Negative effects of altered proprioception

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THE NEGATIVE EFFECTS OF ALTERED PROPRIOCEPTION

1) Asymmetrical loading and altered range of motion

Cassidy, D.C., Ph.D. Journal of Manipulative and Physiological Therapeutics. 1991; 15(9): 570-575. Adjustments increased cervical range of motion and reduced pain more effectively than did mobilization. The mechanism by which spinal manipulation works is not certain. There is no evidence that it reduces subluxation or that minor positional misalignments are of clinical significance. It is more likely that SM exerts a reflex effect on pain and muscle tension. Mechanical stimulation of joint capsule proprioceptors and muscle spindles can result in reflex inhibition of pain, reflex muscle relation and improved mobility.

Herzog, Ph.D. Journal of Manipulative and Physiological Therapeutics. 1991; 14(2): 104-109. Post adjustment improvement in the biomechanics of walking, Chiropractic quantitatively improved the symmetry of load distribution so that patients were indistinguishable from a normal population.

Haldeman, D.C., Ph.D., M.D. Backletter 1994; 9(11): 125. Tremendous outcomes research effort combined with an impressive level of organization on the part of doctors of chiropractic has transformed the reputation of manipulation over a 2 decade span. Outcome research has led to the legitimization of a treatment that was regarded medically as quackery 20 years ago. No other back pain prescription has been subjected to such examination. The evolution of this treatment from the fringes of health care to one of primary consideration is a triumph of science and research over dogma and opinion. When all 54 trials are considered together, the evidence in favor of manipulation as a treatment for back pain is overwhelming.

Seamen, Ph.D. Chiropractic Research and Review Journal. 1993; 2(3): 33-38. Post adjustment improvement in symmetry of load distribution as measured by dual scales after 12 weeks of care: 12.84 pounds to 3.67 pounds.

Purpose of proprioception: Provide awareness of position sense and kinesthesia. Produce coordinated reflex effects on muscle tone and balance. Provide peripheral feedback so the central nervous system can design and modify effective motor programs.

Wyke, M.D. Aspects of Manipulative Therapy. 1985: 67-71. Patterns of normal proprioceptive input are profoundly distorted when articular nociceptive activity is added. This interferes with the precise continuous input necessary for coordinated multisegmental reflexes, which are required for normal patterns of motion, balance, coordination and equilibrium.

Nansel, Ph.D., Slazak, D.C. Advances in Chiropractic 1994; 373-415. Joint capsule proprioceptors connect with gamma-motoneurons and can alter the sensitivity of muscle spindles causing disturbances in muscle tone and restrict motion. Gapping of the joint by spinal manipulation induces a sudden burst of capsular afferent activity, which can cause reflex decreases in muscle tone allowing for an increase in joint movement. Postural muscles (multifidi, rotatores, etc.) can sustain contractions for long periods. Asymmetries in their contractile state can account for asymmetries of range of motion. The sudden stretch of muscles by spinal manipulation causes increase in tension stimulating golgi tendon receptors to inhibit alpha-motoneurons, relaxing muscles. Such changes in muscle activity can last for hours, sometimes days.

1) Abnormal muscle tone.

Nyland, M.Ed., P.T., ATC. JOSPT. 1994; 19(1): 2-11. The mechanoreceptors in ligaments and joint capsules influence gamma-motoneurons and modulate muscle activity and joint stabilization. Failure or destruction of mechanoreceptors’ ability to provide feedback contributes to unpredictable “giving way” and may result in progressive degenerative changes of joints and muscle atrophy. Proprioceptors provide postural and kinesthetic sensation to the sensory regions of the cerebral cortex allowing the brain to make informed decisions for effective motor programs. Afferent input enables motor program changes based on information provided by changes in body position.

Dietz, (Dept. Neurology and Neurophysiology). Physiology reviews. 1992; 72(1):

33-69. Afferent input influences central motor programs. Proprioceptive input from

muscles and joints are required to adjust the motor program by modulating muscle electromyographic activity.

