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Upper Extremity
Anatomy
Proprioceptive
feedback reaches the
central
nervous
system
from
receptors
locatedin
musclesandjoints
2,3,9,14,16,17
vestibular
apparatus
in the inner
ear,17
and the
eyes.
16
Muscle and
joint
recep-
tors are
stimulated by
movements
of
the musculoskeletal
system.
2'3'914'16'17
The vestibular
apparatus
provides
in-
formation
on
whole
body position
and
is stimulated when
upright body
pos-
ture
changes.17
The
eyes
help
orientthe
head
and
body with
respect to
the
en-
vironment. Since athletes
must
attend
to
sport-related stimuli
when
perform-
ing, theyrely
on
information from
mus-
cle and
joint
receptors
and the vestibu-
lar
apparatus
to
balance and maintain
body position.
When visual
stimuli
are
removed
or are
distracting,
damaged
muscle and joint
receptors are re-
educated
to
provide
accurate
positional
information
to
the central
nervous sys-
tem.10,14,15
Proprioception
exercises
at-
tempt to
simulate
sport
situations in the
rehabilitation
setting.
Muscle
receptors are comprised of
muscle spindles
and Golgi tendon
or-
gans.?6"7 Muscle spindles
are
special
muscle fibers in
parallel with regular
skeletal muscle fibers.2"6"7 They
oc-
cur
in
larger
numbers in "skill"
mus-
cles in the hands than in "strength"
muscles in the
legs
and back.2 Muscle
spindles provide information via the
gamma feedback loop
to the
central
nervous system. This loop monitors
change in
muscle
length
and
velocity
of
contraction,2"16
providing indirect
joint position information.'7 When
skeletal
muscle
is
stimulated, muscle
spindles
are
co-activated, maintaining
tension. Decreased muscle
spindle
tension reduces
or
stops its firing.
The
gamma
feedback
loop permits rapid
error
correctionofmusculartension in
30 to
80 ms, while correction through
visual stimuli
may
take as
long
as
200
ms.16
Golgi
tendon
organs
are located
in
tendons
near
the musculotendinous
junction
and in
series
with the
muscle
fibers.
They
monitor
muscle
tension
with
firing
rate
escalating
with
in-
creased muscle
tension.
Excessive fir-
ing
rates
from
Golgi
tendon
organs
cause a
reflex decrease
in
muscle
ten-
2,16,17
Proprioceptive
Training
Jennifer A.
Stone,
MS,
ATC
Nina B.
Partin, MS,
ATC
Joseph
S.
Lueken, MS,
ATC
Kent E.
Timm, PhD,
ATC, PT,
FASCM
Edward
J.
Ryan,
III,
MS,
ATC
Abstract:
Proprioception
following
lower
extremity injuries is commonly
recommended, but there is little in-
formation
on
proprioception
training
following
upper extremity injuries.
No
studies
have
evaluated whether
proprioception
programs
forathletes
in
open
kinetic
chain activities
(throwing, shot
putting)
should
be
different than programs
for athletes
in closed kinetic chain
activities
(gymnastics,
swimming,
kayaking,
or
rowing). In thispaper, we
provide
a
rationale for
proprioception
train-
ing
for upper extremity injuries in
athletes
and the
importance of
ana-
lyzing
the
athlete's
sport and activity
forspecificity ofproprioception
exer-
cises.
We
then discuss
one
popular
proprioception exercise,
rhythmic
stabilization, and
propose several
additional
upper extremity
proprio-
ception e-xercises,
alongwith
instruc-
tions
for
the
athletic
trainer
on how
to
directthe athlete
through these ex-
ercises.
P roprioception training
is an es-
sential
part
of
any
rehabilita-
tion program
to return an ath-
lete
to
preinjury performance levels.
Special
proprioception exercises
are
a
relatively new addition
to sport
re-
habilitation
but have been
an integral
part of programs for patients
with
brain and spinal cord injuries.5
There are two essential parts of
proprioception: the "body's ability
to vary contractile forces of muscles
in
immediate
response to outside
forces"2 and the "sense that tells the
brain which position the limb is in at
any moment in time."
15
Exercises
for range of motion, muscular
strength and endurance, and cardio-
vascular
endurance aid redevelop-
ment
of proprioception
by contract-
ing
muscles and moving joints,
but
athletes
require specific
propriocep-
tion exercises to regain full
muscu-
loskeletal
and athletic
function.'
