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Proprioception: The Forgotten
Sixth Sense
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Elbow Problems and Proprioception
Derya Celik1*, Ebru Kaya Mutlu2
PT, PhD, Associate Proffesor, Istanbul University, Faculty of Health Sciences,
Division of Physiotherapy and Rehabilitation, Istanbul, Turkey
1
PT, MSc, Istanbul University, Faculty of Health Sciences, Division of Physiotherapy
and Rehabilitation, Istanbul, Turkey
2
*Corresponding author: Derya Çelik, PT, PhD, Associate Proffesor, Istanbul
University, Faculty of Health Sciences, Division of Physiotherapy and Rehabilitation,
Istanbul, Turkey, Tel: 0090 212 414 1528, E-mail: [email protected]
Abstract
The term ‘proprioception’ describes the ability to determine the spatial orientation and
movement of body parts from the body itself. It is a fundamental ability used every day to
aid people in relating and communicating with their environment and to enhance motor
skills. Receptors found in the skin, in tendons and muscles and in joints all produce stimuli
necessary for proprioception. Typical joint proprioception may vary in individuals who
suffer from diseases affecting the elbow. Professional athletes are particularly vulnerable to
insufficiencies in proprioception. The loss of proprioception in patients with elbow conditions
has not been comprehensively researched despite the importance of such diseases in
relation to the loss of proprioception, as with conditions affecting other joints. In this
chapter we will discuss the anatomy of elbow, definition of proprioception, assessment and
treatment of elbow joint proprioception. In addition factors influenced the proprioception
will be discussed.
Elbow Anatomy
The elbow joint technically consists of three joints: 1) the humeroulnar joint, 2) the
humeroradial joint, and 3) the proksimal radioulnar joint. These joints operate together to
form the full elbow complex. There are two articular surfaces present at the distal end of
the humerus. The first, the trochlea, controls the ulna, whereas the second, the capitulum,
controls the radius head. Both extension and flexion operate in this process, by interacting
with the two joint surfaces. Additionally, the radius works in conjunction with the ulna
radial notch, producing a complex called the proximal radioulnar joint. This operates
via supination and pronation across the length of the distal radioulnar joint. The three
aforementioned subsidiary joints are encased within the elbow capsule. However, the distal
radioulnar joint is located separately from the rest of the elbow complex, in spite of how it
operates in conjunction with the proximal radioulnar joint [1,2].
For normal functioning, the upper extremity relies on an elbow complex that can move
freely and displays strength and stability. The spatial mobility of the hand is supported by
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the elbow and forearm structure through two functions, namely, upper extremity shortening
and lengthening as well as forearm rotation. The hand would not be able to undertake the
wide range of activities that it does, including, among many others, eating, dressing, lifting,
turning throwing, catching, and using different instruments, without the muscles, which
provide it control and keep it stable [3,4]. The majority of daily activities demand not only
a 100˚ arc of flexion and extension at the elbow, particularly with a range from 30˚ to 130˚,
but also a forearm rotation of 100˚ balanced between pronation and supination [3]. The
extension of the elbow is necessary for tasks such as putting on socks, while the bending of
the elbow is demanded by actions such as taking a drink or eating a meal.
Muscles help to dynamically stabilise and control the elbow joint. A variety of flexor
muscles control this action: biceps brachii, brachialis and brachioradialis. Elbow flexion
and forearm supination are achieved via the biceps brachii. Further elbow flexion is utilised
via the brachialis. The brachioradialis had multiple functions, including elbow flexion,
semisupination, and semipronation. The triceps brachii and related anconeus muscles are
the elbow extensor muscles [1].
The Medial Collateral Ligament (MCL) and Lateral Collateral Ligament (LCL) and the
anterior and posterior joint capsule are the elbow’s static soft-tissue stabilisers. The primary
stabiliser is the MCL and motion ranges from 20-120 degrees, and the elbow’s primary
lateral stabiliser is the LCL. However, it is at the joint capsule that an elbow’s stability
begins and it is used for all three of the articulations of which the elbow is capable. In
both flexion and extension, movement is made possible by the anteriorly and posteriorly
unconstrained capsule. The extra support provided by the MCL and LCL means that the
capsule is rigid laterally and medially. The joint capsule can produce proprioception as it
has a number of nerves. It, in fact, acts as the connection to proprioceptivity for the upper
part of the hand [1,2,4].
The elbow joint can be influenced by the functions of the shoulder, the hand and wrist
and the cervical spine. The elbow complex can be affected by restrictions or weakness found
in these functions. Thus, a comprehensive evaluation of proprioception and the treatment
of disorders or injuries of the elbow require a full understanding of the anatomical system
of not only the elbow but related joints also.
