Rehabilitation Following Upper Extremity Trauma Laura Conway MS - - PowerPoint PPT Presentation

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
• f 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

Afferent sensory input Cerebellum Sensory motor cortex

Motor output/ Awareness

Dorsal Horn Anterior horn

Supraspinal control

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 awareness Promote joint control GMI III Joint position sense Ability to duplicate joint angle Blinded passive rom reproduction IV Kinesthesia Ability to sense joint motion without audiovisual cues Vision occluded alphabet,

• bject pass, ball toss

V Conscious neuromuscular rehab Strengthening specific muscles for joint stability Isometric Isokinetic Eccentric Co-activation VI Unconscious neuromuscular rehab Reactive muscle education Plyometric Rhythmic stabilization

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
• Theraband alphabet
• Dynaflex
• Frisbee with marbles
• Varied weight ball toss
• Vision occluded coin in

bank

• Dixie cup ball catch
• Paddle ball
• Kendama

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

Motor/functional empathy Implicit motor imagery Explicit Motor imagery Mirror therapy Motor/ functional exposure Occupation/higher level exposure

References

• Butler, D. S., & Moseley, L. S. (2003). Explain pain. Adelaide: NOI Publications.
• Cavalcante M, Rodriguez C, Mattar R. Mechanoreceptors and nerve endings in the triangular fibrocatilage in the human wrist. J Hand Surg.

2004;29A:432-435.

• Hagert E. Proprioception of the wrist joint:A review of current concepts and possible implications on rehabilitation of the wrist. JHT . 2010;

23:2-17.

• Hagert E, Persson J, Werner M, Llung B. Evidence of Wrist proprioceptive reflexes elicited after stimulation of scapholunate interosseous
• ligament. J hand Surg AM. 2009:34:642-651.
• Hagert E, Ljung B. Differences in the presence of mechanoreceptors and nerve structures between wrist ligaments may imply differential roles

in stabilization. J orthop Res. 2005; 757-763.

• Karagiannopoulos C, Sitler M, Michlovitz S, Tierney R. A descriptive study on wrist and hand sensory-motor impairment and function

following distal radius fracture intervention. JHT. 2013:26: 204-215.

• Karagiannopoous C, Michlovitz S. Rehabilitation strategies for wrist sensorimotor control impairment: from theory to practice. JHT.

2016;29:154-165.

• Marini F, Squeri V, Morasso P, Masia L. Wrist Proprioception: Amplitude or positional coding?. Frontiers in neorobotics. 2016;10 1-8.
• Moseley, G. L., Butler, D.S., Beames, T.B., & Giles, T.J. (2012). The Graded Motor imagery handbook. Adelaide, Australia: Noigroup.
• Riemann B, Meyers J, Lepart S. Comparison of ankle, knee, hip and trunk corrective action shown during single leg stance on firm, foam

and multiaxial surfaces. Archives of Phys Med Rehab.; 2003:84: 90-95.

• Ramachandran, V. S., & Altschuler, E. L. (2009). The use of visual feedback, in particular mirror visual feedback, in restoring brain
• function. Brain, 132, 1693-1710
• Ramachandran, V.S., & Altschuler, E.L. (2010). Reflections on the hand. Pain, 149, 171-172.
• Ramachandran, V. S., & Hirstein, W. (1998). The perception of phantom limbs: The D.O. Hebb lecture. Brain, 121, 1603-1630.

Thank You!