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6.
Brief resume of the intended work:
6.1 Need for the study :
Proprioceptive acuity is defined as an individual’s ability to sense joint position, movement, and
force to discriminate movements of the limbs. The proprioceptors are located in the joint capsules,
ligaments, muscles, tendons, and skin to detect stimuli such as pain, pressure, touch, and movement.
Their function is critical to both sport performance and activities of daily living. Consequently,
Proprioceptive acuity is an essential component of injury prevention and rehabilitation, but it is often
ignored with devastating consequences, because Proprioceptive deficits may be responsible for many
acute ankle and knee injuries1.The ability to sense joint position, however, is only one of the perceptual
attributes of the proprioceptive system, which also includes the ability to sense movement (amplitude
and angular velocity) and to perceive force and weight.2
Joint position sense is generally defined as the ability to assess the limb position without the
assistance of vision. Position sense at joint is governed by central and peripheral mechanisms, mainly
muscular receptors and also tendinous, articulate, cutaneous and ACL receptors. It is now generally
accepted that the greatest contribution to position sense is from muscular receptors.3 The joint(articulate)
receptors are only activated at the extremes of the joint range during movement a property that makes
them poor candidates to signal joint position .Skin mechanoreceptors contribute little to proprioceptive
acuity, at least in the larger joints of the lower extremity but, any reduction in muscle afferents could be
more detrimental for proprioceptive acuity because signals from muscle spindles appear to be critical to
our ability to sense joint position and movement.
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This role of muscular receptors indicate that
modifying the functional state of the muscle can affect the precision of position sense.3
Impaired proprioception is cited as a major factor predisposing to degenerative joint disease and
ongoing instability in the ACL deficient knee4 however subtle proprioceptive deficits can both
predispose an individual to a greater risk for injury and impair sport performance.1
Stretching is commonly used as a technique for injury prevention in the clinical setting. 5 it has
been suggested that stretching augments the sensibility of mechano receptors of the muscle spindle and
improves the subsequent physical activity / exercise session. The muscular receptors have has an
important role in the elaboration of limb position sense, it seems that stretching may improve sensory
and motor capabilities of perception of JPS. It has been reported that the accuracy of JPS will improve as
the muscle stretched and that this increase in accuracy might be responsible for the increase in motor
capabilities after stretching. Such a increase may be due to a better proprioceptive feed back, but may
also act indirectly by leading to a better sensory imaginary.3 Accordingly stretching may diminish the
amount of error observed when measuring the JPS.6
Halbertsma et al and Magnusson et al reported that static stretching might alter stretch tolerance.
In his study the subjective sensation of stretching is significantly lower after 2 weeks of a stretching
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protocol, indicating that stretch tolerance is altered. This may be due to alteration in muscle spindle or
golgitendon organ firing rate. This assumption is supported by the observation that the sensitivity muscle
spindle are affected by a previous history of muscle stretching.3
The different methods of stretching are ballistic stretching, static stretching, and variations of
proprioceptive neuromuscular facilitation (PNF) techniques and dynamic stretching –Ballistic (bouncing)
stretching is a rapid, jerky movement in which a body part is put into motion and momentum carries the
body part through the range of motion until the muscles are stretched to their physiological limit.Static
stretching is performed by placing muscles at their greatest possible length and holding that position for a
period of time.7 Static stretching is slow and prolonged stretch is applied to avoid the reflex contraction
from the muscle spindle and golgitendon organ. In this stretch the muscle is elongated gently and
maintained for long period of time (30 sec).8J Voss et al have defined proprioreptive neuromuscular
facilitation as a method of promoting or hastening the response of a neuromuscular mechanism through
stimulation of the proprioceptors. Frequently, PNF techniques involve isometric contractions of a
lengthened muscle, followed by further lengthening, either actively or passively.7However dynamic
stretching is moving the limb from its neutral position to end range, where the muscles are at their
