Ćwiczenia proprioceptywne barku.pdf

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,

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--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.

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18 Volume 29 * Number 1 * 1994

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