Recurrent joint instability is either
mechanical
or functional, existing sep-
arately
or
together. With capsular or
ligamentous laxity,
the
joint
is mechan-
ically
unstable due to nonfunctional
supporting structures. Muscular weak-
ness
can also
cause mechanical
insta-
bility since
the musculature crossing
the
joint
cannot hold the
joint
in posi-
tion. The third
cause
of
instability
is
lackof
proprioceptive feedback,
a
func-
tional
instability, causing
an
uncoordi-
nated muscular response to motion
and/or
stress. A
functional
instability
does
not
necessarily
connote a
mechan-
ical
instability,
and muscular weakness
does
not
necessarily
cause a
functional
instability.8
11 18
Jennifer
A. Stone
is Manager
of Internal
Programs in the
Sports
Medicine Division
of the US
Olympic
Committee
at
Colo-
rado
Springs,
CO 80909.
Nina
B.
Partin
is
an
athletic trainer
in Na-
cogdoches,
Tex
and Joseph
S. Lueken is
an
athletic trainer
at
Indiana University
in
Bloomington,
IN.
Edward
J.
Ryan
is Manager
of
External
Programs in the Sports Medicine Division
of the US
Olympic
Committee
at Colo-
rado
Springs.
Kent E. Timm
is Director of Sports Med-
icine
at
St. Luke's
Sports
Medicine
in
Saginaw,
MI.
sion.'
Journal of
Athletic
Training
15
Joint
receptors
are
located in
joint
capsules, ligaments, fat pads, and
pe-
riosteum of the various joints of the
body.
29"14"16"17
As these
structures
are
deformed by motion, joint
recep-
tors
are
stimulated, signaling joint
position and
movement
over
the
en-
tire
range
of motion.17 Joint
recep-
tors
complement information from
muscle spindles and Golgi tendon
or-
gans
by directly registering joint
mo-
tion.16
No single
receptor
provides all the
information
needed
by
the central
nervous
system to
evaluate
posture
and
body position. Input
from
mus-
cle and
joint
receptors,
vestibular
ap-
paratus,
and the
eyes
is
synthesized
for total
body position
information.17
muscular endurance, and/or
muscular
stegh2,4,7,19
Exercise 1-Rhythmic Stabilization
The athlete positions his/her
upper
extremity anywhere in its available
range
of motion and
holds
an
isomet-
ric contraction. The athletic
trainer
provides enough resistance
to
cause
the athlete
to react,
but
not
enough
to
break the isometric contraction.19
As
the
athlete
progresses,
length of time
of rhythmic stabilization increases,
athletic trainer resistance increases,
and
amount
of
contact
area
between
athletic trainer's hands and athlete's
upper
extremity decreases.
Analyze
Activity
The specific activity and
sport
the
athlete is returning
to must
be
ana-
lyzed for specificity of
propriocep-
tion exercises. If athletes normally
use
the
upper
extremity in
an open
kinetic chain fashion, such
as
throw-
ers
in various
sports,
volleyball play-
ers,
basketball
players, and weight
lifters, the proprioception
program
should
emphasize
open
chain
exer-
cises,
such
as
rhythmic
stabilization
at
multiple positions
in
the
range
of
motion and the first
two
exercises
listed below.
If
the athlete
uses
the
upper
extremity
in
a
closed kinetic
chain fashion,
as
in
gymnastics
where he/she
is
weight bearing,
or
in
swimming, canoeing, rowing, or
kay-
aking
where
the body is moved
over
the
stationary hand (swimming)
or
extension
of the hand (canoeing,
rowing,
or
kayaking), proprioception
exercises
should be performed
in
that
manner.
Such exercises involve bal-
ancing
or
moving
on a
trampoline,
wobble board,
or
slide board with
eyes
closed, analogous
to
lower
ex-
2,3,10,12,15
Exercise 2-Mirroring
Upper
Extremity
Move the
uninjured
upper
extrem-
ity passively
to
various positions in
the available
range
of motion. Ask
the
athlete
to
duplicate this position
with his/her injured
upper
extremity,
first with
eyes open,
then closed. If
he/she misses the position, he/she
opens
his/her
eyes
and
actively dupli-
cates
the desired
position. Concen-
trate movement
on
the
injured
area,
ie, focus
on
shoulder positions for
athletes with shoulder
pathology,
el-
bow positions for elbow pathology,
and
so on.
Perform 10
to
20
repeti-
tions of
varying positions
5
to
10
times
daily. Use isokinetic testing
equipment
with
an
electrogoniometer
for
exact
joint position
measure-
ments,
if
desired.18
Rationale
Proprioception retraining following
lower extremity injuries
is
commonly
recommended 1-3,6,10,12-14
but there is
little information
on
proprioception
training following
upper
extremity
in-
juries, especially
in athletes.4
7'18
No
studies have evaluated whether
prop-
rioception
programs
for athletes
in
open
kinetic chain
activities,
eg,
throwing
or
shot
putting,
should
be
different than
programs
for
athletes in
closed
kinetic chain
activities,
eg,
gymnastics, swimming, kayaking,
or
rowing.
