For Healthcare Professionals from Foot Levelers, Inc.

April 2020

Proprioception: Alignment and Movement

Research StudiesPractical

“Proprioception” describes “the sensory information that contributes to the sense of position of self and movement,” perceived both at the conscious and unconscious levels.”1 Our bodies are equipped with several independent, yet interrelated mechanisms to sense and provide this necessary information. Specialized nerve endings are present in the soft tissues of the musculoskeletal system, which interact with the central nervous system and coordinate our body movements, our postural alignment, and our balance. Athletic performance, in particular, relies on this delicately controlled and finely tuned system of receptors and feedback loops, and the validity of the information which is sent into the spinal cord. This coordination allows for appropriate motor responses—and sometimes, beautifully accomplished physical activities.

Proprioceptive Sensory OrgansProprioceptive sensory organs are found in two distinct groups. Some are located in muscles and tendons, while others are within the connective tissues (ligaments and capsules) of the joints (Table 1). There is a constant flow of information regarding the status and function of the musculoskeletal system from these structures to the spinal cord, the cerebellum, and the brain.2 When there is a breakdown in communication, or when improper information is supplied by one or more of these sensors, efficiency of movement decreases. This can become harmful or even injurious to the muscles and joints. Often this breakdown causes minor-to-severe problems with postural coordination and/or joint alignment. Sometimes it is just annoying, or it can be the source of chronic, unresolving pain.

The muscular system is the largest system in the body, and it is the muscles which are responsible for maintaining postural alignment and moving body segments. The most important sensory nerve endings for controlling this massive system are the muscle spindle fibers. Of secondary, but sometimes critical importance, are the Gogli tendon organs, which protect against damage from excessive muscular contraction.

Surrounding and protecting all joints are tough, fibrous tissues which contain a variety of sensory nerve endings. The input from these specialized sensors keeps the nervous system informed as to the location of the joint, and also the degree of stretch, compression, tension, acceleration and rotation.3 These four types of joint mechanoreceptors are classified by their anatomy and their neurological function. 4

Proprioceptive Sensory Organs

Muscles and Tendons Muscle spindle fibersGogli tendon organs

Joint Ligaments and Capsules(Mechanoreceptors)

Type I – low threshold, slow-adaptingType II – low threshold, fast-adaptingType III – high threshold, slow-adaptingType IV – nociceptive (pain endings)

Table 1

Research StudiesPractical

Proprioception

Locations of Greatest ImportanceThese six specialized nerve sensors (Table 1) are found throughout the musculoskeletal system, in all skeletal muscles and in every ligament, joint capsule, and articular connective tissue. Certain

anatomical regions, however, contain more receptors or have distinctive nerve circuits which must be considered. The three areas of greatest importance are: the foot, the spine (generally), and

specifically, the upper cervical spine (Fig 1). Because of the magnitude of sensory input, these three areas are also frequently involved in clinical conditions, and require specific treatment approaches.

The Upper Neck. Proprioceptive organs in the upper cervical region are particularly important in maintaining and correcting postural alignment, and in determining whole-body balance. The deep neck muscles have been found to have many more proprioceptive nerve endings than other skeletal muscles.8 The mechanoreceptors in the upper cervical joints are very sensitive to changes in postural alignment, and are a critical component (along with the vestibular system) in equilibrium and balance.9 In fact, deJong et al. were able to cause major changes in gait simply by anesthetizing the muscle and joint receptors in the neck.10

The Foot. With many small joints, lots of connective and articular tissues, and both intrinsic and extrinsic muscles, the feet are very well-supplied with proprioceptive nerve endings. Mechanoreceptors in the joints along with the muscle spindles of the foot muscles are responsible for the positive support reflexes and a variety of automatic reflexive reactions.5 These include the flexor/extensor reflex, which converts the lower limb into a firm, yet compliant pillar. Weightbearing compresses the joints and muscles, evoking reflexive activity in the extensors and inhibition of the flexor muscles.6

The Spine. The paraspinal muscles have the highest concentration of muscle spindles of all of the muscles in the body.7 Mechanoreceptors (especially the Type IV nociceptors) innervate virtually all of the spinal and paraspinal tissues. These sensory receptors form a dense and highly sensitive network which maintains upright posture and responds rapidly to potentially damaging insults.

Problems Associated with Proprioceptive InputRecurrent Ankle Sprains...recognize the importance of inappropriate afferent signals from injured ankle and foot proprioceptors.