Bullock-Saxton, Ph.D. Spine. 1993; 18(6): 704-708. Problems with the motor regulatory system may be related to impaired proprioceptive input and consequent dysregulation of the central nervous system. Stability and improved motor control can occur through sensorimotor stimulation.

Johansson, (Dept. Physiology) Neuro-Orthopedic. 1990; 9: 1-23. An injured joint is likely to cause persistently disturbed sensory feedback to the central nervous system and therefore existing motor programs have to be modified. Sensory receptors in the joint can influence muscle tone. This produces an interdependence between biomechanical and neurological mechanisms.

Janda, M.D., In Grieve (ed.). Modern Manual Therapy of the Vertebral Column; Churchill Livingstone, Edinburgh, 1986: 197-201. Altered proprioception from joints plays an important role by influencing muscles. Altered proprioception from injured joints changes the coordination between muscles, altering movement patterns, resulting in poor control of posture and movement.

Kirkaldy-Willis, M.D., Cassidy, D.C., Ph.D.: Canadian Family Physician. 1985; 31: 535-540. Articular mechanoreceptor stimulation has a reflexogenic effect on motor unit activity in the muscles operating the joint. Stretching the facet joint capsules can reflexively inhibit facilitated motoneuron pools, which are responsible for the increased muscle excitability and spasms that commonly accompany low back pain. In more chronic cases, there is shortening of periarticular connective tissue and intra-articular adhesions may form. We believe in some cases, manipulation will stretch or break these adhesions. Through these mechanisms spinal manipulation can break the cycle of pain, muscle spasm and immobility.

Nansel, Ph.D., Slazak, D.C. Advance in Chiropractic 1994; 373-415. Joint capsule proprioceptors connect with gamma-motoneurons and can alter the sensitivity of muscle spindles altering muscle tone and joint motion. Gapping of the joint by spinal manipulation induces a sudden burst of capsular afferent activity, which can cause reflex decreases in muscle tone allowing for an increase in joint movement. Postural muscle can sustain contractions for long periods. Asymmetries in their contractile state can account for asymmetries of range of motion. The sudden stretch of muscles by spinal manipulation causes increase in tension stimulating golgi tendon receptors to inhibit alphamotoneurons, relaxing muscles. Such changes in muscle activity can last for hours, sometimes days.

Thabe, M.D., Manual Medicine. 1986; 2: 53-58. Spinal manipulation applied to restricted atlanto-occipital joint results in an immediate disappearance of spontaneous activity in the oblique capitus superior muscle. With spinal manipulation this is more rapid than either anesthetic applied to the joint capsule or to the muscle directly.

Goff, Ed.D. Chiro: Journal of Chiropractic Research and Clinical Investigation. 1991; 7(1): 4-9. Cervical adjustment reduced frontalis muscle tone by 27%. The frontalis is a good indicator of general muscle tone. Adjustment may reduce general muscle tone.

2) Joint Stability

McLain, M.D. Spine 1994; 19(5): 495-501. Articular proprioceptors respond primarily to the extremes rather than to the mid ranges of joint motion. They may initiate protective muscular reflexes important in preventing joint degeneration and instability. Altered mechanoreception has a direct effect on reflex activity of muscle crossing the joint. Joint deafferentation may accelerate degenerative changes. Disturbance of articular innervation may play a role in the development of degenerative and inflammatory diseases and joint dysfunction.

Freeman, M.D. Ankle Sprain. Journal of Bone and Joint Surgery. 1965; 47B(4): 678-685. Forces strong enough to damage ligaments damage nerve fibers, which have lower tensile strength. Results in partial joint deafferentation and functional instability. Wobble board exercises provide sensorimotor facilitation and improve balance and sensorimotor control. Ankle sprain not only damages the lateral ligaments but also damages proprioceptors, nerve fibers which run in the ligaments leading to partial joint deafferentation and instability. Muscles need proprioceptive input in order to perform in a coordinated fashion needed for joint stability.

