Download Kinesthetic and Proprioceptive Retraining Principles

PT 153: THERAPEUTIC EXERCISE 2
THERAPEUTIC EXERCISES
TO IMPROVE
PROPRIOCEPTION AND
KINESTHESIA
Kristofferson G. Mendoza, PTRP
University of the Philippines Manila
College of Allied Medical Professions
Department of Physical Therapy
Learning Objectives
At the end of the session the learners should be able
to:
 Explain relevant theory, concepts, and principles of
kinesthetic and proprioceptive training

Describe applications of kinesthetic and
proprioceptive training

Demonstrate techniques of kinesthetic and
proprioceptive training correctly
Kinesthesia and Proprioception


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
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Perception of joint and body movement as well as
the position of the body, or body segments, in
space
Spatial orientation of body in space
Detects the rate and timing of movements
Muscle exertion and how fast a muscle is being
stretched
Perception of joint and body movement, as well as
the spatial orientation of the body and its
segments
Kinesthesia and Proprioception

Responsible for deep somatosentation

Afferent stimuli from: muscles (muscle spindle),
tendons, ligaments, fascia, Joint

Play an important role in motor control, planning
and adaptive behaviors
Kinesthesia and Proprioception

Corollary Discharge
 Motor
signals sent to the muscle once an action is
planned
 Important in differentiating between active and
passive movement
 Identifies if the motor activity is appropriate in terms
of force and body scheme
Kinesthesia and Proprioception

Corollary Discharge
 Hypothesis
 Only
active joint movement produce an efferent copy
(internal correlate or corollary discharge) of a centrally
generated motor command
 Brain compares the movement to a “reference of
correctness “
 Neuronal model of memory of “how it feels” to move in
that way and “what is achieved”
Kinesthesia and Proprioception

Feedback mechanism

Closed loop mechanism

Open loop mechanism

Feedforward mechanism
Feedback
Schmidt (1998) three types of responses That
produce feedback
 Muscle contraction
 Change that occurs in the environment
 Movement of the body parts in space
(proprioceptive stimuli)
Closed Loop


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Response-produced feedback is compared to a
reference of correctness
The extent of error is determined and correction is
made
Utilized for precision movements that require
sensory feedback (e.g., maintaining balance while sitting
on a ball or standing on a balance beam)
Open Loop

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Muscle commands are pre-programmed and once
triggered run their course
There is no possibility of correction from sensory
feedback
Utilized for movements that occur too fast to rely
on sensory feedback
Utilized for anticipatory aspects of postural control
Feedforward

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“Internal feedback”
Sending of signals in advance of the movement
Postulates that a copy of centrally generated
motor command signals (corollary discharge) is fed
forward and compared to a sensory reference of
correctness.
Used to correct errors that are detected prior to an
action
Kinesthesia and Proprioception

CNS interprets and integrates proprioceptive and
kinesthetic information and then controls
individual muscles and joints to produce
coordinated muscle activation and both joint
stability and joint movement

Following injury and subsequent rest and
immobilization, the central nervous system
“forgets” how to put this information together.
Kinestetic and Proprioceptive
Retraining

Restoration of proprioceptive sensibility to retrain
altered afferent pathways and enhance the
sensation of joint movement

Generally, comprised of weight bearing exercises
(full weight bearing status or confines of allowed
weight bearing)
Kinesthetic and Proprioceptive
Retraining Goals

Improve proprioceptive awareness of safe
posture, safe positioning, and safe movement

Improve functional joint stability through improved
motor coordination related to proprioceptive
awareness
Stages of Rehabiliation

Early training / protection phase

Basic training / controlled motion phase

Immediate to advanced training / return-tofunction phase
Kisner and Colby, 2007
Early Training / Protection

Awareness of what makes symptoms better or
worse

Learn neutral spine

Pelvic tilt / cervical retraction:
passive  active assist  active in comfortable
positions
Kisner and Colby, 2007
Basic Training/Controlled Motion

Active spinal control in supine, quadruped, sitting
and standing

Dynamic maintenance of pain-free position with
activities
Kisner and Colby, 2007
Intermediate to Advanced Training/
Return to Function

Habitual use of the neutral spine in all functional
activities
Kisner and Colby, 2007
Kinesthetic and Proprioceptive
Retraining Principles

Awareness of safe joint positions is of primary
importance and should precede other exercises:
 Supine, side, and prone lying
 Sitting
 Standing
Kinesthetic and Proprioceptive
Retraining Principles

