Proprioceptive deficits and Rehabilitation Following Upper Extremity Trauma Laura Conway MS OTR/L, CHT, COMT UE
Proprioception Proprius: belonging to ones own -ception: to perceive Dr. Elisabet Hagert
Perception and Control • Posture • Balance • Audiovisual-motor coordination • Joint stability
• Preparation for motion • Control of motion • Response to motion
Proprioception- The Info Coming in • Kinesthesia- The conscious sense of joint motion • Joint Position Sense-Conscious appreciation of joint position and angle. • Neuromuscular control- Unconscious control of joints and reflexes
Kinesthesia • Muscle spindles • Skin – especially important when joint distant from muscles spindles • Joints play increased roll when muscle/tendon cross multiple joints
Joint Position Sense • Also related to muscle spindle input • Trainable
Neuromuscular Sense/Proprioception • Difficult to quantify. • Essential to control of the muscles effecting a joint. • Assists in anticipatory control of the muscles for stability and equilibrium. • Acts with the cerebellum in planning, anticipating and executing joint control.
Neuromuscular Control • Lack of neuromuscular control places ligament structures at risk. • System allows for coordinated function but also protection. • Decreases with fatigue. • Development relies on repetition.
Unconscious • Involuntary anticipatory neuromuscular responses for joint stability and control. • Afferent input: muscle and joint receptors • Regulated by; Rapid spinal cord reflexes, SM cortex, cerebellum
Conscious • Willful perception of joint motion or position for stability and control • Afferent input: Muscle and skin • Regulated by: Central integration and interpretation, SM cortex, cerebellum Riemann & Lepart, 2002
Ligament Muscle Reflex • Initiates opposing muscle group • Fast • Protective
Reciprocal Inhibition • Agonist inhibits antagonist- ie. Bicep inhibits triceps • Recurrent inhibition-normally synergistic muscles may become antagonists-ie. FCU inhibits FCR
Role of the Sensory Motor Cortices • Conscious control of the joint • Explicit motor planning
Mechanoreceptors-static • Mechanoreceptors are found within the skin, ligaments and joint capsule. • First line of defense against injury • Pressure • Motion • Velocity Karagiannopoulos C , Michlovitz: 2016
Mechanoreceptors-dynamic • Muscle spindles • Golgi tendon organs • May be remote i.e. fingers
Supraspinal control Cerebellum Sensory motor cortex Dorsal Horn Anterior horn Afferent sensory input Motor output/ Awareness
Role of the Cerebellum • Unconscious neuromuscular control of the joint • Regulates descending motor commands
Distribution of Mechanoreceptors in the Wrist Volar and radial ligaments are less innervated and play a greater role in stabilization with axial load.
Innervation Density • Dorsal Scapholunate • Dorsal radiocarpal • Dorsal intercarpal • Palmar lunotriquetral • Triquetrocapitate/ hamate ligaments Hagert E. 2010
ENOUGH SCIENCE, WHAT DOES THIS MEAN TO ME AND MY PRACTICE?
Goals in Proprioceptive Retraining • Regain coordinated movement for activity performance • Gain/regain muscular control to assist in joint stability
What kinds of injuries result in proprioceptive disruption? • Ligament injuries • TFCC injuries • Basal thumb osteoarthritis • Fractures • Peripheral nerve injuries • CNS dysfunction-concussion? • Amputation/soft tissue trauma
Sensory Motor Dysfunction • Conscious proprioception loss • Sensibility loss • Decreased neuromuscular recruitment • Impaired strength and endurance • Misinterpretation of force/magnitude Karagiannopoulos C JHT (2013)
How Does This Present in Our Patients? • Movement disorder. • Dropping objects that they have the strength to hold. • Balance • Decreased work or athletic performance.
Accurate Information • Changes in tissue may alter accuracy of information • Pain = inhibition • Eventually cortical reorganization
What can we do about it? • Education i.e.. “you did not drop the remote because you’re weak” • Tasks that emphasize speed, position in space, motor planning, interpretation and adjustment of posture for force. • Involve the entire body • Provide complex and challenging surfaces and distractions i.e. BOSU • Work on both conscious and unconscious control
Stages of proprioceptive reeducation Stage Plan Purpose Example I Basic Rehab Edema and pain control Cold corn II Proprioceptive Promote joint control GMI awareness III Joint position Ability to duplicate joint Blinded passive rom sense angle reproduction IV Kinesthesia Ability to sense joint motion Vision occluded alphabet, without audiovisual cues object pass, ball toss V Conscious Strengthening specific Isometric neuromuscular muscles for joint stability Isokinetic rehab Eccentric Co-activation VI Unconscious Reactive muscle education Plyometric neuromuscular Rhythmic stabilization rehab Modified from Hagert 2010
Conscious neuromuscular training • Isokinetic • Isometric • Eccentric • Co-activation
Isokinetic Exercise • Requires specialized machines • Maintains constant speed throughout arc of motion despite increased effort • Increases both strength and endurance
Isometric • Performed at a fixed joint angle • Excellent for building stability • Decrease pain/fear/avoidance • Low risk of injury • May be bilaterally relevant *GMI
Eccentric • Control through deceleration • Activation of antagonist • Greater joint stability • Recruitment
Co-activation • Simultaneous agonist/ antagonist contraction
• Sign language-novel task • Marbles in pvc • Tilt game
Unconscious Neuromuscular Rehabilitation
Grading • Alter wrist angle • Vision occluded • Unstable surface • Alter shoulder angle • Speed • Unstable weight • Moving feet
Dart Throwers Motion • Suggested as a way to stabilize and minimize risk to a disrupted SL joint • Facilitated FCU and ECRL isolated motion inhibits ECU to stabilize and reduce disruption
Proprioceptive Tasks • Posture • Joint stability • Symmetry • Load bearing components • Tolerance of force thought joint
Mirror Feedback Scapular Stabilization
• Ball activities-bounce, throw, varied size and weight. • Rebounder • Rhythmic stabilization • Closed chain exercise • PVC pipes filled with water, marbles.
Tape • Assist • Agonist • Antagonist • Tactile cue
Technology! • Apps-Tilt games • Mouse Maze • Fall Down • Aerox • Tilt Maze • Labyrinth lunacy
Functional Tasks • Reassure that they can use the hand- just don’t handle the china. • Complex resistive patterns that require frequent accommodation. • Cleaning, baking, painting, music.
High Level Additions • Walking • Balance pad • BOSU • Visual distraction • Vision occluded
• Rhythmic stabilization>adjacent arc of motion>unstable surface
Weighted Alphabet Exercises Supine>Standing
• Labyrinth • Kendama • Theraband alphabet • Dynaflex • Frisbee with marbles • Varied weight ball toss • Vision occluded coin in bank • Dixie cup ball catch • Paddle ball
Dosing • Based on task demands • Begin with high reps • Focus and engagement important • Limit with decreased performance accuracy*especially with athletes
Graded Motor Imagery • Pain control • Visual feedback • Joint positon sense • Stimulate somatosensory cortex
GMI: Procedural Steps GMI Procedural Order • Laterality Reconstruction • Imagery • Mirror Box Therapy
Occupation/higher level exposure Motor/ functional exposure Mirror therapy Explicit Motor imagery Implicit motor imagery Motor/functional empathy
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