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Proprioception: The Forgotten
Sixth Sense
Chapter: Hip Problems and Proprioception
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Hip Problems and Proprioception
Sevgi Sevi Subaşi Yeşilyaprak*
Assistant Professor, School of Physical Therapy and Rehabilitation, Dokuz Eylul
University, Izmir, Turkey
*Corresponding author: Sevgi Sevi Subaşi Yeşilyaprak, PT, PhD, Assistant
Professor, School of Physical Therapy and Rehabilitation, Dokuz Eylul University,
Izmir, Turkey, Tel: +902324124926; E-mail: [email protected]
Abstract
Proprioceptive information concerning the status of joint and muscle receptors is
essential for neuromuscular control and functional joint stability [1,2]. The hip joint has
an important role in lower extremity kinetic chain and compromised function of the trunk
and hip stabilizers may underlie the mechanism of leg injuries. Poor proprioception of the
hip may diminish neuromuscular control of the leg and is related to decreased control
of hip joint stability [3]. Deterioration of proprioception is acknowledged as a risk factor
for falls [4]. There is limited number of researches examining proprioception of the hip in
the literature. Reliable and precise hip proprioception measurement techniques are still
being developed [3]. Hip proprioception declines with age [5]. It is correlated with dynamic
balance [5,6]. Increased hip proprioception error is related to decreased gait velocity in
Cerebral Palsy (CP) [6]. Researchers mostly interested in whether hip proprioception impairs
due to fractures/hip replacement [7-10] and the effects of rehabilitation on proprioception
[11]. There is almost no information of the effects of specific proprioceptive training on hip
proprioception and few studies investigated the hip proprioception in sports [12], healthy
young people [3,13] or children with CP [6,14].
In this chapter, definitions and basic neurophysiology of proprioception; interactions with
balance, coordination, and agility; hip proprioception, neuromuscular control and functional
stability; factors influencing hip proprioception; measurement of hip proprioception; hip
and lower extremity injuries, prevention; hip proprioception and problems involving hip
joint, healthy people vs. patients; physical activity, sports, exercise and hip proprioception;
hip proprioception exercises are discussed in detail.
Keywords: Hip; Neuromuscular Control; Proprioception; Proprioceptive Test
Definitions
Proprioception was first defined by Sherrington in 1906 as “the perception of joint and
body movement as well as position of the body, or body segments, in space” [15]. At present,
proprioception is defined as the cumulative input to the Central Nervous System (CNS)
from mechanoreceptors [16]. It’s a complex sense that utilizes inputs from somatosensory,
vestibular, and visual afferent systems. Neural inputs to the CNS are provided from
specialized nerve endings called mechanoreceptors located in skin, muscles, tendons, joint
1
capsules, joint ligaments and fascia [16-18]. The somatosensory system includes two types
of mechanoreceptors as Quick-Adapting (QA) and Slow-Adapting (SA) mechanoreceptors. If
a joint is stimulated continuously by pressure or motion, the QA’s decrease their signaling
of the CNS, while the SA’s maintain signaling. Joint motion sense is mediated primarily
by QA’s, receptors detecting sudden changes in speed and movement, whereas SA’s giving
information to the CNS about joint position, slow changes in position, and sensation [19,20].
Proprioception reflects body’s ability to transmit a sense of position, analyze the information
and react consciously or unconsciously to the stimulation with the proper movement and
posture, including balance, coordination and agility [20].
Sub modalities of the proprioception are;
a. Tension/Force (resistance) Sense (FS)-ability to reproduce the same force,
b. Sense of body or joint movement-the ability to appreciate joint movement, including
the duration, direction, amplitude, speed, acceleration and timing of movements and
kinesthesia-ability to detect the initiation and direction of passive joint movement.
c. Joint Position Sense (JPS)-the ability to reproduce the same joint position actively or
passively,
d. Velocity Sense (VS)-ability to reproduce the same velocity [1,3,21].
Proprioception can be appreciated consciously or unconsciously, contributing to
automatic control of movement, balance, and joint stability, and thus being essential to
carry out activities of daily living, work and sports activities [1].
Neurophysiology of Proprioception
Mechanoreceptors, act as mechanical transducers during the deformation of the related
tissue that contains them, in transmitting neural signals to the CNS via afferent sensory
pathways [1,20,21]. The main receptors contributing to proprioception are located in
muscle, tendon, ligament and capsule. Receptors in skin and fascia are supplementary
sources [20,21]. Muscle spindle afferents respond to stretch of a muscle [17-20]. These SA
receptors, located within skeletal muscle, maintain a symbiotic relationship with articular
receptors to result in sensations of joint motion, joint acceleration and joint position [19].
Current knowledge indicates that proprioception is primarily signaled by muscle receptors,
muscle spindles [17,18,22]. Muscle spindle activity results in contraction of a muscle and
they are considered as able to provide potent afferent information across the entire range of
motion [23]. Golgi Tendon Organs (GTO) detect tension in the muscle and respond not only
stretching but also contraction of a muscle [18,20,22]. GTO activity results in relaxation of
a muscle [20]. Articular mechanoreceptors play a minor role in proprioception through the
midranges of a motion, whereas they can sufficiently stimulated in the end ranges of motion
[24]. Similarly, cutaneous receptors have been hypothesized to respond at the end ranges
of motion [24] and don’t have a major impact on proprioception in normal people [19,20].
However, Callaghan et al., pointed out that injured body segments more rely on cutaneous
receptors in injured subjects [25].
Once afferent nerves of somatosensory, vestibular and visual systems sent the input to
the CNS, motor response is determined by three distinct levels to react the stimuli: the spinal
level; the brain stem; and the higher brain centers such as cerebral cortex or cerebellum
[19-21,26].
The spinal level provides for dynamic muscular stabilization and synchronization of
muscle activation patterns based upon spinal reflexes to respond in its simplest form as
well as activity received from higher levels of the CNS. Articular mechanoreceptors, muscle
spindles and GTOs work together to produce a reflex response and joint stabilization during
conditions of abnormal stress in order to prevent injury [27].
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At the brain stem, the second level of motor control and primary proprioceptive correlation
center, afferent information from mechanoreceptors is integrated with visual and vestibular
inputs via the cerebellum nuclei. It sends excitatory or inhibitory efferent stimulation in
order to control automatic and stereotypical movement patterns and to maintain posture
and balance [19,20]. Proprioceptive information travels to the supraspinal regions of the
CNS via
1. The dorsal lateral tracts (terminating in the somatosensory cortex) which are responsible
for the conscious perception of proprioception, and
2. The spinocerebellar tracts that exhibit fastest transmission velocity for nonconscious
proprioception [1].
