Proprioceptive Training for upper Extremities

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Proprioceptive Training for upper Extremities

• Types of exercises used for upper extremity
  proprioceptive training
• 1- Balance training. One major category of
  proprioceptive exercise is balance training.
  These exercises help to train the proprioceptive
  system in a mostly static activity. Activities or
  exercises in weight bearing using unstable
  supporting surface, profitter, swiss ball,
  balance board are example of balance training in
  the upper extremity.

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• Figure 8 Left, Eyes open, Fitter balance in
  push-up position with platform rocking in the
  frontal plane. Right, Fitter balance in push up
  position with platform rocking in the sagittal
  plane.

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• Figure 9 Eyes open, Gymnastic ball balance
  feet-elevated position

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• 2. Kinetic chain exercises . Open-chain manual
  resistance exercises with rhythmic stabilization
  (Figure 6) are also considered proprioceptively
  enriched. In either case, resistance can be
  modified, depending on pain, as the patient
  progresses

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• Figure10 Rhythmic stabilization (A physical
  therapist provides resistance in all planes of
  movement for upper extremity strengthening. These
  maneuvers activate mechanoreceptors in multiple
  planes, stimulating proprioceptive pathways, and
  are especially helpful in treating rotator cuff
  tendonitis.)

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• Quadruped stabilization on a balance
  board(Figure 11)
  
• Four closed-chain exercises have been described
  to stimulate co-activation in the shoulder
  pushups, horizontal abduction on a slide board,
  and tracing circular motions on a slide board
  with the dominant and nondominant arms (Figure
  12). These exercises accommodate for the
  individual's tolerance to joint loads by
  progressing from a quadruped to a push-up
  position

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• Figure 11 Dynamic shoulder stabilization in all
  four position but with one hand on a wobble board
  and the other hand held off the floor. The
  shoulder girdle is challenged as the patient
  tries to keep the edge of the wobble board from
  touching the floor.

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• Fig. 12 Dynamic stabilization exercises for the
  upper extremity. A, Push-ups. B, Horizontal
  abduction on a slide board

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• Wall push-ups (Figure 13)are also useful and can
  be proprioceptively enhanced by having a physical
  therapist or resistance band provide resistance
  to the patient's back.

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• 3- Sport-specific maneuvers. Rehabilitation is
  incomplete until maneuvers specific to the sport
  and the athlete's position in the sport can be
  performed maximally and without pain or loss of
  function.
• Starting sport-specific maneuvers with weighted
  resistance (eg, swinging a weighted tennis racket
  or baseball bat), Functional positions, "such as
  overhead throwing, should be incorporated and
  are more sport-specific (Figure 14).

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• Fig. 14 Active and passive repositioning
  activities should be performed in functional
  positions specific to individual sports.
•  

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• 4. PNF (Proprioceptive neuromuscular
  facilitation) These techniques may be defined as
  methods of promoting or hastening the response of
  the neuromuscular mechanism through stimulation
  of the proprioceptors. Emphasis is placed on the
  application of maximal resistance through out the
  range of motion, using many combinations of
  motions in a pattern format. Motion is first
  performed in the strongest part of the range,
  with progression toward the weaker parts of the
  range of motion. The patterns used are spiral and
  diagonal in character and closely resemble the
  movements used in sports and in occupational
  activities. (Figure 15 and Figure 16)

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• Figure 15 Extension adduction internal rotation
  pattern of PNF Left or right shoulder exercise.
  Patient is in a supine position. With the
  therapist standing at left or right side of
  patient. (A) The exercise should start on the
  right side. The arm should be entirely straight
  throughout the patterns, keeping the elbow stiff.
  The patient's hand is grasped with your right
  hand when you are standing on the right side.
  Your left hand should support the patients elbow.
  (B) You can start with either the upward or
  downward diagonal. As the patient moves the arm
  into extension internal rotation, the guideline
  should be anterior iliac crest. As the patient
  moves the arm up and out (flexion external
  rotation), the diagonal angle should be
  maintained in the opposite direction from the
  anterior iliac crest. It should be noted that the
  adduction can be added to the extension internal
  rotation pattern and that the abduction can be
  added to the flexion external rotation pattern.
  This exercise is repeated 10 times, with some
  resistance in both diagonal directions.
  

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• Figure 16 Flexion adduction external rotation
  pattern of PNF Left or right shoulder exercise.
  Patient is in a supine position. (A) Starting on
  the right side, you should keep the patient's
  elbow stiff. With your right hand, you grasp the
  patient's hand. With your left hand, you support
  the elbow. Our landmark will be the nose and its
  opposite diagonal. (B) Exercise is begun either
  up and in- or down and out. When going up and in
  toward the nose (flexion external rotation
  adduction), you must remember to keep the elbow
  stiff. When going down and out (extension
  abduction and internal rotation), you can follow
  the opposite diagonal from the nose. The pattern
  and rhythm should be kept. This exercise is
  repeated 10 times in each direction with some
  resistance. (It is important to always be careful
  not to administer too much resistance, only what
  each individual can handle through the fullest
  range.)

