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Don’t Neglect to Propriocept!

“Well, I was walking and I heard somebody call my name and when I turned to look back I kind of hit a rise in the concrete on my next step and boom, I wrenched my back!”

You’ve likely had a patient gingerly walk into your office with this story or a similar one; the patient “stepped funny” and “wrenched” their back. As a conscientious health-care practitioner you assessed their biomechanical and postural peculiarities, managed their pain, performed the necessary adjustments, perhaps even dutifully prescribed some core strengthening/stabilizing (S/S) exercises, and hopefully after a minimal number of visits pronounced then ‘able’ and sent them on their way. But was that enough, what happens when they return with a similar complaint?

I have had more than a few occasions when a concerned chiropractor, under the auspices of requesting that I create a core S/S regimen, has sent me a patient who seems to keep tweaking his/her back. While in all likelihood the patient’s core could indeed be better trained to provide more spinal assistance, the root instigator of the re-occurring injury quite often can be traced to poor proprioceptive abilities.

Let’s take a quick look at what we mean by propriocpetion: Our success or failure as functioning bipeds depends to a large degree on our ability to harness the full capacity of our Nervous System (NS). If we choose to look at how the NS is distributed throughout our bodies we might – and considering it’s effect – do well to think about a physical intelligence or a wise body…and a wise body is a body that is capable of a wide spectrum of functional movement, has good NS sensitivity and speed. And knows how to avoid injury.

NS sensitivity begins with Proprioception. The proprioceptors are tiny nerve cells located in joints, ligaments, skeletal muscle and connective tissue. They act to monitor the degree and rate of displacement and stretch in muscles and joints and report to the Central Nervous System (CNS) on body positions and movement in space. The information they provide is processed in the spinal chord and transferred into motor commands that tell muscles how and when to contract. This feedback system is constant, is fundamentally essential to physical function and performance and in this system, the proprioceptors are the building block of movement. I find it helpful if I imagine that the NS is a super-sophisticated, ultra complex, high-speed phone network, sending messages back & forth at warp speed.

So let’s explain this system using our sore-back patient: Our patient looked back over his shoulder and stepped onto a rise in the ground. His/her foot rotated further than expected, the mechanical pressure (ground force reaction in this case) awakens the proprioceptors in the ankle and hips, and these cells in turn phone up the spinal cord at warp speed and report their position and motion. The spinal chord using that information, quickly holds a conference call with other sensory neurons, integrates their information and forms an action plan. It then initiates the plan by dialing up individual muscles and orders them to contract/relax in a precise order, perhaps something along the lines of; “Hey, Rectus Abdominus, I need you to contract quickly and stabilize in the transverse plane…and you, calf muscle, contract a bit longer and ‘yo!’ quadriceps, ease back on your contraction on the next step!” If this all goes as it should and our spinal chord has received information in time, our patient makes the necessary subconscious corrections, is balanced, and continues along his/her merry way. However, if our patient’s proprioceptors are lethargic and phone up to late, then the entire process is impaired, our walker is off balance, stumbles and has wound up sitting glumly in your office…again.

If the communication process works smoothly, if our bodies are “wise”, the end result is graceful movement and has the quality we call balance. Balance, in effect, is a physical communication skill. However, if one’s proprioceptors aren’t up and running, or haven’t been take off the shelf and used lately, they may be sluggish and may be late in sending off their early-warning notices up the spinal chord and thus impair the spinal chord’s defensive plans of actions. Without proprioception, complex movement would be impossible because you wouldn’t know where your body parts are in space. Poor proprioception makes for awkward, poorly coordinated movement and greater risk of injury.

Improving proprioception is a fundamental starting place when a good Performance coach creates a training strategy for his/her athlete. It is also a critical step –after pain management and abatement – in a sound rehab strategy. The ability to propriocept, thus providing one’s nervous system with a strong sense of body part positioning & location, can help in the avoidance of injury. This ability is as vital a sense as is vision or hearing in that without good proprioception we are blind and deaf to position and movement.

Good Proprioception also correlates with our ability to heal after an injury. Absence of pain is not enough; a patient is not fully recovered until full-functioning Proprioception has been restored. Studies are now showing that healthy subjects detect limb movement and positioning better than their injured counterparts. This is significant in regards to rehabbing patients in that if a patient is slow to detect precarious movement, then they’ll be slow to issue counter-command safety measures.

Proprioceptors and their vital input precede muscular involvement. In planning an effective strategy for your patients think about movement before you think about muscles. Managing your patient’s pain matters. Adjusting their spines, limbs and necks to gain proper corporeal alignment matters. Strengthening muscles to provide stability and support matters. Improving suppleness matters. The success however, of even the most strong, stable, supple, properly aligned body is fundamentally dependent upon well functioning proprioceptors.

So what can you do? How do you include proprioceptive training in a rehab protocol? When I create programs targeting proprioceptive facilitation for my athletes or for patients that are sent to me, I try to follow the following guidelines:

Simplify: Use your imagination! The neat thing about proprioceptive training is that so long as it’s safe and your patients can perform the exercises pain-free, any balancing activity hyper-excites the proprioceptors. You don’t need fancy boards, beams and balls to facilitate proprioceptive recruitment; all you really need is gravity! Move from simple to complex. Move from holding bipedal positions to unipedal positions and while in these positions progress from eyes open to eyes closed, from head still to easy head shaking, from arms in to arms reaching. Just be sure to make the progression easy for your patients to follow.

Pressurize: The best way to wake up those sleepy proprioceptors is to pressurize the system. Our proprioceptors have evolved in response to gravity. Keep in mind we are bipeds (actually unipeds); so training the proprioceptors on our feet is the most efficient way to activate them. By simply taking a step and exaggerating the pressure on the stepping foot we hyper-excite our proprioceptors into action. The more pressure and the farther away the stepping foot is from our centre of gravity the more our proprioceptors perk up.

Globalize: We move in three planes – sagital, frontal, transverse – all the time…up, down, backward, forward, sideways, rotationally, reaching high & low, etc. I refer to this as global movement. Plan your proprioception exercises to be as global as possible. Step on one foot rotationally; reach up and across your body and close your eyes; stand on one foot and horizontally reach your arms to different positions of an imaginary clock…Turn your patients’ proprioceptors on in ways that they will actually be used!

So the next time a patient comes to see you for a second time and you’re scratching your head as to why they have been re-injured, ask yourself whether you’ve adequately addressed their ability to functionally propriocept –it may mean all the difference in the world!