greatest length and then moving the limb back to its original position. This dynamic action is carried out
in a smooth, controlled manner and is repeated for a specific period of time.9
A reliable method for the estimation of JPS is the measurement of the reproduction of a specific
target position, the difference between target position and the estimate position being used .6
A number of techniques for clinically examining proprioceptive acuity are described in the
literature, including threshold detection of passive movement, the absolute method and joint position
sense (JPS). An individual’s JPS primarily determines his or her ability to perceive a target joint angle or
limb position and then, after the limb has been returned to its starting position, to reproduce the
predetermined angle. The conscious ability to position a limb is a highly specialized proprioceptive
function and is a vitally important clinical outcome measure, involving both the control of movement and
stability. The JPS tests are routinely administered by clinicians to assess any proprioceptive deficits in
the knee joint after anterior cruciate ligament injury, stretching, fatigue, pain, patellar taping, and
cooling. The primary reason JPS is assessed by clinicians is to identify any reduction that may
predispose an individual to proprioception-related injury.1
Farahnaz Ghaffarinejad, Shohreh Taghizadeh, Farshid Mohammad studied the effect of static
stretch of muscles surrounding the knee on the knee joint position sense. In this study JPS was estimated
by the ability to reproduce the two target positions (20’ and 45’ of flexion)in the dominant knee and the
absolute angular error (AAE) are defined as the absolute difference between the target angle and the
subject perceived angle of knee flexion. Knee JPS is assessed by the subject’s ability to reproduce
passive positioning of the leg that is the target angle and perceived angle, using an electrogoniometer at
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the lateral aspect of knee joint. The study concluded that accuracy of the knee JPS in 45 ‘ of flexion is
increased subsequent to static stretch regimen of quadriceps , hamstrings and adductors in healthy
subjects.3
The study by Kieran O Sullivan, Elaine Murray, and David Sains Burry on The effect of warm
up, static stretching and dynamic stretching on hamstring flexibility in previously injured subjects
suggest that static stretch has little or no impact on injury prevention it has also become clear that static
stretching may negatively affect immediate physical performance. Because of this dynamic stretching
has been suggested as an alternative to static stretching post warm up, as evidence suggest that dynamic
stretching positively impact on immediate physical performance.9
Streepey et al conducted a study on Effects of Quadriceps and Hamstrings Proprioceptive
Neuromuscular Facilitation Stretching on Knee Movement Sensation. Their study on 18 healthy subjects,
aged 18 to 30 years, on their dominant knee concluded that PNF stretching of the hamstrings and
quadriceps might acutely diminish sensitivity to knee movement. For coaches and trainers, these findings
are consistent with previous reports of loss in muscle force and power immediately after stretching,
suggesting that stretching just before competition may diminish performance.11
Ballistic stretches force the limb into an extended range of motion when the muscle has not
relaxed enough to enter it. It involves fast "bouncing" movements where a double bounce is performed at
the end range of movement. Ballistic stretching should only be used by athletes who know their own
limitations and with supervision by their trainer. Ballistic stretching has been found to be hazardous
towards the body. It can injure vital muscles and nerves with the sharp jerking movements. It is even
possible for tissue to be ripped off the bone.12
Though the study on static stretch on Knee joint position sense in healthy subject by R Larsen et
al, Farahnaz et al shows an positive result on joint position sense, the negative impact after static, PNF
and ballistic stretch which is already proven, like decrease - in performance, movement sense, the need
of a therapist to assist to do the stretching all point out to find out the effectiveness of Dynamic stretch on
joint position sense, as it has already found to increase the performance after the dynamic stretch
moreover dynamic stretch is preferred as warm up program before the sport activities. However, there
are no studies done on Dynamic stretch and joint position sense. Since there are no available literatures
on effect of dynamic stretch on joint position sense there is a need to find out the effect of dynamic
stretch on the joint position sense. The influence of stretch could be negative, neutral or positive on knee
joint JPS and this study is necessary to find this.
