Posts Tagged proprioception

[ARTICLE] Assessment of the correlations between gait speed in post-stroke patients and the time from stroke onset, the level of motor control in the paretic lower limb, proprioception, visual field impairment and functional independence – Full Text PDF


Introduction: Gait recovery is one of the main objectives in the rehabilitation of post-stroke patients. The study aim was to assess the correlations between gait speed in post-stroke hemiparetic patients and the level of motor control in the paretic lower limb, the time from stroke onset, the subjects’ age as well as the impairment of proprioception and visual field.

Materials and methods: This retrospective study was performed at the Clinical Rehabilitation Ward of the Regional Hospital No. 2 in Rzeszow. The study group consisted of 600 patients after a first stroke who walked independently. The measurements focused on gait speed assessed in a 10-meter walking test, motor control in the lower limb according to Brunnström recovery stages, proprioception in lower limbs, visual field as well as functional independence according to The Barthel Index.

Results: The study revealed a slight negative correlation between gait speed and the subjects’ age (r = − 0.25). No correlation was found between mean gait speed and the time from stroke onset. On the other hand, gait speed strongly correlated both with the level of motor control in the lower limb (p = 0.0008) and the incidence of impaired proprioception. Additionally, a strong statistically significant correlation between the patients’ gait speed and the level of functional independence was found with the use of The Barthel Index.

Conclusions: The level of motor control in the paretic lower limb and proprioception are vital factors affecting gait speed and functional independence. Patients with a higher level of functional independence demonstrated higher gait speed.


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via Assessment of the correlations between gait speed in post-stroke patients and the time from stroke onset, the level of motor control in the paretic lower limb, proprioception, visual field impairment and functional independence : Advances in Rehabilitation


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[ARTICLE] A composite robotic-based measure of upper limb proprioception – Full Text



Proprioception is the sense of the position and movement of our limbs, and is vital for executing coordinated movements. Proprioceptive disorders are common following stroke, but clinical tests for measuring impairments in proprioception are simple ordinal scales that are unreliable and relatively crude. We developed and validated specific kinematic parameters to quantify proprioception and compared two common metrics, Euclidean and Mahalanobis distances, to combine these parameters into an overall summary score of proprioception.


We used the KINARM robotic exoskeleton to assess proprioception of the upper limb in subjects with stroke (N = 285. Mean days post-stroke = 12 ± 15). Two aspects of proprioception (position sense and kinesthetic sense) were tested using two mirror-matching tasks without vision. The tasks produced 12 parameters to quantify position sense and eight to quantify kinesthesia. The Euclidean and Mahalanobis distances of the z-scores for these parameters were computed each for position sense, kinesthetic sense, and overall proprioceptive function (average score of position and kinesthetic sense).


A high proportion of stroke subjects were impaired on position matching (57%), kinesthetic matching (65%), and overall proprioception (62%). Robotic tasks were significantly correlated with clinical measures of upper extremity proprioception, motor impairment, and overall functional independence. Composite scores derived from the Euclidean distance and Mahalanobis distance showed strong content validity as they were highly correlated (r = 0.97–0.99).


We have outlined a composite measure of upper extremity proprioception to provide a single continuous outcome measure of proprioceptive function for use in clinical trials of rehabilitation. Multiple aspects of proprioception including sense of position, direction, speed, and amplitude of movement were incorporated into this measure. Despite similarities in the scores obtained with these two distance metrics, the Mahalanobis distance was preferred.


Stroke is heterogeneous, affecting sensory, motor, and cognitive functions that are required for daily activities. While there are well validated tools to assess motor and speech functions (eg. Fugl-Meyer Assessment (FMA) [1], the National Institute of Health Stroke Scale (NIHSS) [2], Chedoke-McMaster Stroke Assessment Impairment Inventory (CMSA) [3]) the use of high quality, validated assessment tools for measuring sensory function post-stroke (proprioception in particular) is limited [4], and there is still a lack of a gold standard assessment. While the FMA and NIHSS have sensory components to the assessment, they are seldom used as a sole measure of sensory impairment in research studies focused on sensation as they are based on relatively coarse scales. Yet, sensory and proprioceptive impairments have a significant negative impact on functional recovery following stroke [56789]. Individuals with sensory and motor impairments, compared to those with just motor impairments, have longer lengths of hospitalization and fewer discharges home [101112]. Furthermore, it has recently been shown that motor and proprioceptive impairments can occur independently after stroke [13].

