Physiotherapy Treatment for Proprioception
We discussed the importance of joint position sense in a previous article. Now it's time to look at the assessment and treatment of proprioceptive difficulties. As proprioception is affected less commonly in many conditions or injuries the physiotherapist will concentrate on the typical problems a patient has such as pain, muscle weakness and joint restriction. These difficulties are usually more limiting initially to the patient and as they begin to settle or improve the physiotherapist can turn their attention to other problems such as lack of proprioceptive input. To fully rehabilitate the patient all aspects of normal or sporting function must be considered or rehabilitation will be incomplete.
Proprioception is very important in the arm as the arm's function is to place the hand in front of the eyes so we can watch while we do something. Precise, controlled movement must have an accurate and effective feedback mechanism to monitor the performance and correct the action to achieve the desired result. Our hands and vision working together are a key part of being able to manipulate objects and get things done. We need to know where our arm is at all times if we are going to be able to use it. I am touch typing, or trying to, a job for which I need to know where my fingers are very precisely, without looking at them most of the time.
Physiotherapists test proprioception in the upper limbs by instructing patients to close their eyes whilst their affected arm is placed in a position which the physiotherapist chooses. Then the patient is told to try and position their arm in a posture which mimics the one the physio has set as closely as they can. Good joint position sense means that accurate reproduction of the position is relatively easy. The physiotherapist will be able to interpret the results of the test and estimate any deficit in the patient's proprioception.
Proprioception has a different function in the lower body as the pelvis and the lower limbs are adapted for weight bearing and locomotion. A loss of joint position sense in the legs can be very disabling as it interferes with our ability to balance and walk. This is illustrated very clearly by a patient of mine who had multiple sclerosis and who told me that he had trouble managing in the dark.
My patient recounted a situation which has probably occurred to many of us: we go into a toilet and the light is already on but as we lock the door we turn the light off automatically. For us the solution is easy, we just turn the light on again. For him it was more difficult. Because he was denied the visual feedback he needed by the darkness he fell over. His nervous system could not accurately tell him where his legs were so he had no idea whether they were bent or straight and could do nothing to correct any change in their position.
The physiotherapist might check the accuracy of the patient's proprioception by asking them to place the leg in a position which they set, as in the arm test above. But more practical for the leg is to test the joint position sense in weight bearing and functional positions. The physiotherapist will observe the patient's gait and this might be obviously abnormal, at least partly due to proprioceptive loss. If the loss is less obvious then the physiotherapist will test their balance with their feet placed together, moving on to one leg standing and even to standing on one leg with the eyes shut.
Physiotherapy treatment to increase joint position sense includes steadily more challenging work for the limb whilst carefully watching with eyes. As the patient improves they are taught to rely more and more on the information flowing in from the ligaments, muscles and joints to correct their movements. Weight bearing through the joint can increase the position sense and this is used to progress the treatment, teaching the brain pathways to reinforce the patterns for coordinated movement. Continued improvement is possible by continuing the exercises given by the physiotherapist but there may be some long term restriction.