Laura Conway MSOTR/L, CHT, COMT UE

Laura Conway MSOTR/L, CHT, COMT UE

Hand Therapy Coordinator-Gulf Coast/ Fieldwork coordinator

Select Live faculty

Select Physical/Hand Therapy, Brandon, Florida, USA

I have no financial relationships to disclose within the past 12 months

relevant to my presentation.

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

Measureable-documentable

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

Balancing act for function

Ligament muscle reflex vs. Reciprocal

inhibition

Ligament muscle reflex

Initiates opposing muscle group

Fast

Protective

Reciprocal Inhibition

Agonist inhibits antagonist- ie. Bicep

inhibits tricep

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

Handout has detail on

mechanoreceptors

Afferent sensory input

Cerebellum

Sensory motor cortex

Motor output/

Awareness

Dorsal HornAnterior horn

Supraspinal control

Role of the Cerebellum

Unconscious neuromuscular control of

the joint

Regulates descending motor comands

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

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 after

trauma

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 alpabet,

object 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

JPS- Evaluation

Using 2 paper goniometers reproduce

40 flexion, 20 flexion 30 extension, 50

extension with vision occluded

Patient self monitors

Tape to a mirror to complete

Naveen E et al. Assessing Proprioceptive Function: Evaluating Joint Position

Matching Methods Against Psychophysical Thresholds. Physical Therapy, Volume 94,

Issue 4, 1 April 2014, Pages 553–561

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

Implicit Motor Planning Activity

Recognize app Hand Flash Cards

Magazine

recognition

Circle

○ 5 right hands

○ 5 left hands

○ 5 right eyes

○ 5 left feet

Explicit Motor Imagery

Darts

Putting

Treatment activities:

Mirror Therapy In the box! Prepare your client!

Mirror Box “Rules to Live By:”

1. If it hurts, STOP.

2. Client must watch the mirror at all times

Start non-threatening & progress as able!

At first just have them observe the hand

Remove or add all jewelry to reflect affected hand

Initiate gentle active motion

Progress to object manipulation

Textures

Gripping

Touching face

Ask about changes in symptoms

May be disorienting

Initiate movement inside the box

Treatment activities:

Mirror therapy• Bounce/roll tennis ball

• Smush/squeeze sponges

• Digiflex squeeze

• Theraputty

• Desensitization buckets

• Warm/cold water baths

• Weight bearing exercise

• Continued AROM in all

planes

Kinesthesia

Varied weight ball/sponge/cotton ball toss

Blind targeting-Coins in bankBalls in a cup

Sort byTextureWeight-eggsShapetemperature

Labyrinth lunacy

Tilt Games

Sorting

By weight By Temperature

Texture Resistance to

pressure

Conscious neuromuscular rehab tasks

Mirror feedback

PVC pipe

Theraband alphabet

Kendama

Isometrics

○ Magazine

○ Flexbar

○ Tennis ball and racket

○ Paddle ball

○ Tennis ball bounce

○ Walk outs

Mirror Feedback

Scapular Stabilization

Also wrist, opposition, elbow ect……..

Weighted alphabet exercises

supine>standing

Coactivation tasks

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

Co-activation Tasks/ Unconscious Control

Hula hoop

Body blade

Water bottle

Plank activities

○ Step up

○ Bosu

○ Balance pad

Gyroscope

BOING

PVC pipe

Hula Hoop

BOING

PVC pipes

Various size pipes

2 caps

PVC Glue

Filling

Water

Marbles-add sponges or

fluido medium for sound

Sand

weights

Medium shift from end to

end

Pronation supination

Uni/bilateral

Rapid exchange

***Add Balance mat

BOSU

Occlude vision walk

Gyroscope Ball

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

40 degrees of

extension

20 degrees of radial

deviation

0 degrees of flexion

0 degrees of ulnar

deviation

Earlier, safer more

stable motion.

Functional

Dart Throwers Motion

Garcia-Elias M, Serrallach XA, Serra JM. Dart-throwing motion in patients with scapholunate instability: a dynamic four-

dimensional computed tomography study. J Hand Surg Eur Vol. 2014;39(4):346e35

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

Labyrinth

Theraband alphabet

Dynaflex

Frisbee with marbles

Varied weight ball toss

Vision occluded coin in bank

Dixie cup ball catch

Paddle ball

Case: Anna

Anna is a 32 y/o female performance

artist/acrobat. She sustained a high

energy Galeazzi fx while performing and

inverted ring act. She was fixated with a

volar plate and immobilized in pronation

for 6 weeks.

1.

