Improving patient responses to body stresses impacting healthy lifestyle
Proprioception is a sense that lets us perceive position, balance and changes in equilibrium on the part of the musculoskeletal system of the body. The human body is equipped with several independent yet interrelated mechanisms to sense and provide this critical information.
Specialized nerve endings present in the soft tissues of the musculoskeletal system interact with the central nervous system to coordinate body movements, postural alignment and balance.
Sensory information highway
Some proprioceptive sensory organs are located in muscles and tendons, while others are within the connective tissues of joints.
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. If any of these sensors begins to transmit false or incorrect information, there is a decrease in movement efficiency, which can have a damaging effect on joints and muscles.
There is the potential for postural problems that can range from just annoying to painful or even hazardous to health.
Data transmission errors
Chronic postural problems — Position receptors in the feet, spine and especially in the neck (head-righting reflexes) must coordinate smoothly to maintain postural equilibrium. Difficulty in achieving or keeping optimal postural alignment, or problems with excessive postural sway, are often caused by inaccurate information sent by spindle sensors in chronically strained muscles or by joint mechanoreceptors.
Post-whiplash headaches and vertigo — More than 30 years ago, researchers demonstrated the involvement of spinal (especially upper cervical) proprioceptors in the various symptom patterns found in post-whiplash patients.1 Complaints associated with problems involving position sensors include: tension headaches, disequilibrium, vertigo, persisting muscle tension and myofascial pain.2 It is apparent that treatment methods that address the proprioception system must be included for recovery.
Chronic pain syndrome — A 2015 study of patients with chronic neck pain found most had significant improvements in cervical proprioception and reduction in pain after upper thoracic and cervical manipulation.3 Many patients with chronic myofascial complaints can be shown to have inappropriate stimulation arising in the joints or muscles in the region.
Athletic performance — Performance in sports is directly determined by the status and coordination of the proprioception system. Injury prevention, return-to-activity rehabilitation, and even winning depend a great deal on how smoothly and quickly the musculoskeletal system can respond to position, speed and balance changes. Many of the currently popular approaches to improving sports performance (such as plyometrics) are based on training and developing proprioceptive responses.5
Getting back on the fast track
Many of the more recent (and some very traditional) treatment approaches to musculoskeletal problems take advantage of proprioceptive concepts.
It has been shown that joint manipulation, especially of the spinal joints, has a direct and immediate effect on receptor responses.6 A small study in humans found that specific spinal manipulation was much more effective than a series of stretching exercises in improving the proprioceptive repositioning of the head in patients with chronic neck pain and positioning problems.7 Another study found that specific spinal manipulation effectively treated a series of patients who demonstrated cervicogenic vertigo (90% became symptom-free).8
Certain soft-tissue techniques, such as kinesiological and myofascial approaches, have been found to be effective in normalizing the balancing capabilities of the position receptors. Trigger-point therapy (using ischemic compression, spray and stretch, or injections) seems to be able to correct imbalances in muscle tone and tension that are perpetuated by sensory receptor problems.9
The more effective stretching maneuvers take advantage of our recent knowledge of the proprioceptive responses in the muscles and joints. A list of some of the more popular procedures includes:
- Active release (Leahy technique)
- Contract-relax (CRAC)
- Muscle energy techniques
- Postisometric relaxation (Lewitt technique)
- Proprioceptive neuromuscular facilitation (PNF)
By activating and coordinating the muscle spindles and the mechanoreceptors, these stretching procedures can be very effective in chronic cases.10
Speeding up the process
Patients with proprioceptive imbalances often benefit from various external supports to help them achieve proper body positioning.
These include custom-made, flexible three-arch orthotics for the foot and ankle that align and balance the entire body from its foundation, cervical pillows for chronic neck pain, and chair supports to provide alignment of the back during sitting.11
It’s important that the custom orthotics and cervical pillows are chosen by the patient’s chiropractor based on a thorough assessment of their individual needs and lifestyle for the most effective care. A study showed that use of custom three-arch orthotics reduced back pain by 34.5% and improved function by 32.3% when combined with chiropractic care.12
Advances have been made in methods for strengthening postural muscles based on our knowledge of proprioception. Since postural (especially back and neck) muscles are tonic, slow-twitch muscles, we must use slow and controlled exercises in an upright position to stimulate and normalize input from position receptors.