Zimny, (Dept. of Anatomy). American Journal of Anatomy. 1988; 182: 16-32. Joint and muscle receptors detect limits of movement of a joint and play a role in synchronizing mechanisms involved with control of movement. The densities of mechanoreceptors are greater in areas related to extreme movements. Mechanoreceptors are the first line of defense in sensing the safe limits of range of motion of a joint. Discharges provide the central nervous system with information about possible joint injury. This input activates reflex mechanisms that act to prevent joint injury.

Nyland, M.Ed., P.T., ATC. JOSPT. 1994; 19(1): 2-11. The mechanoreceptors in ligaments and joint capsules influence gamma-motoneurons and modulate muscle activity and joint stabilization. Failure or destruction of mechanoreceptors’ ability to provide postural and kinesthetic sensation to the sensory regions of the cerebral cortex allowing the brain to make informed decisions for effective motor programs. Afferent input enables motor program changes based on information provided by changes in body position.

Michelson, M.D., Hutchins, M.D. Journal of Bone and Joint Surgery. 1995; 77-B(2) March: 219-224. Type III mechanoreceptors provide sensation at the extremes of movement and act to alert the central nervous system of imminent danger to the joint. Ligaments provide more than structural support. Sensory output from ligaments aids in controlling muscle stiffness and coordination, thereby increasing joint stability. Mechanoreceptors influence gamma motoneurons output, and thereby, the discharge of alpha motoneurons, enhancing muscle contractility. At the extremes of motion, mechanoreceptors elicit protective reflexes to prevent injury to the joint.

4) Coordination, balance and strength.

Gowitzke, Ph.D., Milner, Ph.D. Scientific Bases of Human Movement. Williams and Wilkins, 3^rd edition. 1988. Proprioceptors bring about the cooperation and coordination among muscles effectively. By exciting various proprioceptors, contraction of any muscle tends to organize other muscles to cooperate with it.

Freeman, M.D. and Wyke, M.D. British Journal of Surgery, 1967; 54(12): 990-1001. Articular mechanoreceptors along with descending projections from the brain stem reticular system help determine the coordination and degree of gammamotoneron activity in muscles working a joint. Mechanoreceptors directly influence segmental and intersegmental reflex coordination of muscles. Indirectly, they exert control through supra-segmental projections to brain stem, cerebellum and cortex.

Lauro, D.C. Chiro: Journal of Chiropractic Research and Clinical Investigation, 1991; 6(4): 84-87. Evaluated the effect of spinal manipulation on athletic ability in a group of 50 completely asymptomatic athletes. Result: In randomized trial, the control group improved overall 405% at 6 weeks, 8 of 11 test scores improved, 3 declined. Significant improvement occurred in only 2 of 11 tests. In the adjusted group all 11 tests scores improved, none declined. At 6 weeks overall improvement was 10.57% or 2.35 times better than control group. 20 of 24 athletes were adjusted an additional 6 weeks and were 16.7% better than at baseline at that point. Chiropractic quantitatively improved agility, balance, sped reaction time, kinesthetic perception, and power. How? I. Identify and correct altered biomechanical patterns of activity which if not corrected leads to a) decreased mechanical efficiency, b) increased energy expenditure; c) decreased performance, d) altered load distribution, e) increased risk of injury. Normalize proprioception and fine motor tuning.