Proprioception
Sensory input sent through the brain from receptors in the joints, skin, muscles, eyes
and the vestibular apparatus of the inner ear produce proprioception, the capacity to sense
the spatial orientation of body parts and their movements [5-9] (Figure 1).
AFFERENT INPUT
LEVELS OF MOTOR CONTROL
Peripheral afferents
•
•
•
Joint
Muscle
Skin
Spinal refleks
Visual receptors
Vestibuler receptors
Central Nervous
System
MUSCLE
Cognitive
Programming
Figure 1: Summary of Proprioceptive System.
Figure 1: Summary of Proprioceptive System.
Muscle receptors
The components of muscle receptors are muscle spindles and Golgi tendon organs [6,7].
Special muscle fibers, muscle spindles are positioned parallel to ordinary skeletal muscle
fibers and are present in a large proportion in the “skill” muscles of the hands, but in a more
limited number in the “strength” muscles of the lower extremity and back [10]. The gamma
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feedback loop is employed by these muscle spindles to transmit information to the central
nervous system. This loop provides indirect information regarding joint position through
the detection of modifications in the length of the muscles and velocity of contraction. The
stimulation of skeletal muscle activates the muscle spindles, thus ensuring that tension
is preserved. By contrast, dissipation of tension minimises or terminates muscle spindle
activity. Compared to error correction via visual stimuli, which can take up to 200 ms,
correction of muscle tension through the gamma feedback loop can be done in 30-80 ms. The
location of the Golgi tendon organs is in the tendons, in proximity to the musculotendinous
junction and in line with the muscle fibers. The monitoring of muscle tension is the role
of these Golgi tendon organs, an increase in muscle tension inducing an increase in the
firing rate as well. A reflex decrease in muscle tension occurs when the Golgi tendon organs
generate excessive firing rates [5-7].
Joint receptors
Joint capsules, ligaments, fat pads, and the periosteum of different joints all contain joint
receptors [5]. These are activated by motion-related alterations in the containing structures,
their role being to signal joint position and movement. Joint motion is directly recorded by
the joint receptors, which thus add to the information produced by the muscle spindles and
Golgi tendon organs [11]. The measurement of joint motion is undertaken by both Ruffini
endings and pacinian corpuscles, which can be found in the joint capsule. Positioned on the
flexion side of the joint capsule, the Ruffini endings react and gradually adjust not to the
dislocation of connective tissue, but rather to loads on the area surrounding the connective
tissue. The significant joint motion related to the extension with rotation of the capsule
stimulates these receptors. It is assumed that their function is to delimit and protect the
unstable joint. On the other hand, the Pacinian corpuscles can be found throughout the
capsule, joint and periarticular structures. Due to the fact that they are characterised by
rapid adaptation, these receptors are believed to be susceptible to compression, particularly
during the occurrence of high velocity transformations arising when the joint accelerates
or decelerates during movement [5]. However, as argued by some authors, the contribution
of joint receptors may be of considerable importance when muscle and skin signals are
unavailable [8,12].
Skin
Although the hand is the main location of skin subcutaneous proprioceptive afferent
receptors, these receptors are also essential for the elbow and other joints. A kinaesthetic
function has been tentatively attributed to the skin stretch Type II receptor characterised by
slow adaptation and served by Ruffini endings [13]. In the case of kinaesthesia at the forearm,
position and movement-related information is provided by the stretch of skin over the elbow
when the elbow is flexed. The stretch of skin of the hand and over more proximal joints
produced greater movement illusions when applied in association with muscle vibration
than during the separate application of the two stimuli [14]. It is important to emphasise
that muscle input was not facilitated by skin input, the cutaneous input produced by the
skin stretch being actively and independently involved in kinaesthesia. The skin receptors
are capable of providing information specific to the joint due to their close location to each
joint [14].
The vestibular systems and eye
Signals about the position of the body as a whole is generated by the eyes and the
vestibular system. These are activated when there is a variation in the upright posture of
the body [9]. Information on vertical and horizontal orientation and movement is provided
by the vestibular system (located inside the inner ear) which transmits signals to the central
nervous system. The head and body’s orientation and movement within its surroundings
is facilitated by the eyes. The occulomotor and vestibuler systems provide information on
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whether it is the surroundings or the body itself that is in motion. Variations in orientations
during rapid movements are signalled by the vestibular system which responds very quickly [5].
Assesment of Elbow Joint Proprioception
Joint movement and position perception is yet to be appropriately and objectively
assessed for large scale clinical application. At present, the clinical assessment of
proprioception is conducted via a non-quantitative joint position perception test, in which
subjects are required to give a verbal description of the position of the joint following the
passive movement of the segment by the examiner into a limited number of predetermined
positions. Moreover, in a clinical context, an additional testing method was applied, which
was aimed at determining the extent to which a subject was able to move a joint back into
a predetermined position [15]. Both testing methods can be carried out in ipsilateral as
well as contralateral matching tasks and with the subject blindfolded. Further methods
for assessing proprioception have been employed in a research context. Video cameras,
potentiometers and goniometers have been utilised to measure angles when a limb is moved
into a fixed position that is intended to match the same position of the limb on the opposite
side of the body which has been moved into this position by the examiner. This equipment is
also used to measure the extent of kinaesthesia. The conscious recognition of proprioception
has been calculated using numerous and varied tools such as electromagnetic tracking
mechanisms, commercial isokinetic dynamometers and specially custom-made jigs [15,16].