In fact, closed-chain exercising (whether stretching or strengthening) is being used much more frequently in sports and rehabilitation. By keeping the body upright and weight-bearing during exercising, all the proprioceptors are recruited to condition the muscles and joints. This provides rapid and appropriate neuromuscular learning experience, and allows the skills practiced then to be used in functional everyday and sports-specific situations.
Two areas in which this approach is seen are 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 often can help in normalizing inappropriate receptor input. Even more specialized proprioceptive exercises use gym balls,12 balance and rocker boards,13 and even special “balance shoes.”14 These recognize the complexity of the interconnections between the upper cervical receptors and information from the visual and oculomotor system, and from the vestibular/labyrinthine system.
Proprioception is sometimes referred to as “the silent sixth sense.” At every level, these proprioceptive systems are well-integrated with the motor systems they serve, making them fundamentally critical to managing our daily activities, impacting whether we maintain a healthy lifestyle.
CHRISTINE FOSS, DC, MD, MS. Ed, ATC, DACBSP, DACRB, ICSC, has a master’s degree in sports medicine from Old Dominion University, a Doctorate in Chiropractic from New York Chiropractic College and a Doctor of Medicine degree from the University of Health Sciences. She is a Certified Athletic Trainer, Diplomate of the American Chiropractic Board of Sports Physicians, Diplomate American Chiropractic Rehabilitation Board and an Internationally Certified Sports Chiropractor.
She is currently director and lead instructor of the New York Chiropractic College “Certified Chiropractic Sports Physician” program, Education Chair for Federation Internationale de Chiropractique du Sport and Director of Education for Foot Levelers. She has worked with Team U.S.A. Track and Field, men’s gymnastics and World Games as a medical staff member. She can be reached at drcfoss@gmail.com or @drchristinefoss.
References
- Vertigo due to whiplash injury: a neurotological approach. Acta Otolaryngol (Stockh) Suppl 1985;419:9-29. Hinoki
- Treleaven J, Peterson G, Ludvigsson M, Kammerlind A, Peolsson, A. Balance, dizziness and proprioception in patients with chronic whiplash associated disorders complaining of dizziness: A Prospective randomized study comparing three exercise programs. Man Ther 2016 Apr:22:122-30
- Yang J, Lee B, Kim C. Changes in proprioception and pain in patients with neck pain after upper thoracic manipulation. J Phys Ther Sci 2015 Mar; 27(3): 795-798
- Tantanatip A, Chang K. Myofascial Pain Syndrome. Stat Pearls Publishing, 2022 Jan
- Huang P, Jankaew A, Lin C. Effects of Plyometric and Balance Training on Neuromuscular Control of Recreational Athletes with Functional Ankle Instability. Int J Environ Res Public Health 2021 May: 18(10): 5269.
- Reed W, Long C, Kawchuk G, Pickar J. Nuerall responses to the mechanical parameters of a high velocity, low amplitude spinal manipulation: effect of preload parameters. J Manip Physiol Ther. 2014 Feb; 3792): 68-78.
- Rogers RG. The effects of spinal manipulation on cervical kinesthesia in patients with chronic neck pain: a pilot study. J Manip Physiol Ther1997;20:80-85.
- Fitz-Ritson D. Assessment of cervicogenic findings. J Manip Physiol Ther1991;14:194-198.
- Travell JG, Simons DG. cit., p. 204.
- Kofotolis N, Kellis E. Effects of two 4-week proprioceptive neuromuscular facilitation programs on muscle endurance, flexibility, and functional performance in women with chronic low back pain. Phys Ther2006;86(7):1001-1012.
- Travell JG, Simons DG. cit., p. 593.
- Cambron JA, Dexheimer JM, Duarte M, Freels S. Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2017 Sep;98(9):1752-1762. doi: 10.1016/j.apmr.2017.03.028. Epub 2017 Apr 30. PMID: 28465224.
- Oslance J, Liebenson C. The Proprio System. Los Angeles: Proprio Systems, 1995:28.
- Miller AS, Narson TM. Protocols for proprioceptive active retraining boards. Chir Sports Med1995;9:51-55.
- Janda V, Vavrova M. Sensory motor stimulation. In: Liebenson C, ed. Rehabilitation of the Spine. Baltimore: Williams & Wilkins, 1996:319.