The higher brain centers of the CNS, the motor cortex, basal ganglia and cerebellum, are
responsible for cognitive programming of musculoskeletal motion in which motor commands
are initiated for voluntary movements, and for the cognitive awareness of proprioception.
Cortical pathway allows movements that are repeated and stored as central commands to be
performed without continuous reference to consciousness that means more automatically
[19,26,27].
Integration of the proprioceptive information results in conscious awareness of joint
position and motion sense for motor programming and unconscious joint stabilization to
protect body from injuries via spinal reflexes and to maintain balance and appropriate
posture [19]. With this integration of proprioception, body stability ahead of movement
execution (feedforward) can be coordinated and velocity or timing errors can be corrected
(feedback) [17,18,28].
Interactions with Balance, Coordination and Agility
Balance is “the body’s ability to maintain equilibrium by controlling the body’s center
of gravity over its base of support” in both static and dynamic activities [20]. Strength and
proprioception as well as visual system and vestibular system are important to maintaining
good balance and posture. Proprioception input from the lower extremities is arguably
the most important contributor to standing balance [29]. If proprioceptors are damaged
following an injury or surgery, balance can be impaired [17,18,20].
Coordination, a proprioceptive function, means a smooth pattern of combination of
muscle activities with appropriate intensity and timing. Strength, appropriate activity
perception and feedback mechanism via proprioceptors, repetition and proper inhibition of
undesired muscle activity are the key components for the coordination [20].
Agility is a highly advance skill that can be defined as the ability to control the direction
of body or body segments during rapid movements which requires flexibility, strength,
power, speed, balance and coordination. Agility also involves sudden stopping and starting
the activity [20].
Although a person must have muscle strength, endurance and flexibility to able to
perform various activities, agility to change the direction of movement very quickly and
correctly cannot be expected without proprioception. Additionally, balance is needed to
establish and to maintain stability, so is coordination to produce the activity correctly and
consistently. Proprioception seems very important not only for the rehabilitation process
after an injury but also as a routine part of a therapeutic exercise program for improvement
and to prevent injuries [20].
Hip Proprioception
Muscle spindles are the major mechanoreceptor involved in proprioception [22].
Proprioception changes following physical activity seem to be related at peripheral level with
muscle spindle adaptations [16]. There are sensory nerve end organs, such as, Pacinian
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corpuscles, Golgi-Mazzoni corpuscles, Ruffini endings and articular corpuscles (Krause
corpuscle) in acetabular labrum of the hip [30]. Free nerve endings have been found in
the labrum and ligamentum capitis femoris [31]. Free nerve endings may help to prevent
excessive joint motion that may damage to the acetabular rim and/or adjacent cartilage.
Traumatic or degenerative lesions of the ligamentum capitis femoris can damage free nerve
endings and their ability to transmit a mechanical stimulus as a correct efferent impulse
can be deteriorated. The absence of the muscular reflex might impair the protective function
of the joint with ensuing micro- and/or macro trauma.
There was a lack of information about the distribution of mechanoreceptors in the
capsule and other ligaments of the human hip in the past; furthermore presence of
mechanoreceptors in the labrum was questionable. Since mechanoreceptors are exclusively
present in the loose tissue between the mechanical relevant collagen bundles, high density
of collagen bundles in the area of the labrum was believed eliminating the possibility of the
presence of mechanoreceptors in it. In terms of joint protection; when there is excessive
stress on the ligamentum capitis femoris, it may give afferent signals to prevent further
joint excursion with reflexive muscular response. Moraes et al., [32] recently identified and
quantified mechanoreceptors and free nerve endings in the femoral head ligament, labrum,
and capsule joint in the hip serving to stabilize hip joints. The density of Pacinian corpuscles
is significantly more than densities of Golgi corpuscles and Ruffini endings while free nerve
endings are found with similar density in healthy subjects’ hips.
Neuromuscular control and functional stability
Motor control is a plastic process that undergoes constant review and modification (i.e.,
feed forward and feedback) based upon the integration and analysis of sensory input, efferent
motor commands, and resultant movements. Riemann et al., [2] defined neuromuscular
control as unconscious activation of dynamic restraints occurring in preparation for and
in response to joint motion and loading to maintain and restore functional joint stability
of both the entire body (postural stability) and the segments (joint stability). Proprioceptive
information concerning the status of the joint and muscle receptors is essential for
neuromuscular control and maintaining functional joint stability [1,2]. Muscle spindles were
found to be more important in proprioception, with the active contraction of the muscles can
provide more afferent feedback for the joint position than do the passive movement. Changes
of proprioception are mainly rely on morphological changes in the muscle spindles [33]. The
afferents that signal hip-joint position come mainly from muscles around the hip. Simple
stretch and cutaneous reflexes might be involved in compensating for irregularities and in
adapting to ground conditions [17]. After mechanoreceptor stimulation, increased activity
of γ motor neurons increase muscle activity [34]. Inputs arising from cutaneous or muscle
sources and descending supraspinal commands increase γ motor neuron activity which
increases muscle spindle sensitivity. This sensitivity is controlled by the fusimotor system,
which can vary the strength of activation of intrafusal muscle fibres in muscle spindles by
γ motor neurons [17]. Increased muscle spindle sensitivity improves the ability to resist a
perturbation and assists α motor neuron activation in decreasing the chance of an injury,
simply due to muscle stiffness decreasing the electromechanical delay. Enhanced muscle
stiffness, of which muscle spindles are important component, is argued to be an important
characteristic for dynamic joint stability. Articular mechanoreceptors are attributed
instrumental influence over γ motor neuron activation, and indirectly influence muscle
stiffness [2]. Stiffer muscles should potentially resist sudden joint displacements more
effectively [35]. This may be essential in maintaining functional stability when mechanical
stability is deficient. Additionally, stiffer muscles could transmit loads to muscle spindles
more readily, reducing some of the lag time associated with initiation of reflexive activity [2].
The hip plays an important role in the kinetic chain of the lower extremity. Compromised
function of the trunk and hip stabilizers may underlie the mechanism of lower extremity
4
injuries. Poor proprioception or proprioceptive deficits of the hip may diminish neuromuscular
control of the lower extremity, therefore is related to decreased control of hip joint stability [3].