Methods largely similar to those above have also been employed in the assessment of
elbow proprioception. The identification of the most adequate angle for elbow proprioception
assessment has constituted the focus of many studies. For instance, elbow position was
measured by Brockett et al., [17] with the forearm at angles of 30˚, 60˚ and 90˚ to the
horizontal. Walsh et al., [18] selected an angle of 30˚, 60˚ and 90˚ for eccentric movements
and an angle of 15˚, 30˚ and 45˚ for concentric movements. Goble et al., [19,20] measured
the angle of elbow extension at 15˚ and 30˚, and at 20˚ and 40˚, respectively. However,
despite these experiments, no agreement has been reached with regard to the angle of
elbow extension or flexion motion that ought to be applied in the evalution of position
sense. Based on the response variation exhibited by muscle spindles, Golgi tendon organs,
cutaneous afferents and joint afferents as a result of stretch and muscle length, it can be
implied that proprioception should also display variation in accordance with joint angles
and joint planes. In contrast to joint angles with extreme flexion or extension, enhanced
proprioception at the midranges of joint motion has been noted in a horizontal plane [21-24].
In addition, as observed by Gooey et al., [25], unlike an abducted position, the position with
the arms in front of the body was more conducive to proprioception. On the other hand, only
a handful of assessments have addressed proprioceptive discrepancies across joint angles
in a sagittal plane. Nevertheless, recently conducted studies have provided evidence that
proprioception in a sagittal plane is not unlike that in a horizontal plane, in that it is optimal
at the midranges of joing motion [26-30]. To be more exact, a 90˚ elbow position in relation
to the distal segment [26-28,30] is optimal for the joint position sense, the positioning of
the joint at different angles being accompanied by a linear increase in errors [26,30]. Joint
position sense improvements at angles close to 90˚ were initially attributed to enhanced
muscle activation. However, the central role of this mechanism has recently been dismissed
on the basis of observations of the same pattern regardless of disruptions to external torque
[27] and trunk orientation [28]. It is possible that a position of the hand associated with an
elbow flexion of 90˚ facilitates a better adjustment of the neural population vectors. Be that
as it may, tasks involving multi-joint movements can determine variation in the precision of
the joint position sense, depending on different joint angles.
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Factors for Affecting Elbow Proprioception
Cognition, memory and task matching
In an ipsilateral matching task the subject is firstly given a reference joint angle to hold for
a few seconds with the joint then being moved back to starting position. The subject is then
asked to move the same arm back to the reference joint angle. Memory is clearly a factor in
this task as the subject must remember the reference position in order to replicate it. Thus,
any memory deficiencies in a subject must be considered when deciding whether to carry
out this matching task as it may not accurately reflect the subject’s level of proprioception.
In individuals with memory problems, a degree of the perceived failure in proprioception
may in truth be indicative of a deficiency in memory [20,31].
In a contralateral matching task the subject must replicate a reference joint angle held
by one arm using the opposite arm. In this test the arm holding the reference joint angle
remains in this position while the other arm attempts to replicate the angle. The weakness
in this form of test is that determining the source of proprioception mistakes is problematic
as they may be caused by the arm forming the reference angle or the matching arm. A
further problem is that, as opposed to ipsilateral matching tasks, contralateral matching
tasks demand a higher level of communication between the two hemispheres of the brain
because of the anatomical networks involved in communicating peripheral proprioceptive
signals. Thus, in individuals with orthopaedic issues who also suffer from a neurological
condition, contralateral matching tasks are not necessary [31].
Affected Extremities - Dominance
It is believed that approximately nine out of ten people are right-handed. Various
researchers have illustrated that there is no variation in proprioception acuity between the
non-dominant and dominant sides of the body [32-34]. This has been shown by comparing
joints on either side of the body using a hand repositioning exercise using movements from
the shoulder and elbow. More recently, however, it has been illustrated that, particularly
when tasks require communication between brain hemispheres, the non-dominant elbow
has a particular advantage [19,20,35,36]. It had been identified that, in right-handed
individuals, the right arm showed a position-matching advantage over the non-dominant
left arm yet the non-dominant left arm showed an accuracy advantage illustrated by a lower
number of absolute matching errors than seen in the dominant right arm [20]. For bigger
movements this advantage was even more distinct and the nature of the matching motions
showed that it was not linked to any variations in the movement strategies of particular
limbs. These studies have enriched the understanding of dominant and non-dominant arms
and proprioception showing that in right-handed people the left arm and side is better able to
interpret proprioceptive data. Furthermore, studies also indicate that proprioception in the
dominant right arm does not recover as well after injury as it does in the non-dominant left
arm [19,20]. Thus, therapy to improve proprioception in the dominant right elbow following
injury should be more extensive than that engaged in for the non-dominant left arm.