Abrahams, (Dept. Physiology). In: Garlick D 9^th ed.). Proprioception, Posture, and Emotion. Committee in Postgraduate Medical Education, Kensington, New South Wales, 1982: The evidence that the neck plays a critical role in posture is overwhelming. Muscle receptors may be of great importance in sensing joint position. A characteristic of neck muscles is an abundance of muscle spindles. The spindle density in a large muscle of the neck range from 46-106 / gram, among the highest of anywhere. High spindle density is characteristic of muscle executing fine motor control. The abundance of afferent information may not only be due to fine motor control. Polysynaptic pathways from neck muscle afferents to neck motoneurons are powerful. Afferents leaving neck muscles can exert profound effects on hindlimb motoneuron excitability. The neck structures are unusually rich in receptors. Small muscles close to the cervical vertebrae may have up to 500 muscle spindles / gram, a density almost 100 times as great as some muscles of locomotion and 5 times greater than the large dorsal neck muscles which are regarded as spindle rich. These deep structures play an important role in reflexes and maintenance of posture and provide precise information with respect to position.

Wolf, Ph.D. Journal of Geriatric Society, 1996; 44: 489-497. 2 new studies find elderly patients taking Tai Chi to improve their balance and reduce their number of falls. Tai Chi uses slow graceful and precise body movements to improve both balance and body awareness. Study found 15-week program reduced their rate of falls by 47.5%.

Loudon, Ph.D., PT et al. Ability to Reproduce Head Position after Whiplash. Spine, 1997; 22(8): 865-868. 11 symptomatic whiplash patients (within the past 2 years but greater than 3 months) and 11 age matched asymptomatic controls tried to reproduce various positions of the cervical spine: 30 and 50 degrees of rotation and 20 degrees of lateral bending left and right using a CROM. “Neutral” position was also assessed. Results: Whiplash patients were less accurate in reproducing the angles. Average differences in whiplash patients were 5.01 vs. 1.75 degrees in controls. Whiplash patients possess an inaccurate perception of head position secondary to their injury. Injury of mechanoreceptors in the cervical spine with whiplash has profound effects on postural reflexes. With pain and muscle inflammation there’s inhibition of gamma-motoneuron discharge and information from muscle spindles is inaccurate, altering proprioceptive sensibility. Whiplash patients also had an impaired ability to reproduce a neutral head positions. Whiplash patients may have proprioceptive deficits that do not allow them to accurately calculate head position. Coordination activities and proprioceptive retraining can have positive effects on kinesthetic awareness after injury. Rehabilitation after whiplash should focus not only on range of motion and strength but also on postural awareness.

Janda, M.D., In Grieve (ed.). Modern Manual Therapy of the Vertebral Column; Churchill Livingstone, Edinburgh, 1986: 197-201. Altered proprioception from joint plays an important role by influencing muscles. Altered proprioception from injured joints changes the coordination between muscles, altering movement patterns, resulting in poor control of posture and movement.

Kirklady-Willis, M.D., Cassidy, D.C., Ph.D.: Canadian Family Physician. 1985; 31: 535-540. Articular mechanoreceptor stimulation has a reflexogenic effect on motor unit activity in the muscles operating the joint. Stretching the facet joint capsules can reflexively inhibit facilitated motoneuron pools, which are responsible for the increased muscle excitability and spasms that commonly accompany low back pain. In more chronic cases, there is shortening of periarticular connective tissue and intra-articular adhesions may form. We believe that in some cases, manipulation will stretch or break these adhesions. Through these mechanisms spinal manipulation can break the cycle of pain, muscle spasm and immobility.

5) Degeneration.

Bogduk, M.D., Ph.D. In Grant Review. Physical Therapy of the Cervical and Thoracic Spine. (2^nd ed.). New York, Churchill Livingstone, 1994: 65-76. There is no known mechanism whereby nociceptive afferents can be selectively affected by lesions that cause root compression. Such lesions indiscriminately affect both large diameter afferent fibers (touch, vibration and proprioception) and small diameter fibers (nociceptive). Both compression and ischemia affect large diameter fibers sooner than small.

