A previous article has identified the importance of joint position sense and here we move on to considering the assessment of a deficit and what the physiotherapist is likely to do about it. The physio will very likely concentrate on the problems the patient has most commonly after trauma or illness, namely muscle weakness, loss of joint mobility and pain. Once these are responding to treatment the physiotherapist will consider whether proprioceptive treatment is required. Complete rehabilitation of the patient to their normal activities, whether sporting or functional, cannot occur without retraining the body's nervous and joint systems to accurately receive, interpret and act on proprioceptive inputs.
Our arms are designed for one main function, to position our hands in a functional posture in front of our vision so we can see our activity and correct it. An effective and accurate feedback loop is necessary so we can assess the results of our efforts in real time and re-design our motor activities to get us closer to our goal. A major part of being human is being able to manipulate the world with our incredibly precise hands and detailed binocular vision. Understanding where our individual hand joints are at any one time is vital if we are going to use them effectively. Touch typing, which I am doing now, is a skill for which I must be certain where my hands are and where my fingers are going next.
Upper limb proprioception can be tested by the physiotherapist getting the patient to shut their eyes and then by putting their good arm into a specific position. Once the position has been set by the physiotherapist the patient is asked to put their other, affected, arm into the same position as closely as possible. A person whose joint position sense is unaffected can mirror position of one arm by using the other, very accurately. Any deficits in the ability to understand the position of the arm joints will be apparent after this test.
Proprioception in the legs and lower body is adapted for a different use than in the arms, lower body function being concentrated on bearing weight and walking. The disability from loss of proprioception in the legs can be very damaging as it affects independent mobility and balance. A good illustration of this problem is demonstrated by a multiple sclerosis patient I used to treat who had problems when it was dark.
My patient recounted a situation which has probably occurred to many of us: we go into a toilet and the light is already on but as we lock the door we turn the light off automatically. For us the solution is easy, we just turn the light on again. For him it was more difficult. Because he was denied the visual feedback he needed by the darkness he fell over. His nervous system could not accurately tell him where his legs were so he had no idea whether they were bent or straight and could do nothing to correct any change in their position.
Physiotherapy assessment of the joint position sense can be performed by practical physical tests. The same test as performed on the arms, mimicking the position of one limb by using the other, can be used by more typical tests are performed in weightbearing. Checking the patient's gait can give valuable clues as to what deficiency in proprioception is present. If there is a less clear deficit testing can take the form of asking the patient to maintain their balance in steadily more difficult conditions. Feet together, balancing on one leg and then with the eyes shut is a possible progression.
Physiotherapy treatment to increase joint position sense includes steadily more challenging work for the limb whilst carefully watching with eyes. As the patient improves they are taught to rely more and more on the information flowing in from the ligaments, muscles and joints to correct their movements. Weight bearing through the joint can increase the position sense and this is used to progress the treatment, teaching the brain pathways to reinforce the patterns for coordinated movement. Continued improvement is possible by continuing the exercises given by the physiotherapist but there may be some long term restriction.
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