Hypothesis:
Neither individual
hamstring and quadriceps dynamic stretch nor combined hamstring and
quadriceps dynamic stretch will have any effect on the knee joint position sense.
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6.2 Review of Literature:
Fernando Ribeiro and José Oliveira(2010) conducted a study on Effect of physical exercise and age
on knee joint position sense. This study aimed to test the hypotheses that knee position sense declines
with age and that regular exercise can attenuate that decline. This cross-sectional study encompassed 69
older and 60 young adults divided in four groups. Compared to their non-exercised counterparts,
exercised-young and -old showed lower absolute and relative angular errors. The present data indicates
that age has deleterious effects on knee position sense although regular exercise can attenuate that agerelated decline.
Uwe Proske and Simon C. Gandevia(2010) in their topical review of The kinesthetic senses they
concluded that the senses of limb position and limb movement, has been prompted by recent new
observations on the role of motor commands in position sense. Peripheral receptors, which contribute to
kinaesthesia, are muscle spindles and skin stretch receptors. Joint receptors do not appear to play a
major role at most joints. The evidence supports the existence of two separate senses, the sense of limb
position and the sense of limb movement. Receptors such as muscle spindle primary endings are able to
contribute to both senses. Observations using neuroimaging techniques indicate the involvement of both
the cerebellum and parietal cortex in a multi-sensory comparison, involving operation of a forward
model between the feedback during a movement and its expected profile, based on experience.
Involvement of motor command signals in kinaesthesia has implications for interpretations of certain
clinical conditions.
Streepey, Jefferson W, Mock, Marla J, Riskowski, Jody L2 et al l(2010) conducted a study on
Effects of Quadriceps and Hamstrings Proprioceptive Neuromuscular Facilitation Stretching on Knee
Movement Sensation , concluded that that PNF stretching of the hamstrings and quadriceps may acutely
diminish sensitivity to knee movement.
Joseph T. Costello, BSc; Alan E. Donnelly, (2010) in their systemic review of Cryotherapy and
Joint Position Sense in Healthy Participants quoted the importance of JPS and the different methods of
assessing it. They suggest that The conscious ability to position a limb is a highly specialized
proprioceptive function and is a vitally important clinical outcome measure, involving both the control of
movement and stability. In the 7 studies they reviewed, 3 joints were assessed (shoulder, knee, and
ankle) in a combined 204 healthy participants after a cryotherapy intervention. Four groups found
cryotherapy to have no effect on JPS, whereas 3 others found JPS reduced after a cryotherapy treatment.
Given this brevity of research, we are also unable to make a recommendation as to when athletes can
safely return to participation after treatment. Despite the suggested benefits of cryotherapy, until further
evidence is provided, athletic trainers and clinicians should be cautious when returning individuals to
physically demanding or dynamic tasks after cryotherapy.This study shows a potential risk factor that is
icing which influence proprioception, which may lead to injuries.
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Manoel, Mateus, Harris, Michael, Danoff, Jerome, Miller et al (2008) studied Acute effects of
static, dynamic, and proprioceptive neuromuscular facilitation stretching on muscle power in women.
The purpose of this study was to investigate the acute effects of 3 types of stretching-static, dynamic, and
proprioceptive neuromuscular facilitation (PNF)-on peak muscle power output in women. Concentric
knee extension power was measured isokinetically at 60°·s-1 and 180°·s-1 in 12 healthy and
recreationally active women. Testing occurred before and after each of 3 different stretching protocols
and a control condition in which no stretching was performed. Dynamic stretching produced percentage
increases (8.9% at 60°·s-1 and 6.3% at 180°·s-1) in peak knee extension power at both testing velocities
that were greater than changes in power after static and PNF stretching. The findings suggest that
dynamic stretching may increase acute muscular power to a greater degree than static and PNF
stretching. These findings may have important implications for athletes who participate in events that
rely on a high level of muscular power
Craig A. Wassinger, Joseph B. Myers, Joseph M. Gatti, Kevin M. Conley, Scott M. Lephart (2007)
did a study on proprioception and throwing accuracy in the dominant shoulder after cryotherapy. In the
introduction, they commented the importance of proprioceptive acuity in prevention of sports related
injuries. Mechanoreceptors are present in skin, muscle, and joint tissues and are activated by tissue
deformation, which subsequently sends afferent neural impulses to the central nervous system, and are
used for joint stability and proper joint function. The integrity of the mechanoreceptors and neural
pathways plays a vital role in allowing shoulder mobility and concurrent stability. More over for their
study, they used replication of particular limb position to assess the propriocetion after the cooling
intervention.