Lephart, Ph.D., ATC et al. American Journal of Sports Medicine. 1997; 25(2): 130-137. Proprioceptive neuromuscular control influences 3 levels of motor activation in the central nervous system. 1) Spinal reflexes provide reflex muscular stabilization of joints-Dynamic Stabilization. 2) Brainstem motor control integrates input from joint mechanoreceptors, vestibular centers and visual input to maintain posture and balance. 3) Highest levels of central nervous system function-provides cognitive awareness of body position and kinesthesia needed for control of voluntary movements. Encouraging maximum afferent discharge to these levels of the central nervous system must be the goal in stimulating joint and muscle receptors. The abnormal sequencing of muscle firing can cause asynchronous neuromuscular activation patterns that may predispose articulations to overuse trauma. Loss of normal synchronization of firing patterns can alter joint kinematics resulting in repetitive microtrauma.

Nyland, M.Ed., PT, ATC. JOSPT. 1994; 19(1): 2-11. The mechanoreceptors in ligaments and joint capsules influence gamma-motoneurons and modulate muscle activity and joint stabilization. Failure or destruction of mechanoreceptors’ ability to provide feedback contributes to unpredictable “giving way” and may result in progressive degenerative changes of joints and muscle atrophy. Proprioceptors provide postural and kinesthetic sensation to the sensory regions of the cerebral cortex allowing the brain to make informed decisions for effective motor programs. Afferent input enables motor program changes based on information provided by changes in body position.

Gunn, M.D. Clinics in Sports Medicine. 1985; 4(3): 417-429. The quality and precision of motor performance is partly determined by information received from proprioceptors in the joints and surrounding tendons and ligaments. Immobilization dampens proprioceptors discharge. Loss of feedback control may be the cause of reinjury to the same joint.

Charcot’s Joint. Cecil Textbook of Medicine. 1985: 1958. The result of a chronic progressive degenerative arthropathy in which impairment of proprioception and pain deprives the joint of the normal protective reactions that ordinarily modulate the forces of weight bearing and motion leading to severe destruction and disorganization of the involved joint.

Gottlieb, M.S., D.C. Journal of Manipulative and Physiological Therapeutics, 1997; 20(6): 400-414. Tissues of synovial joints are inherently susceptible to the development of degenerative joint disease if the range of motion or magnitude of loading on articular cartilage is excessive. Joint ligaments, capsules and articular surfaces are not adequate to withstand many of the forces that threaten joints. Much of the joint protection is conferred to a dynamic system of coordinated muscle activity – a protective muscular reflex that prevents injury to a joint by preventing it from exceeding its normal range of motion. The central nervous system is informed by receptors when the limits of motion are about to be exceeded and responds to that sensory information is unable to inform the central nervous system when the normal limits of excursion are about to be exceeded and thus, the joint can be over stressed, leading to breakdown. The nervous system plays an important role in the survival of joints.

Bishop, D.C., Ph.D., M.D. Journal of Manipulative and Physiological Therapeutics, 1993; 16(5): 300-305. If joint mechanics are altered, the cells (chondrocytes and fibroblasts) responsible for biosynthesis of proteoglycans will be stimulated to change the composition of the extracellular matrix to produce connective tissue better suited for the new mechanical demands. In a joint that has been severely injured the connective tissue may change sufficiently to permanently alter the function of the joint and thus predispose to premature degeneration and or further injury. By the same mechanism, maintaining normal joint mechanics may act to prevent premature degeneration and or joint injury.

6) Aberrant sensory input and resultant aberrant motor programs.

Young, M.S. Survey on Ankle Sprains. British Journal of Sports Medicine, 1994; 28(2): 112-116. Previous studies found 67.3% of football players and 70% of basketball players had sprained ankles. 26.5% of athletes surveyed had a history of one ankle sprain, 51.5% had a history of 2 to 4, and 22% had a history of 5 or more ankle sprains.