Relationship of Hip and Lower Extremity Injuries
Weakness and/or imbalances of the hip muscles could lead difficulties in hip control
especially during dynamic movements [36]. In case of poor hip control due to weak gluteus
medius muscle, the hip will tend to move into adduction when loaded. If the hip moves into
adduction, the femur internally rotates and the knee is placed into a valgus position [37].
Leetun et al., found significantly higher hip abduction and external rotation strength in
athletes with no previous injury concerning lower extremity [38]. Diminished proprioception
and core stability of the hip may also has influence on controlling knee movements leading
to valgus angulation and increased strain on the ligaments of the knee [36].
ACL injury is one of the lower extremity injuries that hip proprioception and neuromuscular
control could likely involve. Hip neuromechanical characteristics effects knee angles and
moments. Risk factors for ACL injuries are multifactorial; and possible intrinsic factors
are anatomical, hormonal, neuromuscular and biomechanical characteristics, previous
injury, prior, reconstruction of the ACL, and genetics [39,40]. Female athletes have been
identified at increased risk of ACL injuries during certain sports with the greater injury
rates than men. Several sex-based differences were also identified and there is an important
underlying mechanism in terms of hip proprioception. It’s found that females land from a
jump and perform cutting-pivoting maneuvers with less knee and hip flexion, increased
knee valgus, increased internal rotation of the hip coupled with increased external rotation
of the tibia, and increased quadriceps muscle activation. These movement patterns has been
hypothesized to increase the strain in the ACL during activity or sport, it’s also hypothesized
that the difference in injury incidence rates between males and females may be attributed
to neuromuscular differences and resultant mechanics [40]. Deficits in hip neuromuscular
control in different planes of movement could be involved in the ACL injury mechanism
[41]. Kinematic analyses of the hip and investigations on muscle recruitment related to
the position of the whole lower extremity indicated that females have difficulty controlling
the hip during dynamic movement, revealing the possibility that females may be more
vulnerable to external forces on the lower extremity and has poor control at the hip leading
an increased ACL injury risk. Hip abduction weakness with combination of increased hip
internal rotation, could increase knee valgus [42] resulting in higher ACL injury risk [40].
Further investigation is still warranted to understand the contribution of hip proprioception
to functional knee stability.
Measurement of Hip Proprioception
There are several methods to assess joint proprioception with its sub modalities [3,21,43].
The measurement of proprioception is divided into four modalities:
1) JPS-the ability to reproduce the same joint position,
2) Kinesthesia is measured by (a) Threshold to Detect Passive Motion (TTDPM)-ability to
detect the initiation of passive joint movement, and (b) Threshold to Detection of Movement
Direction (TTDMD)-ability to detect motion and in which direction the motion is occurring,
3) VS-ability to reproduce the same velocity and
4) FS-ability to reproduce the same force [3].
These proprioceptive testing methods rely on conscious appreciation of the
mechanoreceptor input. The differences of the results reported in the literature could be
related to several factors such as testing device (e.g. open vs. closed chain testing or position
of the patient with respect to gravity leading to different muscular actions), the assessment
procedures (e.g. joint angles, active vs. passive testing, direction and speed of the movement,
5
ipsilateral vs. contralateral matching responses), and the study design (e.g. experimental
group compared with control group or bilateral comparison). Seeing the position and the
targets or hearing the noise coming from the test device may give clues to person who is
being tested. Therefore, subjects are usually wear blindfold and headphones, and pneumatic
cuff to eliminate confounding cues. Isokinetic dynamometers, goniometers, electromagnetic
tracking devices, 3D optoelectronic analysis, video analysis, potentiometers, custom-made
jigs, manually controlled or motor-driven proprioception testing devices are used as testing
devices [43].
Joint position sense assessment
JPS assessment measures the accuracy of position replication and can be conducted
actively or passively in both open, and closed kinetic chain positions [43]. The accuracy of
JPS is often measured by goniometers and video analysis systems. The testing protocols
usually comprise the definition of a target position that is identified and appreciated by
the subject, with no vision. Then, the target position is reproduced passively or actively
to the best of subjects’ ability. Active JPS testing is mostly influenced by muscle spindles
and cutaneous information. Mechanoreceptors are sensitive to the joint position. Ruffini
corpuscles detect joint limits. If a joint is moved into its limits, capsule stress increases,
and Ruffini afferents are excited proportionally to the stress. The Golgi tendon organs
are sensitive to joint position, tension and movement, measuring ligament and tendon
tension and sensing active tension within the myotendinous unit. In extreme positions
they fire through their Ib-afferents, thereby inhibiting the α-motor neurons [44]. The test
position, Range of Motion (ROM) and the degree of generalized laxity of a person will affect
the sensitivity of the mechanoreceptors. Procedure of the proprioception test is essentially
similar [3,5-9,11-14,43,45,46]. First; target angle is familiarized by the participant. In target
angle, the participant holds the position for 3-5 sec and remembers what the position feels
like at the hip. Then the patient returns to the starting position passively with the help
of the examiner or actively by him/herself. After a short rest for a few seconds, test angle
is reproduced in the same leg passively or actively. Participant acknowledges verbally or
presses a manual trigger (stop button) when he/she believes that the angle is achieved.
The “replicated angle” is noted. Either active or passive testing results are reported as
the Absolute Angular Error (AAE), defined as the absolute difference between the target
position and the estimated position, the Relative Angular Error (RAE), defined as the signed
arithmetic difference between a test and response position, and the Variable Angular Error
(VAE), commonly represented by the standard deviation from the mean of a set of response
errors [21]. Hip JPS can be assessed in weight bearing standing position and in open chain
activity. Closed chain activity is convenient because it mimics activities of daily life [3]. After
active teaching the target angels of the ROM, test is performed for five to ten times for each
leg. Average of multiple measures is more reliable then only one measure [11]. However
repetitions should be limited because fatigue experienced by the subject from the high
repetition may adversely alter joint proprioception results. The discrepancy in start and stop
angles is recorded as the error. Benjaminse et al., found only hip adduction JPS testing as
a reliable method with an intersession ICC (SEM) of 0.753 (0.248). Intersession ICC’s of
other directions of hip movements varied between 0.070 and 0.737. Intrasession ICC’s were
even lower in all directions and ranged between 0.159 and 0.319. Further investigation
is warranted to develop reliable and precise measurement methods for active JPS of the
hip [3]. Mendelsohn et al., used “passive-to-active” reproduction technique (passive
teaching, active replication) in open chain activity with electrogoniometer in patients after
hip fracture [11]. The mean AAE was calculated. In terms of test–retest reliability, when
more trials were performed proprioception testing produced more reproducible results with
ICCs varying from 0.510 to 0.690, whereas the ICCs of single measurements were lower.