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• 5- Plyometrics. It is a quick powerful movement
  involving pre-stretching of a muscle, followed by
  a shortening cycle. The stretch shortening cycle
  occurs when elastic loading, through a quick
  eccentric muscular contraction, is followed by a
  burst of concentric muscular contraction. (Figure
  17)

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Fig. 17 Plyometric exercises
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• 6- Ballistic stretching uses the momentum of a
  moving body or a limb in an attempt to force it
  beyond its normal range of motion. This is
  stretching, or "warming up", by bouncing into (or
  out of) a stretched position, using the stretched
  muscles as a spring which pulls you out of the
  stretched position, (Fig. 18)

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Proprioceptive Training for Lower Extremities

• Proprioceptive training improves a patient's
  static and dynamic equilibrium. The static
  proprioceptive re-education is begun when
  patients proceed to weight bearing without
  crutches and consists of six stages
• 1-Recovery of sense of body position muscle
  contraction and joint movement.
• 2-Transition from bilateral to unilateral
  activities
• 3-Transition from eyes-open to eyes-closed
  activities.
• 4-Transition from activities on a stable support,
  such as the ground, to unstable surfaces, such as
  a soft mattress, a trampoline and Freeman's
  boards, or more modern equipment, such as the
  kinesthetic ability trainer
• 5-Throwing and catching a football to take the
  patient's mind off active control of his balance.
• 6-Balance recovery exercises are carried out
  different joint positions to evoke different
  responses from the tendon and muscle receptors.

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• An unstable platform promotes reactive muscle
  activity when an athlete attempts to balance and
  a clinician manually perturbs the platform. These
  exercises can facilitate adaptations to reflex
  pathways mediated by peripheral afferents,
  resulting in reactive muscle activation.

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• Proprioceptive exercise on the kinesthetic
  ability trainer

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• "Kickers" use an elastic band fixed to the distal
  aspect of the involved or uninvolved limb. The
  athlete attempts to balance while executing short
  kicks with either knee extension or hip flexion.
  This exercise is most difficult when performed on
  unstable surfaces.

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• The dynamic proprioceptive re-education
• The dynamic proprioceptive re-education is
  indicated for patients needing to resume sports
  that involve running, jumping, landing, sudden
  changes of direction and twisting movements.
  During such sports, athletes are obviously able
  to lose and then regain balance, and avoid falls
  and accidents that might occur by adjusting their
  posture so as to execute harmonious movements in
  a necessarily brief space of time
  

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• Early dynamic joint stabilization exercises begin
  with balance training and partial weight bearing
  on stable surfaces, progressing to partial weight
  bearing on unstable surfaces. Balancing on
  unstable surfaces is initiated once full weight
  bearing is achieved. Exercises such as "kickers"
  also require balance and can begin on stable
  surfaces, progressing to unstable platforms.
  

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• Eccentric loading is accomplished by activities
  such as forward and backward stair climbing or
  backward downhill walking. Strength and balance
  exercises can be combined and executed with light
  external forces to increase the level of
  difficulty.
  

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• Plyometric activities such as low-impact hopping
  may commence once weight bearing is achieved
  Double-leg bounding is an effective intermediate
  exercise, because the uninvolved limb can be used
  for assistance. Stretch-shortening exercises are
  a necessary component for conditioning the
  neuromuscular apparatus to respond more quickly
  and forcefully, permitting eccentric deceleration
  then developing explosive concentric
  contractions.
  

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• The dynamic proprioceptive re-education consists
  of seven stages-
• 1- Slow exercises followed by quicker movement
• 2- Exercise with limited effort followed by
  exercisesrequiring greater strength
• 3- Exercises requiring volition, followed by
  exercisesdone freely
• 4- Progress from walking to jogging
• 5- Running and sprinting
• 6- Jumping and changes of direction
• 7- Twirling and twisting around the injured or
  operated knee

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• Balance and control proprioceptive exercises
• 1.    Stand on one leg.    2.    Stand on one
  leg with eyes closed.    3.    Stand on one leg
  throw and catch a ball.    4.    Stand on one
  leg bend and straighten knee    

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• 5.    Stand on one leg- pick up item from
  floor.   
• 6.    Hold knee dip throw and catch a ball.
• 7.    Stand on one leg move other leg to side,
  front and back.  
• 8.    Push up onto toes (2 legs) and hold.  
• 9.   Push up onto toes with eyes closed.   
• 10.   Push back onto heels, balance and hold.
• 11.   Push up on toes on one leg.     

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• Walking proprioceptive exercises
• 13.    Walk forward along a straight
  line. 14.    Walk on tip toes along straight
  line.  15.    Walk backwards along straight
  line.16.    Side step along straight
  line.  17.    Walk sideways crossing one foot
  over other (Cariocas).  18.    Walk fast in one
  direction, quickly changing direction at
  intervals.

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• Running proprioceptive exercises
• 19.    Run fast in one direction.    20.    Run
  backwards and do sidesteps.    21.    Fast
  crossovers (Cariocas).    22.    Run in figure
  of eight make it smaller and smaller.    

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• 23.    Hopping on spot.    24.    Hop forwards
  and backwards stop between hops.    25.    Hop
  in zigzags.    26.    Hop on and off
  step.    27.    Do triple jump - run, hop, jump
  and land.

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• Balance and strength exercises are combined by
  incorporating light external forces and
  increasing the level of difficulty for balancing
  while strengthening the muscles required for
  dynamic stabilization

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Figure
16 The Fitter is useful for weight shifting
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• Plyometrics begin with low-impact hopping,
  progressing to double-leg bounding, and finally
  single-leg hopping.