The importance of proprioception has been covered in a previous article so this article concentrates on the assessment and management of problems due to loss of joint position sense. Physiotherapists concentrate mostly on pain, loss of joint ranges and poor muscle power initially as these are the commonest restrictions found clinically. However they will always consider joint position sense once the more typically troublesome symptoms are settling. Full rehabilitation of the patient back to normal or sporting activity cannot be said to be complete without retraining the proprioceptive function of the body's joint and nervous systems.
Putting our hands in front of our faces is the reason we have arms, because to be able to manipulate objects we have to be able to see what we are doing. An effective and precise system to give us close feedback is required so we can check on how our performance is matching our movement plans and then make the necessary corrections. With our very mobile hand joints and our binocular vision we have evolved the ability to precisely manipulate objects and perform useful work to change our environments. We have to know where the joints of our arms and hands are at any time if we are going to do activities like touch typing, which I am doing now, and for which I must have accurate feedback about the position and movements of my fingers.
Upper limb proprioception can be tested by the physiotherapist getting the patient to shut their eyes and then by putting their good arm into a specific position. Once the position has been set by the physiotherapist the patient is asked to put their other, affected, arm into the same position as closely as possible. A person whose joint position sense is unaffected can mirror position of one arm by using the other, very accurately. Any deficits in the ability to understand the position of the arm joints will be apparent after this test.
The lower body, the legs and pelvis, is adapted to carry the large muscles and sustain the large weights which are involved in running and walking. Interfering with our ability to be independent in mobility is very difficult and any loss of joint position sense in the legs is serious. This is well illustrated by an ex-patient of mine with multiple sclerosis, who had problems in the dark.
My patient told me a short story with which many of us can identify. He went into a toilet and shut the door, locking it behind him. He automatically turned on the light, not noticing that the light was already on, something we have all probably done. Unfortunately for my patient, when the light went out so did the visual clues he was getting from his eyes gauging his movement in space, causing him to fall over at once! Since his proprioception was inaccurate he could not figure out where his legs where moment to moment and could not readjust any inaccuracies.
Physiotherapists test patients' joint position sense routinely on assessing a patient after trauma or neurological illness. Getting the patient to mirror the position of the good leg with the affected leg can be used if the problem is profound or the patient is in bed. More practical ways of testing use weight bearing positions, starting with checking the gait which might give an indication of any losses of the joint position sense. Less dramatic limitations can show up with balance testing, starting with standing with the feet together and moving on to standing on one leg and balancing with the eyes shut.
Proprioceptive ability can be re-trained by the physiotherapist who will initially ask patients to move their limbs under visual control, gradually withdrawing this until they can rely on the information pouring in from the bodily structures for co-ordinated movement. Adding compression by encouraging weight bearing through the joint can increase the proprioceptive input through the structures and improve the accuracy of input and of the movement response. Even though the patient may not be able to entirely regain their abilities, by working at the deficiencies they can continue to improve. - 14130
Putting our hands in front of our faces is the reason we have arms, because to be able to manipulate objects we have to be able to see what we are doing. An effective and precise system to give us close feedback is required so we can check on how our performance is matching our movement plans and then make the necessary corrections. With our very mobile hand joints and our binocular vision we have evolved the ability to precisely manipulate objects and perform useful work to change our environments. We have to know where the joints of our arms and hands are at any time if we are going to do activities like touch typing, which I am doing now, and for which I must have accurate feedback about the position and movements of my fingers.
Upper limb proprioception can be tested by the physiotherapist getting the patient to shut their eyes and then by putting their good arm into a specific position. Once the position has been set by the physiotherapist the patient is asked to put their other, affected, arm into the same position as closely as possible. A person whose joint position sense is unaffected can mirror position of one arm by using the other, very accurately. Any deficits in the ability to understand the position of the arm joints will be apparent after this test.
The lower body, the legs and pelvis, is adapted to carry the large muscles and sustain the large weights which are involved in running and walking. Interfering with our ability to be independent in mobility is very difficult and any loss of joint position sense in the legs is serious. This is well illustrated by an ex-patient of mine with multiple sclerosis, who had problems in the dark.
My patient told me a short story with which many of us can identify. He went into a toilet and shut the door, locking it behind him. He automatically turned on the light, not noticing that the light was already on, something we have all probably done. Unfortunately for my patient, when the light went out so did the visual clues he was getting from his eyes gauging his movement in space, causing him to fall over at once! Since his proprioception was inaccurate he could not figure out where his legs where moment to moment and could not readjust any inaccuracies.
Physiotherapists test patients' joint position sense routinely on assessing a patient after trauma or neurological illness. Getting the patient to mirror the position of the good leg with the affected leg can be used if the problem is profound or the patient is in bed. More practical ways of testing use weight bearing positions, starting with checking the gait which might give an indication of any losses of the joint position sense. Less dramatic limitations can show up with balance testing, starting with standing with the feet together and moving on to standing on one leg and balancing with the eyes shut.
Proprioceptive ability can be re-trained by the physiotherapist who will initially ask patients to move their limbs under visual control, gradually withdrawing this until they can rely on the information pouring in from the bodily structures for co-ordinated movement. Adding compression by encouraging weight bearing through the joint can increase the proprioceptive input through the structures and improve the accuracy of input and of the movement response. Even though the patient may not be able to entirely regain their abilities, by working at the deficiencies they can continue to improve. - 14130
About the Author:
Jonathan Blood Smyth is Superintendent of a large team of Physiotherapists at an NHS hospital in Devon. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Berkshire or elsewhere in the UK.
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