Authors recommended the use of non-injured side as the control in the assessment of hip
proprioception. This finding can guide other researchers or clinicians planning to measure
6
hip flexion [11]. Proprioceptive testing in the closed-chain model allows partial body weight
bearing during test [12]. Additionally, in the close chained testing, there might be additional
afferent inputs from receptors of lower extremity muscles. The input from muscle would
integrate with the hip proprioceptive information, resulting in more accurate perception.
Lin et al., [12] declared that the AE could be considered as the representative of accuracy of
overall performance. The VE represents the inconsistency in each performance (response).
These two variables demonstrated the validity (AE) and reliability (VE) of the repositioning
test [12]. Functional squat system is another option for close chained proprioceptive
testing [47]. This system is reliable and valid for assessment of motor coordination and
proprioception and mimics the movement-coordination pattern of a squat jump under the
control of external load throughout the concentric and eccentric phases. Although this test
position for a whole lower extremity is more like a real life activity, researchers pointed
out that these sorts of tests that includes weight-bearing procedures can provide extra
sensations that may directly affect joint receptors [47]. Electromagnetic tracking motion
analysis system [13] and potentiometer was also used to measure hip JPS proprioception
[8,9]. It has been suggested that the velocity of angular displacement is of considerable
importance in perception of joint position, and that initial limb position has no effect on
joint position recognition [9]. However, there is no reliability information of these methods,
neither is of hip JPS assessment during internal and external rotation [6,14].
Kinesthesia
Sense of limb movement is assessed by measuring the TTDPM and TTDMD. These tests
quantifies a subject’s ability to consciously detect movement, as well as, its direction and
is often performed on some type of proprioception testing device such as an isokinetic
dynamometer [3,21,43]. Testing speeds are slow, ranging from 0.5 to 2°/s, in order to target
the slow-adapting mechanoreceptors such as Ruffini endings or Golgi-type organs while
minimally stimulating muscle receptors [43]. In shutting down muscle activity, TTDPM is
often chosen to assess afferent activity following ligament pathology [3]. While the examiner
passively move the leg, subject indicates (usually stops the device by pressing a “hold”
button) when the passive movement is detected and the examiner records the amount of
movement occurring before detection [21].
Benjaminse et al., indicated a reliable and precise method of measuring hip TTDPM [3].
Participant’s hip was moved passively at a rate of 0.25°/s using an isokinetic dynamometer.
The participant was instructed to focus on their hip position and press a stop button as
soon as motion was perceived and the direction of movement could be identified. The
displacement between the initiation of motion and the subject’s perception of motion and
direction was recorded in degrees. Sagittal plane testing was done in supine position with
the knee extended. The test started with the hip in 45° of flexion. Frontal plane testing was
done in side-lying position with the knee extended. The test started with the hip in 15° of
abduction. Five repetitions for each direction were performed in a randomized order. Good
intra-session reliability was shown for hip abduction, and adduction with ICCs between
of 0.825 and 0.765, respectively. Good intersession reliability was shown for hip flexion,
extension, abduction, and adduction with the ICCs ranged between 0.777 and 0.810 [3].
Wingert et al., [14] assessed hip kinesthesia with goniometer and limb positioning device.
Participants immediately reported movement direction on detecting passive hip rotation of
approximately 0.5°/s with a maximum displacement of 4°. Movement was imposed passively
using a control rod attached to the back of the goniometer. Direction was pseudorandomly
selected per trial. Performance accuracy was the number of correct responses in 10 trials
for each limb. However, there is no reliability information regarding this methodology [14].
Force sense
Sense of tension is assessed with measuring the ability to reproduce torque magnitudes
produced by a group of muscles [43]. The force-matching protocols are conducted without
7
vision and with low load, as the ability to reproduce force is associated with the recruitment
of motor units and its firing frequency. The difference between the target force and the
torque produced is used to quantify the accuracy of sense of tension [21]. Benjaminse et
al., measured FS by assessing the ability to reproduce a reference torque in hip joint. FS
is thought to have two sources: the sense of tension generated by afferent feedback from
the muscle, and the sense of effort generated centrally. FS reproduction should provide
information regarding the integrity of muscle spindles and Golgi tendon organs per given
effort. Further investigation is needed to develop reliable techniques for FS measurements
of the hip [3].
Velocity sense
Currently, there is no study on the ability to reproduce the same velocity in hip joint that
is the last sub modality of the proprioception.
Hip Proprioception and Age
There is limited number of researches examining proprioception of the hip in the
literature. Most of the studies have been conducted on middle aged or older adults [79,11,18,32,46,47], whereas few studies focused on younger populations [3,6,12-14]. Pickard
et al., investigated the effect of age on hip JPS and declared no difference between young
and older subjects’ active or passive JPS. It’s known that people who exercise regularly
have greater strength and shorter reaction times. Therefore, the reason of that they were
unable to show a difference of proprioception between age groups might have been that their
older group included active people. In both age groups, hip JPS were more accurate when
performed actively than passively, especially when performed in the inner range of the hip
abductor muscles. As the muscle spindles are regarded as more important in proprioception,
active contraction of the hip abductors that requires contribution of the muscle spindles
might provide more afferent feedback regarding joint position than do the passive movement
[13]. Wingert et al., were the first researchers showing that hip proprioception declines with
age. They determined that older and middle aged adults had significantly increased JPS
error compared to younger adults. Kinesthesia was deteriorated in older adults compared
to younger and middle aged adults. Correlation between age and proprioception was also
found. Moreover, hip proprioception was correlated with dynamic balance whereas no
correlation was found in postural sway during static stance [5]. Two strategies were stated
in maintaining dynamic postural control: a hip strategy and an ankle strategy. Generally,
the ankle strategy is most often used by healthy individuals whereas the hip strategy is used
by elderly individuals. Positive correlation between hip proprioception and dynamic balance
can be explained by the findings of two researchers. Shumway-Cook and Horak suggested
that stance on pliant surfaces caused an increased reliance on a hip strategy [48]. It’s
stated that the ankle is of primary importance during single-leg stance on firm, foam, and
multiaxial surfaces, whereas proximal joints having an increased role in more challenging
conditions [49,50].
