board balance on one leg; f) One-leg balance on flat ground.
© Outcomes Assessment available thru FCER
Recurrent subluxations. When patients respond in an incomplete manner to standard chiropractic adjustments, one factor that must be considered is the status of the proprioceptive system. If inappropriate information is supplied by position receptors, the body’s movement habits, muscle-tension factors, and pain patterns remain unchanged. A 1997 study demonstrated a correlation between chronic neck pain, more frequent subluxations, and standing balance.4 Figure 1 demonstrates a progressive pattern of balance routines.
Chronic pain syndromes. Another 1997 study of patients with chronic neck pain found that most had significant, unrecognized problems in function of their proprioceptive systems.5 Many patients with chronic myofascial complaints can have inappropriate stimulation arising in the joints or muscles in the region.6
Sports performance. Athletic performance is directly determined by the status and coordination of the proprioception system. Injury prevention, return-to-sports rehabilitation, and even winning depend on how smoothly and quickly the musculoskeletal system can respond to position, speed, and balance changes. Many of the newer approaches to improving sports performance (such as plyometrics) are based on training and developing proprioceptive responses.7
Treatment Approaches
Much of the more recent (and some traditional) treatments for musculoskeletal problems take advantage of proprioceptive concepts. Joint manipulation, especially of the spinal joints, has a direct and immediate effect in normalizing receptor responses. This had been hypothesized for several years based on clinical responses and neurological studies in animals.8 A small study in humans found that specific spinal manipulation was more effective than a series of stretching exercises in improving the proprioceptive repositioning of the head in patients with chronic neck pain and positioning problems.5 Another study found that specific spinal manipulation effectively treated a series of patients who demonstrated cervicogenic vertigo (90% became symptom-free).9
Various soft-tissue techniques, such as kinesiological and myofascial approaches, are effective in normalizing the balancing capabilities of the position receptors. Trigger-point therapy (using ischemic compression, spray and stretch, or injections) seems to correct imbalances in muscle tone and tension, which are perpetuated by sensory receptor problems.10
The more effective stretching maneuvers take advantage of recent knowledge of the proprioceptive responses in the muscles and joints. A list of some of the more popular procedures includes: proprioceptive neuromuscular facilitation (PNF), postisometric relaxation (Lewitt technique), contract-relax (CRAC), muscle-energy techniques, and active release (Leahy technique). By activating and coordinating the muscle spindles and the mechanoreceptors, these stretching procedures can be very effective in chronic cases.
Patients with proprioceptive imbalances often benefit from various external supports to help them achieve proper body positioning, including orthotics for the foot and ankle, cervical pillows in chronic neck pain, and chair supports to provide alignment of the back during sitting.11
Advances have been made in methods for strengthening postural muscles based on our knowledge of proprioception. Since postural (especially back and neck) muscles are tonic, slow-twitch muscles, use slow and controlled exercises in an upright position to stimulate and normalize input from position receptors.
Closed-chain exercising (whether stretching or strengthening) is being used much more frequently in sports and rehabilitation. By keeping the body upright and weight bearing during exercising, all of the proprioceptors are recruited to condition the muscle and joints. This provides a more rapid and appropriate neuromuscular learning experience and allows the skills practiced to be used in functional, everyday, and sports-specific situations.
Two areas where this approach is seen are walking and balance retraining. Walking is a basic, deeply ingrained motor pattern, sometimes called cross-crawl. Brisk walking with a good arm swing activates this neurological program and can often help in normalizing inappropriate receptor input. Even more specialized proprioceptive exercises use gym balls, balance and rocker boards, and special balance shoes.12
To help re-coordinate and improve the function of the upper cervical proprioceptive system, specific eye-head-neck coordination exercises have been developed. These recognize the complexity of the interconnections between the upper cervical receptors and information from the visual and oculomotor system, and the vestibular/labyrinthine system.13
Kim D. Christensen, DC, DACRB, CCSP, CSCS, founded the SportsMedicine & Rehab Clinics of Washington. He is a team doctor to high school and university athletic programs, a postgraduate faculty member at numerous chiropractic colleges, president of the ACA Rehab Council, and a lecturer and the author of many musculoskeletal rehabilitation and nutrition texts. He can be reached at PeaceHealth Hospital via email:kchristensen@peacehealth.org.
References
1. Gatterman MI, ed. Chiropractic Management of Spine-Related Disorders. Baltimore, Md: Williams & Wilkins; 1990:413.
2. Hinoki M. Vertigo due to whiplash injury: a neurotological approach. Acta Otolaryngol Suppl. 1985; 419:9–29.
3. Fitz-Ritson D. The chiropractic management and rehabilitation of cervical trauma. J Manipulative Physiol Ther. 1990; 13(1):17–25.
4. McPartland JM, Brodeur RR, Hallgren RC. Chronic neck pain, standing balance, and suboccipital muscle atrophy: a pilot study. J Manipulative Physiol Ther. 1997; 20(1):24–29.
5. Rogers RG. The effects of spinal manipulation on cervical kinesthesia in patients with chronic neck pain: a pilot study. J Manipulative Physiol Ther. 1997; 20(2):80–85.
6. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Md: Williams & Wilkins; 1983:36.
7. Gleddie N, Marshall D. Plyometric training for basketball. Strength and Conditioning. 1996; 18:20–25.
8. Slosberg M. Effects of altered afferent articular input on sensation, proprioception, muscle tone and sympathetic reflex responses. J Manipulative Physiol Ther. 1988; 11(5):400–408.
9. Fitz-Ritson D. Assessment of cervicogenic vertigo. J Manipulative Physiol Ther. 1991; 14(3): 194–198.
10. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Md: Williams & Wilkins; 1983:204.
11. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Md: Williams & Wilkins; 1983:593.
12. Janda V, Vavrova M. Sensory motor stimulation. In: Liebenson C. ed. Rehabilitation of the Spine. Baltimore, Md: Williams & Wilkins; 1996:319.
13. Fitz-Ritson D. Phasic exercises for cervical rehabilitation after “whiplash” trauma. J Manipulative Physiol Ther. 1995; 18(1):21–24.
Resources