Guyton, M.D., Textbook of Medical Physiology (9^th ed.). WB Saunders, Philadelphia 1996; 714. The vestibular apparatus detects the orientation and movements only of the head. Therefore, it is essential that the nervous centers also receive appropriate information depicting the orientation of the head with respect to the body. This information is transmitted from the proprioceptors of the neck and body directly into the vestibular and reticular nuclei of the brain stem and also indirectly by way of the cerebellum. By far the most important proprioceptive information needed for the maintenance of equilibrium is that derived from the joint receptors of the neck.

Wyke, M.D. Neurology of Cervical Joints. Physiotherapy, 1979; 65(3): 72-76. Electrical or mechanical stimulation of 1 C3-C4 facet joint results in a coordinated pattern of motor responses in all 4 extremities including the rectus and biceps femoris, biceps and triceps brachiaii.

Norre, M.D. Vertigo and the Cervical Spine. Medic Physica, 1986; 9: 183-194. Vertigo results from a disturbance in sensory input from vestibular apparatus, eyes, and proprioceptors (especially of the neck) which renders the pattern abnormal and dysharmonic. The dysfunction of one sensor makes its signal contradictory to that of the others resulting in a sensory mismatch. Neck proprioceptors have a sensory function equivalent to vestibular function. Stimulation of neck proprioceptors produces the same ocular reflexes as does the vestibular system: Cervico-Ocular Reflex.

Hinoki, M.D. Vertigo Post-Whiplash due to Over excitation of Cervical Proprioceptors. Acta Otolaryngology, 1988; Suppl 419: 9-29. As a result of tissue injury and inflammation there is over excitation of cervical and lumbar proprioceptors. Their input produces dysregulation of the central nervous system. This is a trigger-target effect. In 68.4% of patients there is increased disequilibrium due to pulsed stimulation or saline injections applied to injured neck muscles which was reduced by a cervical collar.

Radanov, M.D. Cognitive Deficits Post-Cervical Soft Tissue Injury. Spine, 1992; 17(2): 127-131. In whiplash, functional brain stem disturbance was reported without morphologic lesions in any part of the brain. It was noted that cognitive impairment and reduced speed of information processing disappeared with the use of cervical collar or infiltration of deep neck muscles with local anesthetic. A reflex influence of proprioceptors can lead to functional brain stem disturbances.

Heikkila, M.D. Scandinavian Journal of Rehabilitation, 1996; 28: 133-138. Study of kinesthetic sensibility in 14 whiplash patients (MVA 2-3 years before) vs. 34 healthy subjects and the effects of a rehab program. Subjects were tested in terms of head repositioning accuracy. All patients had pain and decreased range of motion immediately after injury and persistent neck symptoms. Whiplash patients were significantly less precise in repositioning their heads but this improved after 5 weeks of rehab. Cervicocephalic kinesthesia is probably linked to sensory information from muscular and articular proprioception. A flexion-extension injury results in proprioceptive dysfunction either by lesioning or functional impairment of muscular and articular receptors, or by alteration in afferent integration and tuning.

Gottlieb, M.S., D.C. Journal of Manipulative and Physiological Therapeutics, 1997; 20(6): 400-414. Tissues of synovial joints are inherently susceptible to the development of degenerative joint disease if the range of motion or magnitude of loading on articular cartilage is excessive. Joint ligaments, capsules and articular surfaces are not adequate to withstand many of the forces that threaten joints. Much of the joint protection is conferred to a dynamic system of coordinated muscle activity – a protective muscular reflex that prevents injury to a joint by preventing it from exceeding its normal range of motion. The central nervous system is informed by receptors when the limits of motion are about to be exceeded and responds to that sensory information with motor signals to the muscles crossing the joint, causing appropriate muscle contraction or relaxation to protect the joint. A joint lacking this sensory information is unable to inform the central nervous system when the normal limits of excursion are about to be exceeded and thus, the joint can be over stressed, leading to breakdown. The nervous system plays an important role in the survival of joints.

Negative effects of altered proprioception

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