Hip Proprioception and Problems Involving Hip Joint, Healthy People
vs. Patients
Hip fracture in older people is a major public problem causing disability, mortality
and morbidity [11]. Deterioration of joint proprioception was declared to be one of the
risk factors for falls because errors in proprioceptive acuity can lead to faulty or delayed
corrective reactions [4]. Thus, researchers interested in hip proprioception whether
proprioception impairs due to fractures, treatment methods such as hemiarthroplasty
or total hip replacement and also the effects of rehabilitation on proprioception. Studies
investigating hip proprioception in older adults agree that people with hip fracture or total
hip replacement or hemiarthroplasty have no proprioceptive deficit [7,8,10]. Ishii et al.,
8
determined that hip joint proprioception of people with hip fracture was not found to be
diminished compared to age-matched normal controls. Moreover proprioception in patients
treated with hemiarthroplasty wasn’t deteriorated when compared with patients treated
by osteosynthesis [7]. They pointed out that the surgical capsulotomy and replacement of
femoral head didn’t affect the ability to detect joint position. The physiologic implication
of that study is that substantial extracapsular components such as stretch receptors in
the adjacent tendons and muscles influence hip joint proprioception, rather than capsule
and femoral head. It’s stated that a decline in lower limb proprioception may contribute
to abnormal balance responses and increased falls in the older population. Skinner et al.,
defended that a decrease in proprioception could lead to abnormal joint biomechanics
during functional activities such as walking so that, over a period of time, degenerative joint
disease may occur [51].
Pain was found as an important factor for impaired postural balance. Pain-induced
neural muscle inhibition or altered proprioceptive feedback from a painful body part can
negatively affect the motor responses needed to control balance [50]. However, to date there
is no study on the relationship between pain and hip proprioception.
Moraes et al., identified mechanoreceptors and free nerve endings in the femoral head
ligament, labrum, and capsule joint in hip serving to stabilize hip joints [32]. Reduction in
the number of collagen fibers and vessels was found in the hips with arthrosis. Morphology
of mechanoreceptors was similar in the hips with or without arthrosis. The density of
Pacinian corpuscles was significantly more than densities of Golgi corpuscles and Ruffini
endings while free nerve endings were found with similar density in healthy subjects’
hips. In the hips of the patients with arthrosis, there was a significant reduction of Golgi
corpuscles when compared with Pacinian corpuscles and free nerve endings. Total density
of mechanoreceptors in the hip without arthrosis was found to be more pronounced and a
decrease determined in the number of the nerve endings observed in hips with arthrosis.
These findings demonstrate the evidence of the significant role of these structures in
the proprioceptive system and stability of the joints. Authors stated that their findings
are valuable to help to develop an efficient rehabilitation program, and they recommend
performing studies to clarify the functions of the mechanoreceptors in the hip joints, as the
treatment of most orthopedic diseases is beginning to include programs for proprioceptive
rehabilitation [32].
It’s been aforementioned that only few studies focused on role of hip proprioception in
the young population [3,6,12-14]. Benjaminse et al., [3] aimed to establish the intrasession
and intersession reliability and precision of TTDPM, FS, and active JPS tests for the hip in
healthy individuals between the ages of 18 and 30 years. A reliable and precise method of
measuring hip TTDPM was established. However, they stated that further study is needed
to develop reliable measurement methods for FS and active JPS of the hip and to identify
if TTDPM is related to hip kinematics, hip kinetics, and muscle activation about the hip
during functional activities [3]. Other studies including young population were on children
with CP [6,14]. Proprioception impairment in the lower extremity can directly impact balance
and gait [17]. People with CP has balance problems and tend to rely disproportionately on
visual input to maintain posture and to position their limbs during gait or other functional
activities, which may be due to deficits in proprioception. Wingert et al., assessed active JPS
and kinesthesia of hip joint internal/external rotation bilaterally in patients with hemiplegic
and diplegic CP (both have milder impairment) and an age-matched group without disability
[14]. They found bilateral joint-position sense deficits in the lower extremities of both CP
groups, whereas kinesthesia was rather similar. There was no proprioceptive error when
the participant was able to see his/her leg and targets. It’s suggested that patients with CP
use visual input as a compensatory mechanism for activities involving JPS. Researchers
indicated that internal rotation errors reflect common lower extremity musculoskeletal
alignment in CP. Patients with CP have increased internal femoral torsion and hip
9
adduction during standing and walking compared to people without disability. Abnormal
biomechanical alignment, muscle weakness or imbalance, and/or increased muscle tone
related to CP cause internally oriented joint-position errors. Additionally, muscle changes
related to spasticity also might impair joint-position sense over time by shortening and
stiffening muscle tissue, altering the muscle-joint relationship and disrupting the sensitivity
of muscle spindles, which contribute to proprioception [14,17]. It’s known that ankle
strategy is typically utilized for Anterior–Posterior (AP) balance and a hip strategy is typically
utilized for Medial-Lateral (ML) balance [52]. Largest contributor to ML balance in both
healthy and CP children was found as transverse body rotation and this was proportionately
even greater in patients with CP perhaps as a consequence of compensation for poor ankle
control [53]. Cherng et al., showed that CP patients don’t differ from healthy ones in their
static balance abilities whereas there are certain deficiencies in dynamic balance [54]. In
the light of these information Damiano et al., investigated the contribution of hip joint
proprioception to static and dynamic balance in milder diplegic and hemiplegic CP [6]. They
believed that measurement of hip proprioception is relevant in CP because patients tend to
rely disproportionately more on this joint in their balance strategies compared to healthy
people. They have found that increased hip proprioception error was related to increased
postural sway and decreased gait velocity, especially in children with hemiplegic CP, whose
dominant side hip proprioception error was an important determinant of gait velocity.
Patients with CP had greater differences from control values in the center of pressure in
ML direction than in the AP direction, possibly due to both biomechanical and neurological
changes seen in CP.
Physical Activity, Sports Participation, Exercise and Hip Proprioception
Favorable effects of regular physical activity or specific exercise programs on physiologic
systems are acknowledged. Regular proprioceptive activities allow retaining an excellent
response to somatosensory inputs, which may be useful for maintaining proper balance
in everyday life [55]. However, there is limited information on the effects of proprioceptive
exercises on hip proprioception and there are few studies showing the effects of physical
therapy exercise programs on hip proprioception. After a hip fracture progressive gain of the
range of motion, strengthening and functional drills, proprioceptive, balance-related and
postural drills, are usually used when bone union process is satisfactory and/or the surgical
procedure assures protection and stiffness to the injured part and partial or total load is
allowed to the affected limb. Yet, it seems there is no evidence for specific proprioceptive
exercises to improve proprioception. Generally, physical therapy programs consisting
strength and endurance exercises and/or balance and gait drills were used [11,56].
