June 2007

The importance of proprioceptive re‑training in spinal rehabilitation

by Dr. Charles Annunziata

Are you giving your patients the best possible care when it comes to spinal rehabilitation? Before answering that question look at this scenario.

A patient suffers a whiplash injury and presents to your office with neck pain. After ruling out any fractures or instabilities, we would first reduce the neck pain using specific pain reducing techniques such as electric stimulation, ice, adjustments, myofascial release, or cold laser therapy just to name a few. Once the pain was 75 % reduced, we would introduce some passive stretching to restore flexibility and gradually move into active and PNF stretching as the patient shows improvement. Finally, we would build strength in the neck muscles through resistant range of motion techniques. How would you rate our rehabilitation? Did we address all of the key points? If you said "yes," read on!

Although our treatment plan above was thorough, we did not address restoring the injured joint's proprioception. Proprioception is the ability to sense the position, location, orientation, and movement of the body and its parts in relation to each other without the aid of visual and touch sensations. Sensory input from mechanoreceptors, located in joints, tendons, muscles, and ligaments is processed by the CNS to form internal models of body configuration, which is proprioception. The CNS uses these internal models for planning and correction of motor commands. Injury to a joint not only results in a mechanical disturbance, but also in a loss of joint sensation due to deafferentation of these peripheral mechanoreceptors rendering the joint functionally unstable.

Unfortunately, when we think of an injured joint we usually think of a larger distal joint such as a knee or an ankle. We need to recognize that an injury to the spine, such as whiplash, is actually like an ankle sprain/strain to each one of our spinal joints in that area. In fact, the spinal joints are enriched with more mechanoreceptors than a distal joint, such as the ankle, and require even more attention to restoring proper proprioception.

Studies have shown that the level of proprioception can be adversely affected by injury, such as whiplash and if not addressed properly may increase the risk of a re‑injury to that area in the future. Patients suffering a whiplash injury displayed difficulty in head repositioning tasks compared to a non‑injured group as well as reduced proprioceptive acuity in the shoulder (Sjolander et al. 2004). Many studies have also showed an increase incidence in ankle re‑injury when rehabilitation techniques did not address proprioception re‑training (Verhagen et al. 2004).

Proprioceptive re‑training will not only help restore function to a joint and decrease the chances of re‑injury, but will also aid in patients who have reached a plateau in their rehabilitation and still suffer with chronic pain. Neurophysiologic studies have linked pain development in the lumbar spine region of the vertebral column with disturbances in the mechanoreceptors and probably with impairment of the superior proprioception centers. Therefore, exercise programs that enhance proprioception may be beneficial for managing chronic low back pain (Yamashita et al 1990).

Introducing proprioception re‑training into your normal spinal rehabilitation treatment program is easy and affordable using wobble boards, swill balls, or any exercise that puts the patient into a simulated position of vulnerability while in a controlled and progressive manner. Some examples may be standing on a wobble board and rocking back and forth, or sitting on a swiss ball while performing pelvic tilts, or even lying prone on a swiss ball while performing cross crawl exercises with your arms and legs. There are countless numbers of exercises that can be performed to increase proprioception to injured joints. I recommend software called Phases Rehab (phasesrehab.com) to learn more about these exercises.

Restoring proprioception after an injury is critical to restoring the sensory capabilities of a joint essential for detecting motion and position and improving its functional stability. Implementing proprioceptive rehabilitative techniques into your practice will surely take your care to the next level.

(Dr. Charles Annunziata is a national lecturer with DC Seminars and speaks on such topics as Myofascial Release Technique,, Rehabilitation of the Spine, and Clinical Documentation. DC Seminars provides both live and on‑line approved continuing education seminars throughout the country. For more information, go to dcseminarsinfo.com or contact Dr. Annunziata at 800‑897‑2476.)