Age
One effect of the aging process is changes in the central and peripheral nervous systems.
For example, teenagers are better at matching tasks than children and can more effectively
employ kinematic procedures to complete these tasks. In comparison to teenagers, children
make a higher number of absolute errors in matching tasks. A child’s matching motions
are shorter and less consistent in terms of the speed of such movements. The correlation
between mistakes in position replication and age is nonmotonic. From the age of eight,
position matching continues to improve until the child is grown [31]. The component of
memory in the evaluation of proprioception ability in the elderly, when using matching task
models based on memory, is a significant consideration and common daily actions may be
5
performed less successfully [36]. However, it has been argued that it is in fact an inactive
lifestyle that contributes more to a decrease in proprioception than memory deficiencies
[37]. A fair conclusion to draw would be that proprioceptive information is received quicker
in younger people than it is in older people.
Visual or proprioseptive feedback
Based on the variations between the dominant and non-dominant arms during
tasks requiring both arms, it can be seen that the non-dominant arm better processes
proprioceptive responses than the dominant arm which may be more dependent on visual
information. When an action involving both arms takes place, visual responses are focused
on the dominant arm as this is the arm that usually carries out detailed tasks like the
manipulation of items, for example, sharpening a pencil, while the non-dominant arm is
charged with stabilising objects, for example, holding the pencil-sharpener steady, and thus
depends upon proprioceptive information in completing these actions. This clearly shows
that the dominant arm is better at processing visual feedback and the non-dominant arm
has the edge when it comes to proprioceptive information processing. These differences
may illustrate essential variations between the dominant and non-dominant arms and
hemispheres when carrying out actions involving both sides and where the non-dominant
side must stabilise an item using proprioception and the dominant side must manoeuver
an item with the aid of visual information [19,35]. Thus, it can be concluded that to develop
elbow joint proprioception in the dominant arm following an elbow injury, proprioceptive
information is less valuable that visual information.
Task difficulty
Overall, for more complex Contralateral Remembered (CR) rather than Ipsilateral
Remembered (IR) tasks with a higher target velocity, more matching errors occurred. For IR
tasks, a matching advantage in the non-dominant arm in terms of velocity discrimination
and matching has been identified. This illustrates that a number of elements, namely task
complexity, maximum velocity and favoured limb, affects matching performance in terms of
dynamic proprioceptive response. When the velocity of motions was increased and more was
required in terms of proprioceptive processing, matching errors also went up. Additionally,
in regards to the number of errors in average acceleration in IR tasks, a distinct variation
between the dominant and non-dominant arms has equally been identified [35].
Proprioceptive Exercise
Proprioception exercise have been found improve function, decrease of the risk of
injury and improvement of normal movement pattern. The objective of such activities is
for individuals to complete them as precisely as possible. Thus, the activities should start
simple and increase in complexity over time. Furthermore, these activities should come
early on in the programme during therapy sessions when the individual is not yet too tired
to perform them well.
Depending on when the injury occurred, proprioception activities start simple and become
more difficult. An initial proprioception task will demand sufficient muscle movement to
generate the required outcome and are carried out at a relaxed speed and in controlled
conditions. Increasing the pace of these exercises or requesting they be carried out in a
more controlled way makes them more difficult to complete. Another option when seeking
to increase the difficult of such exercises is to require that two or more tasks be carried out
at the same time.
Problems with the joint capsule, ligaments, tendons and muscles are the main cause of
elbow complaints and result in loss of proprioception. Therefore, any therapeutic programme
should include activities designed to improve proprioception. The type of activities required
will vary depending on the age of the individual concerned and their profession, the nature of
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the injury and when the injury occurred. Proprioceptive activities may be open kinetic chain
exercises or closed kinetic chain exercises and should be selected based on the previously
listed factors.
Excersie 1: Rolling the ball on the wall or surface [38].
Excersie 2: Rolling the ball on the wall or surface [38].
Excersie 3: Transfering exercise ball [38].
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Excersie 4: Weight bearing exercise uneven ground [38].
Excersie 5: Proprioceptive exercise on balance board [38].
Excersie 6: Proprioceptive exercise on unstable moving surface [38].
8
Excersie 7: Catching a ball [38].
Excersie 8: Throwing and catching a ball [38].
9
Excersie 9: Transfering body weight on swiss ball in prone position [38].
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