Practice of safe movements (basic body
mechanics) should follow, in:
 Rolling
 Supine
 Sit
to sit
to stand
 Walking
forward and in reverse
Kinesthetic and Proprioceptive
Retraining Principles

Awareness of safe joint positions and observance
of safe movements should be integrated into
work-specific activities, recreation-specific
activities, and sport-specific activities
Kinesthetic and Proprioceptive
Retraining Principles

Patient education is always a must:
 Active,
informed patient involvement
 Self-management
and safe progression of
treatments
 Injury
prevention through task and environmental
modification
Phases of Training

Static stabilization exercises with closed chain
loading and unloading (weight shifting)

Transitional stabilization exercises

Dynamic stabilization exercises
Voight, 2000
Static Stabilization

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Isometric exercises around the involved joint on
solid and even surfaces, then to unstable surfaces
Initiated with controlled balance training and joint
repositioning
Tools: mini-trampoline, balance board, swiss ball,
wobble board
Voight, 2000
Static Stabilization
DOUBLE
LIMB
SUPPORT
SINGLE
LIMB
SUPPORT
SINGLE
LIMB
SUPPORT
WITH
TASK- OR
SPORTSPECIFIC
SKILL
Static Stabilization
Static Stabilization
Static Stabilization
Transitional Stabilization

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Involves conscious control of motion without
impact
Replaces isometric exercises with controlled
concentric and eccentric exercises
Stimulates dynamic postural response
Increases “muscle stiffness” which in turn
increases dynamic stabilization around the joint
by resisting and absorbing joint load
Voight, 2000
Transitional Stabilization
Step-up
Transitional Stabilization
One-leg Box Squat
Transitional Stabilization
Lunges
Transitional Stabilization
SMALL
RANGE
LARGE
RANGE
Dynamic Stabilization

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Includes unconscious loading of the joint
Involves both ballistic and impact exercises
Muscle strength, endurance and flexibility and
NM control to achieve stability and mobility
Mediated by articular mechanoreceptors
Voight, 2000
Dynamic Stabilization
Side Plank
Bridge
Plank
Dynamic Stabilization
Hip Lift
Dynamic Stabilization
CCK IN PAIN
FREE RANGE
TO
IMPROVE
STABILITY
ALTERATIONS
IN JOINT
POSITIONING
RHYTHMIC
STABILIZATION/
COCONTRACTION
OPEN CHAIN
PLYOMETRIC
EXERCISES
Dynamic Stabilization
Sample Proprioceptive Exercises

Standing and leaning
against treatment table

Weight-shifting in a
push-up position
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Rocking forward and
backward in quadruped

Maintenance of sitting
on v.ball while
alternately moving limbs

Maintenance of kneeling

Standing on one leg on
BAPS board
Techniques for the Pediatric
Population

Slow stretch or alternate
compression

Rhythmic vibration and
stretch

Joint approximation

Joint pounding

Joint distraction

Joint moblization
Techniques for the Geriatric
Population

The approach is functional and task-oriented

Stimulate heavy work patterns

Give many opportunity to enhance sensory-motor
activity to cause the brain to have a clear “body
map”
Techniques for the Geriatric
Population

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Use of weights in the form of vests
Promoting reaching, stretching, elongation of
muscles
Task modification to allow pushing, pulling, sliding,
carrying, lifting
Maintenance of quiet standing
Hopping in a trampoline
Techniques for the Geriatric
Population: Precautions
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Poor depth perceptions
Poor stabilization
Low tone and slack joints
Painful joints
Poorly articulated joints
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Spinal and skeletal
deformities
Severe osteoporosis
Weak grip
Bilateral neglect
References
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Dutton, M. (2004). Orthopaedic Examination, Evaluation &
Intervention. NY: McGraw-Hill.
Kisner, C. & Colby, L. A. (2002). Therapeutic Exercise: Foundations and
Techniques (4th ed.) PA: F.A. Davis Company
O’ Sullivan, S.B. and Schmitz, T.Z. (2002) Physical rehabilitation:
Assessment and Treatment (4th ed.) PA: F.A. Davis Company
Tiongson C. and Julio Veloso JM. Lecture Slides on Evidence Based
Approach to Assessment and Treatment of ACL Rupture.
Lopez, L. (2007). Lecture Slides on Kinesthetic and Proprioceptive
Training.
Encabo, M. (2008). Lecture Slides on Kinesthetic and Proprioceptive
Training.
THANK YOU