Injuries requiring
surgery
and/or
periods
of immobilization
tend
to
have
larger proprioceptive
deficits
due
to
time loss and decreased
use.2
Current
injury
management,
there-
fore,
encourages
early, protected
motion whenever
possible.12
As
mentioned
earlier,
musculoskeletal
motion stimulates muscle
and
joint
receptors
in the
injured
area,
main-
taining
a
limited
neurological
re-
sponse
of these receptors.
Rehabilitation
programs
begin
with
restoration of
range
of
motion,
mus-
cular
endurance,
and muscular
strength.
These
exercises,
in
a non-
specific fashion,
stimulate
joint
and
muscle
proprioceptors
in
the
injured
extremity.2 Proprioceptive
neuromus-
cular
facilitation exercises
(PNF), by
their
design,
contribute
to
propriocep-
tionwhile
developing
range
of
motion,
tremity
exercises. In
con
trast to
lower
extremity propriocep-
tion
training,
closed kinetic chain
upper
extremity proprioception
exer-
cises
appear
later in the rehabilitation
program
due
to
the
amount
of
strength required
to
support
body
weight
on
the
injured extremity.
Exercise
3-Duplicating Position,
Injured
Upper
Extremity
Move
the injured
upper
extremity
passively
to
a
position
within its
available
range
of
motion, then
re-
turn
it
to
its
resting position. Again,
emphasize positions
in the
injured
area.
Then,
ask the athlete
to
ac-
tively duplicate
the
movement,
first
with
his/her
eyes open,
then
closed.
If
he/she
misses the
position, he/she
opens
his/her
eyes
and
actively
moves
to
the desired
position.
Per-
form 10
to
20
repetitions
of
varying
positions
5
to
10 times
daily.
Exercises
Open
kinetic chain
proprioception
exercises
begin
when
range
of
mo-
tion and
pain permit.
One
popular
proprioception
exercise for the
upper
extremity
is
rhythmic
stabilization.
No other
open
kinetic chain
exer-
cises
are
reported
in
the literature.
We
are
proposing
several additional
upper
extremity proprioception
exer-
cises. The exercises
move
from
open
to
closed kinetic chain. If
an
athlete
does
not
use
his/her
upper
extremity
in
a
closed kinetic chain
fashion, the
progression
finishes with
open
ki-
netic chain exercises.
Exercise 4-Double
and
Single Arm
Balancing
Have
the athlete balance
with
both
hands
on
the
floor,
a
wobble board
(Fig 1), and finally
a
trampoline (Fig
16
Volume 29
*
Number
1 * 1994
strength.2''"
from right to left in the frontal plane
(Fig3), then
movethe
athleteparallel
to
the Fitter and rock it back and forth in
the sagittal plane (Fig 4). Next,
move
the athlete so that he/she is
at a
450
an-
gle to the Fitter and rock it
on
that di-
agonal.
Repeat on the
other diagonal.
Progress through the four
body
posi-
tions
as
in
Exercise 3.
As
the athlete
progresses,
decrease the number of
re-
sistancecords
ontheFitter,
making
the
platform more unstable. Startwith one
repetition of 15 seconds and extend
to
three to five repetitions of
60
seconds
each.
Fig
1.-Eyes
open, double arm bal- Fig 2.-Eyes open, single arm balance
ance in
kneeling push-up position
on
in push-up position on trampoline.
wobble board.
Exercise 6-Ball Balancing
Have the athlete balance
on
his/her
hands on a
48-inch
Gymnastikball®
(Ledragomma, Italy), first with
eyes
open, then closed
(Fig 5). Progress
from both hands
on one
large
ball
to
each
hand
on
separateballs and then
to
the
injured
arm on
one
ball.
Also,
prog-
ress through the four body
positions
as
in Exercise 3. Use
a
spotter,
especially
when
doing
this exercise for the first
time or changing body positions, since
the
athlete may
fall
off
the
Gymnastik-
ball®.
Start with
one
repetition of
10
seconds
and
progress
to
three
to
five
repetitions of
60
seconds each.
These exercises help
redevelop
proprioception
in athletes
with
inju-
ries
to
the upper
extremity.
The last
2). Progress
through the
following
body positions, first with eyes open,
then
closed. Start
in the
quadruped
position
and
progress
to
kneeling
push-up, full push-up,
and
finally
feet-elevated (feet
level
or
higher
than
shoulders) positions. Also,
move
from balancing
on
both hands
to
balancing
only on the injured
hand.