Some commonly used clinical assessments of proprioception post-stroke include: 1) simple passive limb movement detection test [14] in which an examiner moves a subject’s limb segment with their eyes closed, and subjects are asked to say which direction the limb was moved; 2) the Revised Nottingham Sensory Assessment [1516] in which the subject is asked to mirror match the movement of a passively moved limb by a therapist; and 3) the Thumb Localizing Test [17] which involves passive movement of a subject’s arm and hand to a random position overhead, and is followed by subjects reaching to grasp their thumb with the opposite (less affected) hand. These assessments are scored crudely as normal, slightly impaired, or absent, and lack the sensitivity to detect smaller changes in proprioceptive function in part due to poor inter- and intrarater reliability [1819]. Therefore, establishing an objective and reproducible method to assess proprioceptive impairments post-stroke is vital to evaluating the efficacy of different treatments.

Other more advanced methods to assess proprioception have been developed [20212223], with many using robotic technology to measure the kinematics of an individual’s movements. Assessment devices can now measure position sense and kinesthetic impairments after stroke using arm contralateral matching [13242526], in which a subject’s affected arm is passively moved by the robot to a position, and the subject mirror-matches the movement/position with their less affected limb. Another paradigm involves passive movement of a subject’s limb to a specified position, returning the limb to the starting position, and then having subjects actively move the same arm to this remembered position [2126]. This method has an advantage in that it does not require interhemispheric transfer of information, but has limited value in assessing people with concurrent motor deficits, or in assessing kinematic aspects of proprioception, such movement speed and amplitude perception. Further, results can be confounded by problems with spatial working memory. Threshold for detection of passive movement paradigms have also been used to assess proprioception [2728]. This paradigm eliminates confounds due to motor impairment and interhemispheric transfer of information but again, little information about the kinematics of movement perception (e.g. speed or direction) are gained from this task, and it typically takes much longer to complete than position/movement matching. Lastly, Carey et al. [20] have developed and validated a wrist position sense test, where a subject’s wrist is moved to a position (wrist flexion or extension) and without vision of the wrist the subject has to use their other arm to move a cursor to the direction the wrist is pointing. This method minimizes confounds due to interhemispheric information transfer and motor deficits, but again does not provide information about kinesthetic impairments.

Many of these assessments are reliable, reproducible, objective, and provide quantitative measures of proprioceptive function in the upper limbs. Dukelow et al. [1324], used a KINARM robot (BKIN Technologies, Kingston, ON), and detailed a contralateral position-matching task for the upper extremities that can measure various aspects of an individual’s position sense including: absolute error, variability in matching positions, systematic shifts in perceived workspace, and perceived contraction or expansion of the workspace. Similarly, Semrau et al. [25] recently detailed a kinesthetic matching task using the KINARM robot that can measure an individual’s ability to mirror-match the speed, direction, and amplitude of a robotically moved limb [825]. These tasks are reliable [24], and provide numerous parameters that describe an individual’s position or kinesthetic sense impairments and can be used to guide a rehabilitation program tailored to the individual. Furthermore, these studies have shown a strong relationship between proprioceptive impairments and functional independence post-stroke, yet proprioceptive impairments are often not addressed in day-to-day therapy. Reliable and quantitative assessment tools are therefore critical for testing the efficacy of rehabilitation treatments, as in clinical rehabilitation trials.

While multiple kinematic parameters can provide a level of exactness around the nature of an individual’s proprioceptive impairments and are helpful for rehabilitation planning, a summary measure is needed for clinical therapeutic trials in rehabilitation. Thus, a single continuous metric of upper limb proprioceptive function that combines all parameters from the position and kinesthetic matching robotic tasks was developed using two common measures of distance, Euclidean distance (EDist) and Mahalanobis distance (MDist) [29]. The EDist was chosen as it is an easily interpretable calculation and considers each parameter independently. It is the square root of the sum of squared distances between data points (i.e. the straight-line distance between two points in three-dimensional space). The MDist is the next measure we used to compare with the EDist. It was chosen because the calculation accounts for correlations between parameters (by using the inverse of the variance-covariance matrix of the data set of interest), therefore preventing the overweighting of correlated parameters in the calculation. It is the distance between a point and the center of a distribution, measured along the major axes of variation (i.e. the standard deviation of an object in more than one dimension) [3031].. Because the kinematic parameters derived from the robotic tasks may demonstrate some degree of correlation with one another [13], the MDist can account for this auto-correlation. Theoretically, it should perform better at identifying stroke subjects who perform abnormally on the tasks and those who have atypical patterns of behavior relative to controls. The MDist is generally preferred over the EDist for multivariable data since it can cope with different structures of data [31].