Farahnaz Ghaffarinejad, Shohreh Taghizadeh, Farshid Mohammadi(2007) conducted a study on
Effect of static stretching of muscles surrounding the knee on knee joint position sense. Objective was to
evaluate if a stretch regimen consisting of three 30 s stretches alters the knee JPS. 39 healthy students (21
women, 18 men) volunteered to participate in this study. JPS was estimated by the ability to reproduce
the two target positions (20° and 45° of flexion) in the dominant knee. Measurements were repeated
three times. The author concluded the the accuracy of the knee JPS in 45° of flexion is improved
subsequent to a static stretch regimen of quadriceps, hamstring and adductors in healthy subjects. The
reason for no difference in absolute angle error value at 200 of flexion could be due to the afferent input
of the ACL in early ranges of knee flexion, the muscle stretching regimen minimally influences the knee
JPS, but in 45° of flexion the stretching may improve the awareness of joint position. MacDonald et al
reported that in early ranges of knee flexion, afferent input from the ACL is most likely to be detected,
but in the intermediate ranges, muscle receptors are primarily responsible for knee JPS and stretching
may affect these receptors.
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Sedat Tolga Aydoğ, Zafer Hasçelik, H. Ali Demirel, Onur Tetik, Ece Aydoğ and Mahmut Nedim
Doral (2005) conducted a study on The effect of menstural cycle on the knee joint position sense . They
applied knee joint position sense test at two different directions through out the three different phases of
menstrual cycle . In their study higher value of reposition error from the target angle of 400 was found in
the menstural phase than luteal phase. In conclusion they have demonstrated that active knee joint
position sense was significantly reduced in the mensturation period
R Larsen, H Lund, R Christensen Danneskiold, H Bliddal etal(2005) conducted a study on Effect of
static stretching of quadriceps and hamstring muscles on knee joint position sense. Objectives of this
study were to evaluate if a stretch regimen consisting of three 30-second stretches would alter joint
position sense (JPS). Measurements were repeated three times in a sitting and a prone position on the
dominant leg measured before and immediately after the static stretch. The static stretch consisted of a
30-second stretch followed by a 30-second pause, repeated three times. The conclusion was static stretch
regimen had no effect on JPS in healthy volunteers. The JPS was measured using two electrogoniometer.
We conclude that static stretching has no significant effect on JPS of the knee in healthy subjects.
Francois Tremblay; Lorein Estephan; Martine Legendre; Ste´phanie Sulpher(2001) studied the
influence of local cooling on proprioceptive acuity in the quadriceps muscle. They checked the
discriminative capacity to changes in weight applied to the test(precooled) knee as outcome measure. In
the discussion part, they have made very vital description about the role skin ,joint and nerve conduction
in propriocetion acuity . A reduction in skin afferents, although critical for tactile and pain sensations, is
of less consequence for proprioceptive abilities. Indeed, skin mechanoreceptors contribute little to
proprioceptive acuity, at least in the larger joints of the lower extremity. Alternatively, any reduction in
muscle afferents could be more detrimental for proprioceptive acuity because signals from muscle
spindles appear to be critical to our ability to sense joint position and movement. They concluded a rapid
return to play after ice therapy might not be necessarily detrimental for the athlete. Of course, other
components of motor performance (egg: strength and flexibility) might be affected after ice therapy and
health care professionals, therefore, must fully evaluate the conditions and circumstances before
returning an athlete to action.