Post-Whiplash Headaches and Vertigo...importance of spinal (especially upper cervical) proprioceptors in the various symptom patterns found in post-whiplash patients.13

Chronic Postural Problems...position receptors in the feet, spine and especially the neck (head-righting reflexes) must coordinate smoothly in order to maintain postural equilibrium.

Recurrent Subluxations...when patients respond in an incomplete manner to standard Chiropractic adjustments, one factor which must be considered is the status of their proprioceptive system.

Chronic Pain Syndromes...a study of patients with chronic neck pain found that most had significant, unrecognized problems in function of their proprioceptive system.16

Sports Performance...performance in athletics is directly determined by the status and coordination for the proprioception system.

Fig 1: Areas of greatest proprioceptive input.

For the Patient “Aha!” Moment Proprioceptive Testing Orthotics

Demonstrate to patients the power of functional orthotics—how they can help strengthen the communication paths between the brain and muscles, resulting in improved strength, agility and balance. This simple test shows inefficiency without orthotics, efficiency with orthotics.

Includes one large pair testing orthotics, one small pair testing orthotics, and instructions on testing.

Proprioceptive Testing

After finishing the side view video of the patient standing on

the functional orthotics...

“Stay standing on the functional orthotics for a moment, I

am going to do a muscle test to see if your nervous system

communicates to your muscles in an efficient manner.”

1) Hold your arm up real strong and don’t let me push it down,

resist.(tests strong).

2) Good, now step off the funtional orthotics and let’s re-test.

Hold the arm up real strong, resist. (weak test)

3) Stand back on the functional orthotics and lets check that

again.(tests strong).

That tells me that your brain is communicating more efficiently to your

muscles when you stand on the functional orthotics than when you aren’t

standing on them.

The fact that the arches in your feet flatten out a little like we saw on the

foot scan contribute to stress in your nervous system and that weakens

some of your postural muscles, we just used your arm muscle to test it.”

Without Orthotics With Orthotics

Unsupported Supported

Less ResistanceMore Resistance

PHASE 1Functional Squat Test Protocol

1. Ask the patient to “stand with your feet shoulder-width apart and raise your hands straight up in the air. Now I want you to squat down like you are sitting in a chair.” Have them repeat that motion twice while recording it on video.

2. Facing the doctor, have the patient stand on the Proprioceptive Test Orthotics, “with your feet shoulder-width apart and hands straight up in the air, squat down like you are sitting in a chair.” Video tape two repetitions of the maneuver.

3. Have them turn to the left and repeat the test, video taping them from the side view. Note how patient’s arms do not cover ear.

4. While the patient is still turned to the left, have them stand on the Proprioceptive Test Orthotics and repeat the maneuver. Note how patient’s arm does cover ear.

© 2015 Foot Levelers, Inc. M11812-0415

Orthotics

Orthotics

For the maximum impact, Foot Levelers

recommends the use of a postural screening software.

PHASE 2

Research StudiesPractical

Proprioception

1. Johnson EO, Soucacos PN. 2010. Proprioception. In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation. Available online: http://cirrie.buffalo.edu/encyclopedia/en/article/337/

2. Johnson EO, Babis GC, Soultanis KC, Soucacos PN 2008 Functional neuroanatomy of proprioception. Journal of Surgical Orthopaedic Advances 17(3):159-64.

3. Slosberg M. Effects of altered afferent articular input on sensation, proprioception, muscle tone and sympathetic reflex responses. J Manip Physiol Ther 1988; 11:400-408.

4. Wyke BD. Thenerology of joints. Ann R Coll Surg Engl 1967; 41:25.

5. Freeman MAR, Wyke BD. Articular contributions to limb muscle reflexes. J Physiol 1964; 171:20.

6. Panzer DM, FEtchel SG, Gatterman MI. Postural complex . In: Gatterman MI, ed. Chiropractic Management of Spine-Related Disorders. Baltimore: Williams & Wilkins, 1990:263.

7. Fitz-Ritson D. The anatomy and physiology of the muscle spindle and its role in posture. Can J Physiol Pharmacol 1982; 26:144-150.

8. Abrahams VC. The physiology of neck muscles: their role in head movement and maintainence of posture. Can J Physiol Pharmacol; 55:332.

9. Wyke BD. Neurology of the cervical spinal joints.

Physiotherapy 1979; 65: 72-76.10. deJong PT, deJong VB, Jonkees L. Ataxia and

nystagmus induced by the injection of local anesthetics. Ann Neurol 1977; 1:240-246.

11. Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprans. J Bone Joint Surg Am 1955; 37:1237.

12. Freeman MAR, Dean MRE, Hanham IWF. The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br 1965; 47:678-685.

13. Hinoki M. Vertigo due to whiplash injury: a neurological approach. Acta Otolaryngol (Stockh) Sppl 1984; 419L9-29.

14. Fitz-Ritson D. The Chiropractic Management and rehabilitation of cervical trauma. J Manip Physiol Ther 1990; 13:17-25.

15. McPartland JM, Brodeur RR, Hallgren RC. Chronic neck pain, standing balance, and suboccipital muscle atrophy—a pilot study. J Manip Physiol Ther 1997; 20:24-29.

16. Rogers RG. The effects of spinal manipulation on cervical kinesthesia in patients with chronic neck pain: a pilot study. J Manip Physiol Ther 1997; 20:80-85.

17. Travell JG, Simons DG. Myofacasial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Williams & Wilkins, 1983:36.

18. Gleddie N, Marshall D. Plyometric training for

basketball. Strength & Conditioning 1996; 18:20-25.19. Slosberg M. Effects of altered afferent articular

input on sensation, proprioception, muscle tone and sympathetic reflex responses. J Manip Physiol Ther 1988; 11:400-408.

20. Rogers RG. The effects of spinal manipulation on cervical kinesthesia in patients with chronic neck pain: a pilot study. J Manip Physiol Ther 1997; 20:80-85.

21. Fitz-Ritson D. Assessment of cervicogenic findings. J Manip Physiol Ther 1991; 14:194-198.

22. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Williams & Wilkins, 1983:204.

23. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Williams & Wilkins, 1983:593.

24. Oslance J, Liebenson C. The Proprio System. Los Angeles: Proprio Systems, 1995:28.

25. Miller AS, Narson TM. Protocols for proprioceptive active retraining boards. Chir Sports Med 1995; 9:51-55.

26. Janda V, Vavrova M. Sensory motor stimulation. In: Liebenson C. ed Rehabilitation of the Spine. Baltimore: Wiliams & Wilkins, 1996: 319.

27. Fitz-Ritson D. Phasic exercises for cervical rehabilitation after “whiplash”. J Manip Physiol Ther 1995; 18:21-24.

References

Treatment ApproachesMany of the more recent (and some very traditional) treatment approaches to musculoskeletal problems take advantage of proprioceptive concepts. Joint manipulation, especially of the spinal joints, has a direct and immediate effect in normalizing receptor responses.19, 20, 21

Various soft tissue techniques, such as kinesiological and myofascial approaches have been found to be effective. Trigger point therapy helps to correct imbalances in muscle tone and tension which are perpetuated by sensory receptor problems.22

The more effective stretching maneuvers take advantage of our recent knowledge of the proprioceptive responses in the muscles and joints: proprioceptive neuromuscular facilitation (PNF), postisometric relaxation (Lewitt technique), contract-relax (CRAC), muscle energy techniques, and active release (Leahy technique).

Patients with proprioceptive imbalances often benefit from various external supports to help them achieve proper body positioning. These may include

orthotics for the foot and ankle, cervical pillows in chronic neck pain (Fig. 2), and chair supports to provide alignment of the back during sitting.23

Advances have been made in methods for strengthening postural muscles based on our knowledge of proprioception. Since postural (especially neck and back) muscles are tonic,

slow-twitch muscles, we must use slow and controlled exercises in an upright position, in order to stimulate and normalize input from position receptors.

In fact, closed chain exercises are being used much more frequently in sports and rehabilitation. By keeping the body upright and weightbearing during exercising, the proprioceptors are recruited to condition the muscle and joints. (Fig. 3).

Two areas where this approach is seen are in walking and balance retraining. Walking is a basic, deeply ingrained motor pattern, sometimes called cross-crawl. Brisk walking with a good arm swing activates this neurological program, and can often help in normalizing inappropriate receptor input. Even more specialized proprioceptive exercises use gym balls,24 balance and rocker boards,25 and even special “balance shoes.”26

To help re-coordinate and improve the function of the upper cervical proprioceptive system, specific eye-head-neck coordination exercises have been developed.27 These recognize the complexity of the interconnections between the upper cervical receptors and information from the visual and oculomotor system, and the vestibular/labyrinthine system.

Fig 3: Backsys® Rehabilitation

Fig 2: Orthotics/Pillow