Chiropractic care includes more rehabilitation than ever. Most chiropractic institutions now offer rehabilitation programs, with graduates more prepared for providing rehab programs for most patients. One area of rehabilitation that is gaining much interest is that of the proprioceptive nervous system. The proprioceptive mechanism is involved in the self-regulation of posture and movement through stimuli originating in the receptors imbedded in the joints, tendons, muscles, and labyrinth. These mechanisms, along with the vestibular system, can feel the pull of gravity and help the body unconsciously stay oriented and balanced. This balancing system is enhanced and dulled by various factors, and this article will discuss those factors.

Patient Knowledge

Figure 1. WinPosture technology puts the patient into a standardized position with regard to foot placement—making the test reproducible—and measures the oscillation of the body during a specific time frame.

Most people have never heard of the word proprioception, and will not understand when told of the status of their system or the corrective exercises that will be done. Simply put, we tell patients that the proprioceptive system helps the body adapt to the surrounding environment and be as balanced as possible. For example: "If you're running on an uneven surface, you don't always watch the ground to maintain balance. Proprioceptive input from your eyes, neck, ankles, and other joints do the job for you. Likewise, when you're walking up a hill, you don't need a calculator to determine the exact angle for balance."

Proprioception, and a person's center of gravity from a chiropractic standpoint, is primarily related to the feet, the cervical spine, other musculoskeletal structures of the body (biomechanics), and the eyes. Yes, other balance-contributing factors exist, such as the inner ear. From a chiropractor's point of view, however, these are the primary areas of focus. With this in mind, it is most helpful to get a starting point, or status report, of a patient's center of gravity during the initial exam. Technology is available today that will help a practitioner determine a patient's center of gravity, with eyes open and closed, and also the amount of sway during a fixed period of time, which will reflect the strength of the nervous system and core.

Geriatric Population

Figure 2. The WinPosture System provides customized interactive exercise programs for neuromuscular rehab.

In addition to the younger population, our elderly society has a tremendous need for balance testing and rehabilitation. Most people are never alerted as to the need for balancing exercises as they enter adulthood and beyond. Falling is an increasing hazard for older generations, impacting quality of life and life expectancy. With faulty biomechanics and poor conditioning, it's no wonder their balance mechanisms begin a long, slow, steady decline, and before they reach 60 years old, their balance system is already impaired and they are not even aware of it. This results in a reduced activity schedule, and ultimately, weight gain and premature degeneration of the joints.

As chiropractors, we are best equipped to address this issue. All patients, especially those over the age of 45, should be tested and put on a specific proprioceptive program designed to strengthen their balancing mechanisms while also enhancing the patients' ability to remain active. As the number of people reaching 60 and beyond is increasing every day, along with the desire by many to stay active throughout their lifetimes, we would do well to notify the public that this technology is available.

WinPosture Technology

This system is designed to be standard protocol for the examination, and provides invaluable information that can guide the doctor regarding appropriate recommendations. The platform puts the patient into a standardized position with regard to foot placement (Figure 1)—making the test reproducible—and measures the oscillation of the body during a specific time frame.

The patient is then asked to focus on a specific point in front of them for either 26 or 52 seconds. During this period, he or she is told to stand as still as possible. The test is then repeated with eyes closed.

The WinPosture system also provides customized interactive exercise programs for neuromuscular rehab (Figure 2), lower spine and extremity range of motion, and strengthening exercises. Visual feedback during proprioceptive training is effective in balance rehab for older women.

The following proprioceptive programs are a great reinforcement to the exercises provided with such technology in your office and for home care.

Proprioceptive Program

This program must begin at a level where most people aren't intimidated by the demands. In cases where the patient is less stable and unsure of their balance, be sure to have them perform these exercises in a doorway or next to a table so they're able to support themselves if needed.

With shoes off, the patient will stand on one foot for a fixed period of time, depending upon his or her ability. Normally, this time can range from 5 seconds to 20 seconds. Again, in a less-stable patient, allow them to hold onto something, and take the hand off for brief moments at a time until the patient gains the confidence and ability to stand without assistance.

This exercise should be done multiple times on each foot, attempting to hold the position without the other foot dropping to the ground for support. This takes practice and time, but patients will see the improvements rather quickly. The exercise is then done again, with eyes closed, in the same manner. Obviously in the less-stable patients, improvements must be made before recommending eyes-closed exercises.

Stability Trainers

Figure 3. Phase 3 of the conditioning program involves using the second-least-stable trainer.

Once a patient has mastered this level of training, and this can occur in 1 week or may take as long as 2 to 3 months, we then graduate them to the next level. The Thera-Band® Stability Trainers are very effective in helping patients reach higher levels of stability as well as improved centers of gravity. Stability Trainers are oval-shaped, color-coded pads, supplied in three densities to provide a progressive system of balance training. Standing on unstable surfaces forces an individual to work harder at maintaining balance. The second phase of this program would be to use the most firm Thera-Band Stability Trainer, which is green. Although very firm, this trainer is much less firm than the ground, and requires much effort in order to balance yourself for 15 to 20 seconds on one foot at a time. The challenge is that much greater when attempting with eyes closed.

The patient will then graduate to Phase 3, which is the next level of the stability trainer (Figure 3).

The final stage of this conditioning program is to use the least stable trainer, which is black. Typically, the only patients who will graduate to this level are strong or youthful patients, as this is a very unstable surface (Figure 4). The black pads offer on one side a surface with rounded points providing tactile inputs for increased sensorimotor training.

Patient Management

The only way to get maximum stabilization results with patients is to manage them over a long enough period of time to allow the proprioceptive nervous system a chance to become strengthened fully. This can't happen overnight, and requires a consistency to achieve this result. Patients must continue these exercises for 3 to 9 months to reach such levels. It really should be a part of their daily activities.

Re-testing every 6 to 8 weeks allows a patient to see his progress and motivates him to continue the exercises.

Figure 4. The final stage of the program is to use the least stable trainer.

Chiropractic is the most advanced profession in addressing proprioceptive weaknesses and imbalances. With the technology now available to assess a patient's center of gravity, and with tools available to improve these findings, any patient has tremendous potential for improvement. The key is good patient management during the program. It is recommended to have multiple stability trainers in the office to periodically test the patient, and time and document the findings. This brief test can be done every third or fourth visit, and this is the best way to motivate and manage patients through their program.

In addition, chiropractic adjustments are the most powerful tool to improve joint mobility, enhancing proprioceptive activity and efficiency. No other profession has this asset available to it, and it would make perfect sense for our profession to market and continue research on the benefits of chiropractic adjustments with regard to the balance and proprioceptive nervous system.

Serge Sautré, DC, is a 1994 graduate of Life University, past director of the Olympic Chiropractic Center in Costa Rica, and is currently in private practice in Atlanta. He is also consultant for WinPosture technology.