Hip proprioception improvement was found following rehabilitation of hip fracture [11].
Mendelsohn et al., tested proprioception first within 48 hrs of admission to the rehabilitation
unit and again within 48 hrs of discharge. A complex program composed of range of motion,
flexibility, and strengthening exercises; balance, gait, and stair retraining; and activities of
daily living training were performed. It was stated that this rehabilitation program improved
proprioception indirectly related to other variables, gait, isometric muscular strength since
they depend on the full integrity of proprioceptive sensations to be regarded as satisfactory
and appropriate for each individual [11,18]. This improvement probably due to induced
morphological changes in the muscle spindles [33] because physical activity doesn’t change
the amount of the mechanoreceptors [57]. Modulation of the muscle spindle gain and the
induction of plastic modifications in the CNS by regular physical activity and exercise are
able to change proprioception [57]. Beneficial effects of physical therapy and kinesitherapy
on postural stability in men with hip osteoarthritis were shown previously [58] but no
direct measurement for proprioception was performed. Ozer Kaya et al., examined lower
extremity proprioception after calisthenics and pilates exercise training in sedentary adult
women in their randomized controlled trial [47]. They measured not the pure hip or knee
joint proprioception, but rather they followed a multijoint approach in a squat position.
10
Neither calisthenics nor pilates exercise trainings improved proprioception after 6 months,
but improved lower extremity coordination [47]. One study investigated the hip and knee
proprioception in elite, amateur, and novice healthy young men tennis players [12]. Joint
angle duplication in closed chained position test was used to determine proprioception.
Matching error was smaller in the stance-dominant leg, possibly due to more practicing
stance-dominant leg because the adjustment of the height of center of gravity before a stroke
might more depend on the stance leg in tennis. The elite tennis players had the less amount
of error in the position-matching test than the amateur and novice groups. Proprioceptive
sensitivity of healthy people can depend on their activity and skill level. Supporting this
statement, people with intensive training, like professional athletes, have better performance
in proprioception testing. Researchers pointed out the need of prospective design using a
proprioception testing apparatus with accurate velocity control to determine the causality
between proprioception and training [12].
Injury/Re-Injury Prevention
Three systems work together to maintain postural control: The somatosensory system,
the vestibular and the visual system. The vestibular system, gathers information from the
vestibules and semicircular canals of the inner ear for overall body posture and balance.
The visual system helps to maintain balance. If the eyes are closed, help of the visual system
is removed. Some of the imbalances within the athletes are not recognized and are therefore
not modified until an injury occurs. When an injury occurs in a joint, the joint loses its
ability to gauge stresses placed upon it and react to it appropriately [59]. In case of an injury
muscle, tendon, and ligament are damaged. In the mean time, mechanoreceptors are also
damaged leading decreased neural afferent input and diminished kinesthetic acuity and,
therefore, neuromuscular control. The coupling effect of ligamentous trauma resulting in
mechanical instability and proprioceptive deficits contributes to functional instability. This
could cause to further microtrauma and re-injury. Deteriorated proprioception may play a
more significant role than pain impulses in preventing injury. Re-injury rates and the cause
of chronic injuries may be attributed, to a greater extent, to proprioceptive deficits [27].
Peroneal muscles assist maintaining balance in the ankle strategy, which is most
often used by healthy individuals. Ankle strategy is used when perturbation is slow
and low amplitude. The hip strategy is used when the perturbation is fast and large
amplitude. Interestingly, hip strategy that is used by elderly individuals is also adopted
by individuals who have sustained an ankle sprain. In this strategy, gluteus medius
muscle is used to correct posture and keep an individual balanced and erect [60]. Leavey
et al., investigated the effects of 6 weeks gluteus medius strength training, proprioception
training, and a combination of those on dynamic postural control measured with The
Star Excursion Balance Test [61]. Use of exercises for proprioception, gluteus medius
strength, or a combination program was found as beneficial to improve dynamic postural
control in healthy, active individuals [61]. Proprioceptive system could have a role for
this improvement. Nevertheless, the specific contribution of the systems was not known
since the authors didn’t use discriminative measurements for each system. These
findings may be valuable for elderly people and athletes who tend to injure certain joints
repeatedly. For the lower extremity, mechanoreceptors located within the joints are
most functionally stimulated in closed-kinetic chain positions with perpendicular axial
loading of the joint. These exercises are recommended at various positions throughout
the full range of motion because of the difference in the afferent response that has
been observed at different joint positions [27]. Improved hip proprioceptive function may
potentially reduce the risk of injury and even may improve performance as it has been
shown for other joints such as knee, ankle and shoulder [27]. However, there is a lack of
information on the relationship between hip proprioception and lower extremity injuries.
Furthermore the preventive effects of good hip proprioception or the effects of specific
hip proprioception training on injury/re-injury prevention are still unknown. Studies
11
using direct proprioception measurement methods to understand the pure effect of
proprioception instead of the information derived from multiple systems (somatosensory,
visual and vestibular) in maintaining postural control are also needed.
Hip Proprioception Exercises
Although very little is known about the effects of proprioceptive exercises on hip
proprioception, still there are proprioceptive exercises that can be performed based
on the proposed effects of them and mechanisms of the possible improvement of
proprioception. Proprioceptive exercises stimulate the nervous system promoting
muscle responses that encourage neuromuscular control. Goals of the proprioceptive
training are; increasing the frequency of muscle unit stimulation, the synchronicity of
motor unit firing and proprioceptive and kinesthetic awareness. For the proprioceptive
rehabilitation, retraining of altered afferent pathways to enhance the sensation of joint
movement is crucial. Encouraging maximum afferent discharge to the CNS is the goal in
stimulating joint/muscle receptors. Activities with sudden alterations in joint positioning
that necessitate reflex neuromuscular control stimulates reflex joint stimulation at the
level of spinal cord. Balance and postural activities with Eyes Open (EO) or Eyes Closed
(EC) enhance motor function at the brainstem. Performing joint positioning activities,
especially at joint end ranges with high repetition stimulates the conversion of conscious
to unconscious motor programming. Kinesthetic and proprioception training can
enhance this function [27]. As it is for any type of exercise training, a proper progression
should be followed for proprioceptive exercises too, starting with static balance activities,
progressing to dynamic balance activities and finally advancing to coordination and
agility training. Training starts with simple exercises and complexity is increased as
proprioception improves. The surface, the distance, or the weight of the objects (i.e.,
medicine ball) used to distract the individual is changed. From EO condition to EC, from
the position on two feet to one foot, standing still for a few seconds to 30 sec, simple
to complex, focusing to distracting, slow speed to fast movements can be used for the
progression.