N D Carter, T R Jenkinson, D Wilson, D WJones, A S Torode et al(1997) conducted a study on
joint position sense and rehabilitation in the anterior cruciate ligament deficient knee. Impaired joint
position sense (JPS) has been shown in anterior cruciate ligament (ACL) deficient and osteoarthritic
knees. The aim of this study was to determine further if ACL deficient knees show abnormal JPS and the
effect of exercise therapy on JPS, and also to assess the relation between JPS, functional stability, and
strength. The author concluded that JPS were impaired in ACL deficient knees. Although knee stability
improved with exercise therapy, there was no improvement in JPS.In their discussion part author
commented that other studies have shown correlation between JPS and assessment of knee joint stability.
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Episodic joint instability leads to joint capsule laxity and a subsequent reduction of afferent activity. This
may contribute to impaired JPS. If this were so, then with each episode of instability that causes joint
swelling one might expect a difference in the threshold of response from capsule receptors in acute and
chronic lesions. Other studies report the preservation of JPS in locally anaesthetized joints. ' This
suggests a role also for muscle spindles in joint proprioception.
It is considered that muscle spindles
may provide crude awareness of joint position whilst joint receptors are responsible for fine-tuning.
1.3 Objective of the study :
1. To study the effect of dynamic stretch of hamstrings on knee joint JPS.
2. To study the effect of dynamic stretch of quadriceps on knee joint JPS.
3. To study the effect of combined dynamic hamstring and quadriceps stretching on knee joint
position sense.
7.
Materials and Methods:
7.1 Source of Data: Padmashree Institute of physiotherapy.
7.2 Method of collection of data:
Population: Healthy subjects.
Sample design: Random sampling.
Study design: Cross over experimental design.
Sample size: 30
Duration of the Study: 3 months.
Materials required:

Treatment Table

Towel as Blindfold to close the eyes

Pen

Paper

Stop watch

Standard goniometer.

Two long scales.

Velcro strap.
Inclusion criteria:
 The age range 21–26 yrs , height range 160–190cms, and weight range 50- 80.
 Males subjects
 Full range of motion in the knee.
 Muscle power minimum of 4/5 on manual muscle testing.
Exclusion criteria:
 Subjects with known knee joint pathology.
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 Subjects who had a history of trauma to the lower extremity, rheumatologic, orthopedic or
neuromuscular disorders.
 Subjects with restricted knee joint range of motion.
 Subjects with sensory deficits.
 Visual or auditory defect.
Methodology:
The study is an experimental, cross overdesign comprising three group .The 30 subjects are
randomly allocated to group A(10 members) ,group B (10 members) and group C(10 members) using
chit method. The chit/randomising letter and the instructions regarding stretching will be in 30 envelops.
Each subject take one envelope, which the subject opened after receiving the instructions. So the
investigator is blinded and do not know which subject belong to a particular group. After the stretching
had been performed, the written material is replaced in the envelope and returned to the tester. The
written material contained an illustration of the position, the instructions, a timetable, and the figure of a
person from the front and from behind on which the subject is told to indicate where the stretch is felt
.The each group undergoes specific stretching randomly and the observer is blinded. The three studies
are separated with a gap of one day to wash out any interference. On day one each group A,B and C will
undergo respective stretches, similarly stretches are repeated on day 2 and 3 as per the envelope.The pre
and post intervention scores are made through direct observation and documented. The JPS is measured
before and after intervention.