Initially,
perform each balance
for 15
seconds
and
gradually extend
to 60 seconds. Perform 5 to 10 repe-
titions
three
to five times
daily.
Exercise
5-Fitter®
Have the athlete "stand" on the Fit-
ter
(Stack Enterprises,
Calgary, Al-
berta, Canada)
on
his/her hands.
Move
through the following
body
positions
first
with eyes open, then with eyes
closed. Stabilize
the
Fitterwith
four re-
sistance
cords
and position the athlete
perpendicular
to
it.
Rock
the Fitter
Fig 3.-Eyes
open,
Fitter®
balance
in
push-up position
with
platform rocking
in
the frontal
plane.
Fig
4.-Fitter® balance
in
push-up
position
with
platform rocking
in
the
saggital plane.
Journal of Athletic
Training
17
"w-f
44r
A-01
k,
AW
.4
niques in Sports Medicine. St. Louis, MO:
Times Mirror/Mosby College Publishing;
1990:331-341.
7. Janda DH, Loubert P. A preventive
program
focusing
on
the glenohumeral joint. Clin
Sports Med. 1991;10:955-971.
8. Karlsson J, Andreasson GO. The effect of
ex-
ternal ankle
support
in chronic lateral ankle
joint instability. Am J Sports Med.
1992;20:
257-261.
9.
Kennedy JC, Alexander IJ, Hayes KC. Nerve
supply of the human knee and its functional
importance. Am J Sports Med. 1982;10:329-
335.
10. Kulund DN. The Injured Athlete. Philadel-
phia, PA: JB Lippencott; 1982:527-528.
11. Lentell GL, Katzman LL, Walters MR. The
relationship between muscle function and
an-
kle stability. J Orthop Sport Phys Ther. 1990;
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12. Maddalo A, Walter JF. Rehabilitation of foot
and ankle linkage
system.
In: Nicholas JA,
Hershman EB, eds. The LowerExtremity and
Spine
in
Sports Medicine. St. Louis, MO:
The
CV Mosby Company; 1986:560-583.
13. Markey KL. Functional rehabilitation
of the
anterior cruciate ligament deficient knee.
Sports Med. 1991;12:407-417.
14. Markey KL. Rehabilitation
ofthe anterior
cru-
ciate
ligament deficient knee. Clin Sports
Med. 1985;4:513-526.
15. Riehl R. Rehabilitation of lower leg injuries.
In:
Prentice WE, ed. Rehabilitation Tech-
niques
in
Sports Medicine.
St Louis, MO:
Times Mirror/Mosby College Publishing;
1990:316-330.
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17. Schmidt
RA.
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IL:
Human Kinetics Books; 1991:
47-48.
18. Smith RL, Brunolli J. Shoulder kinesthesia af-
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Ther.
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tive
NeuromuscularFacilitation: Patternsand
Techniques. Philadelphia: Harper & Row,
Publishers; 1985;302-303.
--I
Fig 5.-Eyes
open,
Gymnastikball®
balance in feet-elevated
position.
three
exercises
are
especially
useful
for athletes who
use
the
upper
ex-
tremity
in
a
closed
kinetic chain fash-
ion
and become
more
challenging
through
the
progression
from
eyes
open
to
eyes
closed
and
through
the
various body positions.
This
paper was
funded
through
grants
provided by
the
National
Ath-
letic
Trainers' Association and Bax-
ter
Healthcare.
sponses
to
lateral perturbation in healthy sub-
jects and ankle sprain patients. Med Sci Sport
Exerc. 1992;24:171-176.
2. Day RW, Wildermuth BP. Proprioceptive
training
in
rehabilitation of
lower
extremity
in-
juries.
In:
Grana WA, Lombardo JA, Sharkey
BJ, Stone JA, eds. Advances
in
Sport Medi-
cine and Fitness. Chicago, IL: Year Book;
1988:241-257.
3. Derscheid
GL,
Brown
WC. Rehabilitation of
the ankle. Clin Sports Med. 1985;4:527-544.
4. Dilorenzo CE, Parkes JC, Chmelar RD. Im-
portance
of shoulder and cervical
dysfunction
in etiology and
treatment
of athletic
elbow
in-
juries.
J
Orthop SportPhys Ther. 1990;11:402-
409.
5.
Griffin
JW. Use of
proprioceptive
stimuli in
therapeutic exercise. Phys Ther.
1974;54:
1072-1079.
6. Hunter
SL.
Rehabilitation of ankle injuries.
In: Prentice WE, ed. Rehabilitation Tech-
References
1.
Brunt D, Andersen JC, Huntsman B, Reinhert
LB,
Thorell AL, Sterling JC. Postural
re-
18
Volume
29 *
Number
1 * 1994
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