FOOSH

2. Radius

FX

4. Distal ulna

migrates distally

4. radius

migrates

proximally

3. DRUJ

disruption

Mechanism

Physical exam

AROM

Wrist flexion 35

Wrist

extension

0

Radial

deviation

10

Ulnar

deviation

5

Pronation 85

Supination -40

MCP PIP DIP

II 0/60 0/55 0/30

III 0/60 0/50 0/25

III 0/55 0/65 0/25

IV 0/40 5/65 0/30

Bunnel –littler demonstrates a 30 degree

Difference in PIP Passive flexion

Impression

Edema

Intrinsic tightness

Supination -40 degrees

Maladaptive grasp pattern- wrist flexed

with grasp

Diffuse hypersensitivity

Highly motivated, athlete

Assessment of JPS

Assess the ability to reproduce a passive joint position after a 3 second delay.

MCID at 8 and 12 weeks

5.0 and 7.09

Greater baseline data

needs investigation

Karagiannopoulos and Michlovitz 2016

Proprioceptive concerns

Highly dynamic vocational needs

Must be able to support her body weight

on wrists when inverted

Must be able to safely lift and support

another performer

High degree of tortion and axial force

across joints

Sense of velocity

Goals

Proximal and distal joint stability

Accurate JPS at speed and under load

Joint protection at extremes of range

Tolerance/ accuracy of assessment of

force through joint

Strength and endurance

Eventual return to performance

Early interventions

Edema management

Cold corn-counter irritant

Functional grasp activities

Gross bilateral activities

GMI

Graded motor imagery

Pain control

Visual feedback

Joint positon sense

Stimulate somatosensory cortex

Late/ advanced interventions

Isometrics

Rhythmic stabilization-water bottle, body

blade

Weight bearing tasks

Eccentrics

Task simulation

Grading

Alter wrist angle

Vision occluded

Unstable surface

Alter shoulder angle

Speed

Unstable weight

Moving feet

Job specific simulation

Rolling stool hand

walks

Sustained overhead

hold with unstable

surface

Sustained overhead

carry

Weight bag lift

Walking/ stepping

with body blade

Weight bag catch

and throw

Dosing

Based on task demands

Begin with high reps

Focus and engagement important

Limit with decreased performance

accuracy*especially with athletes

Outcomes

Wrist extension and supination deficit

Swelling and pain following long practice

or multiple performances

Able to modify her act and perform

safely

Case: Eric

Patient is a 42 y/o RHD male with a 6

month complaint of lateral elbow, forearm

and shoulder pain. He is a competitive

pistol marksman. 3 years ago he was in a

MVA with C3-C5 herniation. Pain after

practice and rapid decline in performance

after ½ hour. Weight trains.

Physical exam

Mills, Cozen’s and Maudsley’s negative.

Gross grip R #124 L #115

No heat upon palpation

Joint play equal bilaterally at the elbow

Pain not reproduced with palpation.

Physical Exam

Unilateral atrophy/ weakness of trapezius, rhomboids, supraspinatus and infraspinatus.

Scapula protracted, elevated and

Positive CPR for cervical radiculopathy (cervical rotation<60, +ULTT, +spurlings, relief with traction) Traction -

Palpation of the triangular interval/ space painful with pain radiating to forearm

Right shoulder has a rounded posture

Tight pec minor, subscapularis, teres

major

Shoulder external rotation 60 (85)

degrees

+ Flip sign

Kibler test 2.5 cm at 45 degrees

Impression

C3-C5 radiculopathy

Suprascapular nerve impairment

Radial nerve irritation

Scapular dyskinesia

Proprioceptive concerns

Decreased triceps, anconeus and wrist extensor control

Scapular position while shooting increases radial nerve symptoms

Poor proximal stability

Radiculopathy

Decreased control with athletic performance

Rapid fatigue with athletic performance

Goals

Increase positional awareness of

scapula throughout range

Increase ability to maintain scapular

stability underload

Increase endurance of scapular

stabilizers

Intervention

PT to address radicular symptoms

Proximal stabilization exercises

Soft tissue mobilization

Neural mobilization

Capsular stretching to regain external

rotation

JPS in the mirror

Begin with static positions

Vision occluded

Unstable surface

Unstable load

Mirror feedback scapular

exercises

Rhythmic stabilization>adjacent arc of

motion>unstable surface

Weighted alphabet exercises

supine>standing

Outcome

Improved pain

Increased practice time tolerated to

normal

Independent in self management

Referred for reassessment with hand

surgeon and possible neurosurgery

referral

Case: Noreen

Patient is a 65 y/o female 6 weeks s/p

trapeziectomy with ligamentous

reconstruction. Patient is evaluated after

pin and cast removal.

Has the “dropseys”

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.

Garcia-Elias M, Serrallach XA, Serra JM. Dart-throwing motion in patients with scapholunate instability: a dynamic four-dimensional computed tomography study. J Hand Surg Eur Vol. 2014;39(4):346e35

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!