The subjects will be given oral commands to take the experimental leg to the target angle of 50 0
and 700 and the position will be maintained for 5 seconds. The subject is then asked to return the leg to
the resting position. After a few seconds, he is asked voluntarily to place the same leg in the same
position and notify the investigator when he believed the position is obtained. The position is then
maintained for five seconds and called the estimated angle. The target angle will be given randomly so
that there is no learning effect.The absolute angular error (AAE) is defined as the absolute difference
between the target angle and the subject perceived angle of knee flexion. AAE values are measured
before and immediately after the dynamic stretch. Measurements were repeated three times. There will
be two test positions one is supine and other one is prone. In supine, the subject lower legs are hanging
from the edge of treatment table with a resting position angle of 900 at knee and in prone the knee is
slightly flexed at 150 of rest position and a roll of towel will be kept to maintain this position. A long
thin stick / or metal road will be aligned along the long axis of test leg with head of fibula and lateral
maleoli as reference points , the stick will be long enough to go 15 cm beyond the heel. The stick/rod
will be secured in place with Velcro/micropore.
The testing table is close to the wall where entire 1800 protractor will be drawn with subdivisions.
The measurements are taken when patient reaches the target / perceived angles where the stick stands
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corresponds to the divisions on the wall makings. After oral and written instruction, stretching is carried
out 3 times as a self-applied dynamic stretching of 3 repetitions with 30 seconds rest in between.. In
addition, a watch with a second hand is placed in front of the subject so that the stretch could be
performed with an interval of 30 seconds.
Participants are barefoot and will be dressed in shorts during all tests. In supine knee joint and the
distal part of the hamstrings are free from the table. After correct positioning and aligning the knee joint
axis of flexion and extension to the axis of protractor on the wall the subject is fixed with straps around
the waist and back and secured to the table. After positioning of the subject the entire set up is calibrated
in the resting position, setting the knee joint angle to 90˚ in the supine position and 15˚ in the prone
position. After each session, data will be recorded with pen. Only dominant legs will be tested. To avoid
distractions, all testing is conducted in a quiet room, by the same investigator, using the same commands.
Outcomes measures:
Custom drawn protractor to measure range of motion.
Statistics:
1. Statistical analysis will be performed using SPSS software (version 7) for windows. Alpha value
will be set as 0.05.
2. Descriptive statistics will be used to find out mean,standard deviation,name for baseline and
demographic variables.
3. Analysis of variance will be used to test for difference among demographic variables such as age.
4. ANOVA test will be used to compare the absolute angle error between three groups.
5. Unpaired t-test will be used to compare pre and post measurements of knee range of motion to
measure absolute anglular error(AAE).
6. Microsoft word, excel, will be used to generate table,graph etc.
7.4 Ethical Clearance
As my study includes human subjects, ethical clearance for the study has been obtained from the
institutional ethical committee, Padmashree institute of physiotherapy.
8.
List of References
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Participants: A Systematic Review. Journal of Athletic Training 2010 jun; 45(3):306–316.
2. Franc¸ois Tremblay, Lorein Estephan, Martine Legendre, Ste´phanie Sulpher. Influence of
Local Cooling on Proprioceptive Acuity in the Quadriceps Muscle. Journal of Athletic Training
2001; 36(2):119–123.
3. Farahnaz Ghaffarinejad, Shoreh Taghizadeh, Farshid Mohamed. Effect of static stretching of
muscles surrounding the knee on knee joint position sense. Br J sports med 2007; 41:684-687.
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4. N D Carter, T R Jenkinson, D Wilson, D WJones, A S Torode. Joint position sense and
rehabilitation in the anterior cruciate ligament deficient knee. BrJ Sports Med 1997; 31:209-212.
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women. J Strength Cond Res 2008 Sep; 22(5):1528-1534.
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introduction they commented the importance of proprioceptive aquity in prevention of sports
related injuries. J Athl Train 2007 Mar;42(1):84-89.
16. Fernando Ribeiro and José Oliveira. Effect of physical exercise and age on knee joint position
sense.Archives of Gerontology and Geriatrics. July-August 2010;51(1):64-67.
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10
Proprioception and throwing accuracy in the dominant shoulder after cryotherapy.J Athl Train.
2007 Jan-Mar; 42(1): 84–89.
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