Highlights of the proprioceptive exercise training program
Adequate warm up should be performed before proprioception exercises. Training could
be three times a week for at least 6-8 weeks.
Body weight, age, level of competition and footwear should be considered while planning
a proprioceptive training. Children and older adults have higher risk of injury. Children’s
CNS is not fully developed and information is not transmitted quickly enough to provide the
necessary safeguards against excessive body stresses. Message transmissions to and from
the CNS tend to slow with age [62]. Acute inflammation, postoperative conditions, instability
should be carefully evaluated.
Correct technique is the vital part of the whole training. Good postural alignment
during each movement with no compensating with the other parts of the body should be
provided during proprioceptive exercises. If the proper technique cannot be maintained
during exercises the difficulty level should be decreased to a level that the individual can
perform correctly. Feedback is needed to recognize the successful completion of a task. High
repetition is also very important for cognitive programming of motor patterns [63]. However,
fatigue should be avoided [64]. If proprioceptive exercise training is properly planned and
executed, proprioception can be improved and the risk of future injuries can be reduced.
Females need special attention when planning these trainings due to particular reasons.
They exhibit a wider pelvis and increased genu valgus, generate muscular force more slowly
than males, tend to have less developed thigh musculature, exhibit less effective dynamic
stabilization, and lose hip control upon landing when performing jumps [65].
12
Closed chain exercises
Most of the physical therapy programs have been developed to take advantage of
the force-generation and loading characteristics of closed-chain exercises. Closed chain
exercises could be an important part of hip proprioceptive training because, the effect
that closed-chain exercise have on the entire kinetic chain is more functionally important
than the effect on one joint alone (i.e. ankle or knee). Closed-chain exercises are based on
application of a load to the distal end of an extremity that doesn’t move freely due to either
positioning or the load type (axially applied load). Subsequent joint motion takes place in
multiple planes while the limb is supporting weight [66]. Closed kinetic-chain exercises
are very specific to the functional demands placed on the lower extremity during sport or
occupational activities [63,66]. During closed chain activities, the body moves over the foot
resulting in simultaneous movement of all lower extremity joints and coordinated muscular
activity including concentric and eccentric co-contraction of antagonistic muscle groups
that are required to control all segments of the kinetic chain [63]. Kinetic-chain segment
motions and positions are created by agonist-antagonist muscle activation patterns. Cocontraction of these force couples around a joint occurs to control joint perturbations and
to gain stability. Resultant synergistic patterns create postural stability throughout the
entire extremity while allowing voluntary muscle activity at the distal segment. It’s highly
dependent on joint- and angle-specific proprioceptive feedback [27]. In terms of lower
extremity neuromuscular control, hamstring muscles act not only as a part of a lengthdependent force couple to control anterior tibial translation, but also as a part of a forcedependent pattern to coordinate hip and knee motion, stabilize the hip, and transfer loads
up and down the leg. Most of the proprioceptive exercise programs use closed chain activities
because they simulate biomechanical and physiologic requirements. Mechanically, they
initiate joint movements from a base of support, emphasize sequential control of segment
position/motion, place the segments in functionally correct positions, and control the load
transfer. Physiologically, they utilize both length-dependent and activity-specific forcedependent activation patterns, emphasize position-specific proprioceptive feedback to
initiate and control activity. After an injury, activation of the inhibited muscles should be
encouraged by “facilitation of muscle activation” with placing the extremity in a closed-chain
position, emphasizing the normal activation pattern, and progressively “unmasking” the
target muscle by eliminating the substituting muscle. Micro or macro trauma to tissues that
contain mechanoreceptors may cause proprioceptive deficits due to partial deafferentation
leading possible re-injury. Maintaining neuromuscular control or regaining it after injury or
surgery is a necessary prerequisite for the individual in returning daily life or occupation,
and for the athlete in returning to sports [27].
Hip proprioception exercise training program
In the first stages of the training (Phase I) closed chain exercises and active repositioning
of the hip joint can be performed [63]. Initially, proprioceptive exercise training usually
begins with two-legged support stance on a flat surface in static conditions, and then is
moved into a one-legged support stance as a progression. Early emphasis is placed on
achievement and maintenance of a position of 0° of hip extension with neutral pelvic tilt
for maximum activation of the hip muscles. Most of the lower extremity exercises proceed
from this ideal position [66]. Depending on the individual’s level, standing still on the floor
starting from the position on two feet for 30 sec (can be started with 10 sec according to
patient’s ability and gradually progressed to 30 sec) with EO is continued with EC. Tandem
stance (one foot in front of the other, heel to toe) or standing on one foot (keeping hip and
trunk in extension posture) with EO and then EC can be practiced for 30 sec for each [20].
Patient may touch a table, chair or wall for support if she/he doesn’t feel secure, at the very
beginning (Figure 1).
13
Figure 1: Early-stage lower extremity closed chain exercise; standing on one leg.
Tools such as soft surfaces (i.e., foam), stability trainer, balance board, disc trainer,
BOSU balance trainer, or trampoline fulfill the need of unstable surface throughout
the progression [62,66]. It should be noted that standing on an unstable surface is
called proprioceptive training, however in fact it is a combined training of proprioceptive,
vestibular, and visual systems, since the visual and vestibular systems help the
somatosensory system to maintain control and balance on unstable surface. If the
eyes are closed, the contribution of the visual system drops out. Standing still on both
feet is progressed by calf-raises, multidirectional hip positions, squats, and lunges.
Perturbation could be performed. Elastic resistive band can be looped around the body
or leg as training progressed.
Closed chain exercises can be also performed on floor/exercise mat. Bridging exercise
is performed in supine position with palms facing down and feet on the floor in hook-lying
position. This exercise can be progressed from two-legged position to one-legged position
as one knee is extended and held at the same level as the other kneecap. Side-lying plank
exercise with and without knee support can be added the exercise program, respectively
[67-69].
