Five Evidence-Based Ways to Hone Proprioception
Published on the 06 July 2017
Published on the 06 July 2017
Ever been reading a really stellar book, sitting at the beach, drinking a canned soft drink?
You’re lost, engrossed in your novel and never once look down at that drink.
Yet, without fail, your arm drops down, your hand cups, your fingers lightly grip that can of fizz and the perfect number of actin-myosin cross bridges activate to bring that drink to lips.
There isn’t a jerk or a tremor or a single carbonated drip. Your body functions like a machine. You have just operated at the pleasure of your body’s well-honed proprioceptive loops.
Day to day, most of us do not take a second thought about proprioception. Just as you might never consider your breathing patterns (until now), you never once pondered your body’s position in the world today (ditto) (Mortola et al. 2016). But all this bliss can change in a minute.
When something — some injury or traumatic event — inhibits bodily awareness, it can make life miserable until rectified. But, you might ask, is it even possible to train proprioception?
Proprioceptive training can be easily broken into 5 different categories of techniques (Aman et al. 2014). Each of these categories contains a wide variety of treatments — everything from simple balance training to magnetic stimulation. With such a wide playing field of treatments, the question must be asked: do any of these actually work?
When you think of training proprioception, active movement and balance training are probably the first type of interventions that come to mind.
Balance training (especially) remains an ever-popular technique for many different applications. These kinds of proprioception training programs require the patient to actively move limbs, segment of limbs or whole body. Although often simple, these interventions offer a high success rate and user-friendly nature that makes them appealing for many patient goals, such as reducing the fear of falling (Kumar et al. 2016).
There seems to be no end to the kind of balance training programs which have been studied. Entire programs have been designed based on exotic Latin dances (without the stars, presumably) (Sofianidis et al. 2016), horseback riding, and even slacklining (Donath et al. 2016) (balancing over narrow nylon ribbons – yes, people can do it, but to what end?)
In an interesting twist, researchers recently looked at what happens when the balance training regimes implemented are not simple — and instead are designed to push patients to the limits of their capacities (Leavy et al. 2017). A 2017 study described how Parkinson’s patients responded to being “maximally challenged in a secure and supportive group environment, circumstances that stood in contrast to participants’ everyday lives.” How did they respond? Well, they liked it.
Although ‘passive movement’ seems like an oxymoron, repetitive passive movement, can also greatly improve proprioception. This type of training occurs when an apparatus or machine is used to move the body instead of the patient.
In some cases, even robots can be used to effectively administer this type of training (Furnari et al. 2017). Although therapy might not be the first thing that pops to mind when you think about robots, robot-guided passive movement can improve mobility and motor-function in patients with neurological disorders.
These techniques can also be used for decreasing pain during other training interventions. In patients with bilateral scapular downward-rotation, passive correction treatment was used to do just that (Ha et al. 2011). The treatment improved their active movements by decreasing the pain they felt during the motion. Not only did these patients report decreased pain, but they also found an improvement in their range of motion.
Passive movement regimes can make a great place to start with a patient who might not be ready or able for active movement training.
Electrical and magnetic stimulation, acupuncture, and vibration all are examples of training interventions that use somatosensory stimulation to aid proprioception (Wang et al. 2017).
While some types of somatosensory stimulation training are still experimental in nature, there has been increasing research on the effects of these interventions.
As just one example of how somatosensory training can improve quality of life, consider gait training. Many patients post-stroke may struggle with gait disorders for years post-event. However, something as simple as vibration therapy can help immensely with such problems, even after a significant amount of time has passed.
After participating in an intervention in which vibrators were affixed to their limbs, patients found significant improvement in their gait (Sueyoshi et al. 2017). Imagine how a small, simple device such as this can be added to a pre-existing gait training plan to improve a patient’s quality of life.
It now appears that the most effective training programs include somatosensory stimulation as a key component. Incredibly, some forms of somatosensory stimulation (for example whole body vibration) have demonstrated dramatic results within a single session or a few hours of intervention; because of this, these interventions should never be ignored in the clinic (Aman et al. 2015).
Take the previous training category just one step further and you will come to somatosensory discrimination training (Aman et al. 2015).
These interventions use opposing somatosensory stimuli to test the patient’s ability to differentiate between them. You might have a patient explore different objects with their hand, discriminate between textures, or gauge the position of their wrist or ankle joints.
This type of training has an interesting ability to help clinicians differentiate between diagnoses. Take for example multiple-system atrophy (MSA). While it is notoriously difficult to distinguish between MSA and Parkinson’s disease, somatosensory discrimination can make muddy waters clearer. Patients with MSA had greater difficulty distinguishing between two tactile stimuli applied to their skin than the patients with Parkinson’s disease (Rocchi et al. 2013).
Somatosensory discrimination is even making a showing in the low back pain literature (Kälin et al. 2016).
It would be a safe bet to assume if two types of training were effective, combining them could give your patients compounded results. Although there are fewer studies on the effects of combined systems, there is evidence to believe this assumption of efficacy is true.
In fact, combining training systems can improve daily life, postural control, and might even have a chance to decrease fall risk in the elderly (Kristinsdottir & Baldursdottir 2014).
There no longer appears to be any doubt that training programs can improve proprioception. There is a growing consensus about the type, duration, applicability and scope of proprioceptive training (Aman et al. 2014).
Rule of thumb? Active movements provide a more significant training effect, although a combination of active and passive movements (with and without the provision of exteroceptive feedback) show the largest improvements.
Treatments which last longer routinely show greater improvements in proprioceptive outcomes, with regimens lasting greater than 6 weeks demonstrating the greatest significance; however, there is no “meeting of the minds” on what an ideal training dosage should be.
Finally, keep in mind that proprioceptive training is not a single-trick pony. It is not effective for the “neurological” population alone, nor for the gymnast, nor the surgical patient. Proprioceptive training appears to favor a single population most: those who are willing to try it.
Andrea Salzman, MS, PT graduated from the University of Alabama at Birmingham with a Master’s degree in physical therapy in 1992. Over the last two decades, she has held numerous prominent leadership roles in the physical therapy field, with a heavy emphasis on academic writing and administrative functions. Between 1995 and 1998, Salzman served as the Editor-in-Chief of an American Physical Therapy Association (APTA) journal. In 2010, Salzman received one of the highest honors given to a physical therapist from the American Physical Therapy Association, the Judy Cirullo Leadership Award. Between 2012 and the present, Salzman has written 12 physical therapy courses for Care2Learn, Relias Learning and reviewed over 100 other course offerings. Currently, Salzman continues in her writing, leadership and administrative roles at Aquatic Therapy University and 10K Health.