Exercise ball is also used to improve neuromuscular control of the trunk and hip [70]. It
is a stabilization tool for neuromuscular control using inhibition or facilitation. It facilitates
automatic postural reactions and co-contraction ultimately reflex stabilization. Swinging on
the ball either facilitates muscle spindle with faster, longer amplitude and more variation in
movements or inhibits muscle spindle with slow, short amplitude and rhythmic movements.
Bridge knee extension, bridge hip lift stabilization, wall squat, sitting knee extension, sitting
hip flexion and pelvic clock exercises can be recommended to improve hip proprioception
(Figure 2, 3, 4) [71].
14
Figure 2A: Bridge knee extension.
Figure 2B: Bridge hip lift stabilization.
A
B
C
Figure 4: Pelvic clock exercises.
15
In addition, bridging exercise can be performed with positioning of the distal portions of
lower limbs in a sling suspension system to add a dynamic stabilization effort [72]. Bridging
exercise starts from the supine position with palms facing down and the ankle regions
of both lower legs is placed with the feet at shoulder width in the holding straps of the
sling system to establish the body suspension point during the exercise. The height of the
straps is adjusted in accordance with the knee level in hook-lying position with knee flexed
to 90 degree. Bridging exercise is performed using an abdominal drawing-in maneuver.
To perform the bridging exercise, pelvis is lifted into the air until the angle of hip flexion
reaches 0 degree while maintaining straight alignment of the knees, hips, and shoulders
[72,73]. Progression should be arranged considering the fact that hip joint has an increased
role in more challenging conditions [49,50]. Progression is first achieved by removing one
knee from the sling and holding it at the same level as the other knee, second by having
both knees placed in the sling and placing a balance cushion in between the scapulae to
provide an unstable proximal surface upon which to perform the bridge, and finally third
by placing the ankles in two separate slings and performing the bridge and then abduct the
legs one at a time before lowering back to the starting position [72]. Park et al., stated that
during dynamic limb movements such as hip abduction and adduction, and particularly
bilateral movements proprioceptive system activation might increase [73]. Integration of hip
movements may make bridging exercise more challenging because it requires controlling
the errors of active repositioning against the destabilizing torque and perturbation force of
the trunk during the hip movements [72,73]. Dynamic hip movements can provide a better
opportunity to facilitate sensory-motor feedback, leading recruitment of trunk muscles
during the bridging exercise to establish efficient motor control strategies [73]. Closed
kinetic chain stabilizing exercise of the lumbo-pelvo-hip complex can be performed in the
prone position as well with or without a sling [74].
As soon as the static activities are performed properly with good coordination and speed,
more dynamic activities should be added the training program (Phase II). Resistive elastic
band quick kick exercises in multiple directions of hip movements are also recommended to
improve proprioception, strength and stabilization of the stance leg thanks to their closed
chain nature (Figure 5).
A
B
C
Figure 5: (A) Hip abduction with resistive elastic band “Quick Kick” (B) Hip extension with resistive elastic band “Quick Kick”
(C) Hip flexion with resistive elastic band “Quick Kick”.
16
Kicking activity is used to stimulate proprioceptors around the joint in response to
positional changes of the body’s center of gravity. Reflex activation and co-contraction
of muscles occurs during resistive kick and this activation seems more in kick when
compared to other closed chain exercises such as step-up or trampoline [75,76]. Use of
proprioceptive exercise tools can also be continued in this phase but in more dynamic
fashion such as standing on one foot with repeated multidirectional hip movements,
and squats. Progression in perturbation exercises and use of elastic resistive bands
looped around the leg while standing on foam could be useful to increase complexity.
Sliding board, fitter, or Bongo Board fit in this phase [66]. Playing catches with medicine
ball in different weights is a distracting activity that can be used during progression.
Dynamic lunges, walking (+cone walking and/or use of sports cord) or running forward,
backward and lateral directions can be used increasing speed or complexity in time.
Co-contraction lateral slides, mini-tramp hopping and jogging, pogo ball balancing and
hopping, advance lateral slide board exercises are performed towards the end of this
phase and continued in the last phase if needed [63].
In advanced level (Phase III), agility and coordination exercises such as pivoting,
twisting, reaction cutting drills, shuttle run, carioca crossover maneuvers, four-corner
running, and/or jumping are performed. Plyometric exercises take place in the program.
Sport specific activities both on unstable platforms and in the playing field should also
be performed in the athlete’s advance training towards the final stages [20,63].
Cross-training
A proprioceptive cross-training (contralateral training) effect was found for ankle [77].
It’s pointed out that the CNS takes the pattern of control established in the trained leg and
applies it to the unworked one. Possible mechanism suggested for this is a phenomenon
in the nervous system, both at the level of the spinal cord and the motor cortex [78]. If
proprioceptive cross-training effects for hip can be determined, that information would be
highly valuable and have large implications for the rehabilitation. Rehabilitation protocols
could be designed to include proprioceptive training of the sound leg in the very early stages
of the rehabilitation when the injured leg is not ready to start training directly. Athlete could
return to normal more quickly when training is resumed. Similarly, in neurologic problems
involving unilateral extremity, proprioceptive exercises for the sound side of the body could
help the contralateral side. More recently, Kim et al., found that short duration isokinetic
exercise training of the contralateral hip improves single-limb stance in the interested leg
[78]. Further research should be performed to clarify how effective cross-training is in
comparison to direct training of the leg to improve proprioception and balance and the exact
mechanism of this improvement.
In brief, drawing certain conclusions with limited information on hip proprioception in
the literature may be difficult. Hip proprioception is still an exciting and promising new
area for future research. Future studies are needed to develop reliable measurement
techniques for hip proprioception in order to interpret the results precisely. There is also a
need of researches designed to understand the factors influencing hip proprioception such
as muscle strength, gender, muscle functions, and laxity; injury/fall risk, prevention and
rehabilitation strategies focusing on hip proprioception; proprioceptive and other specific
exercise regimens or techniques for improved hip proprioceptive accuracy in healthy
people, patients, and athletes; usage of external device or taping for the hip region; effects
of cryotherapy and heat therapy, regular physical activity, warm up, and fatigue on hip
proprioception; hip proprioception in specific diseases with somatosensory deficits. As
high quality studies are increased in the scope, understanding the hip proprioception and
correctly interpreting the results would be easier; therefore clinical decision process would
be optimized.
17
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