MDist (or variants of it) has recently been used in other studies when examining reaching movements after stroke [32].. Our primary aim was to examine differences and similarities between two summary scores (EDist and MDist) in their ability to differentiate proprioceptive impairment in individuals with stroke from controls in a large patient sample. We hypothesized that using a composite proprioception score calculated from the Mahalanobis distance would more accurately identify impaired proprioception in individuals with stroke compared to a proprioception score calculated from the Euclidean distance.[…]


Continue —>  A composite robotic-based measure of upper limb proprioception | Journal of NeuroEngineering and Rehabilitation | Full Text


Fig. 1a KINARM robotic exoskeleton (BKIN Technologies, Kingston, ON, Canda). Subjects are seated in the wheelchair base with arms supported by the arm troughs. b Top-down view of the position matching task. The stroke affected arm was positioned by the robot (black targets, green lines) and subjects were required to mirror-match the target positions with their opposite hand (open targets, blue lines). Nine targets were matched to six times each for a total of 54 trials, presented in pseudorandom order. c Top-down view of an exemplar subject performing one trial of the kinesthetic matching task. The stroke affected arm was moved by the robot between two targets (green lines) and subjects were required to mirror match the speed, direction, and amplitude of movement as soon as they felt the robot move their arm (blue lines). The speed versus time profile represents the temporal aspects of the task, by measuring the response latency (time to initiation of the active arm movement) and peak speed ratio (difference between peak speeds of the passive (green) and active (blue) hands)

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[Abstract] Effect of elastic bandage on postural control in subjects with chronic ankle instability: a randomised clinical trial

Purpose: To report the immediate and prolonged (one week) effects of elastic bandage (EB) on balance control in subjects with chronic ankle instability.
Material and methods: Twenty-eight individuals successfully completed the study protocol, of whom 14 were randomly assigned to the EB group (7 men, 7 women) and 14 were assigned to the non-standardised tape (NST) group (9 men, 5 women). To objectively measure postural sway we used computerised dynamic posturography (CDP) with sensory organisation test (SOT) and unilateral stance (US) test. We analysed the following SOT parameters: the composite SOT score, the composite SOT strategy and the SOT condition 2 and its strategy. In addition, we studied the centre of gravity (COG) sway velocity with open eyes and close eyes during the US test.
Results: Repeated measures ANOVA showed a significant effect for time in composite SOT score (F= 34.98; p= <0.01), composite SOT strategy (F= 12.082; p= 0.02), and COG sway with open eyes (F= 3.382; p= 0.039) in EB group and NST group. Therefore, there were improvements in balance control after bandage applications (defined as better scores in SOT parameters and decreased COG sway in US test). However, no differences between groups were observed in the most relevant parameters.
Conclusions: This study did not observe differences between EB and NST during the follow-up in the majority of measurements. Several outcome measures for SOT and US tests improved in both groups immediately after bandage applications and after one week of use. EB of the ankle joint has no advantage as compared to the non-standardised tape.

Implications for rehabilitation

  • Elastic bandage (EB) of the ankle joint has no advantage as compared to the non-standardised tape.
  • The effects of the bandages could be due to a greater subjective sense of security.
  • It is important to be prudent with the use of bandage, since a greater sense of safety could also bring with it a greater risk of injury.
  • The application of the bandage on subjects with chronic ankle instability (CAI) should be prolonged and used alongside other physiotherapy treatments.

Source: Effect of elastic bandage on postural control in subjects with chronic ankle instability: a randomised clinical trial

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[ARTICLE] Strength of ~20-Hz Rebound and Motor Recovery After Stroke – Full Text


Background. Stroke is a major cause of disability worldwide, and effective rehabilitation is crucial to regain skills for independent living. Recently, novel therapeutic approaches manipulating the excitatory-inhibitory balance of the motor cortex have been introduced to boost recovery after stroke. However, stroke-induced neurophysiological changes of the motor cortex may vary despite of similar clinical symptoms. Therefore, better understanding of excitability changes after stroke is essential when developing and targeting novel therapeutic approaches.

Objective and Methods. We identified recovery-related alterations in motor cortex excitability after stroke using magnetoencephalography. Dynamics (suppression and rebound) of the ~20-Hz motor cortex rhythm were monitored during passive movement of the index finger in 23 stroke patients with upper limb paresis at acute phase, 1 month, and 1 year after stroke.

Results. After stroke, the strength of the ~20-Hz rebound to stimulation of both impaired and healthy hand was decreased with respect to the controls in the affected (AH) and unaffected (UH) hemispheres, and increased during recovery. Importantly, the rebound strength was lower than that of the controls in the AH and UH also to healthy-hand stimulation despite of intact afferent input. In the AH, the rebound strength to impaired-hand stimulation correlated with hand motor recovery.

Conclusions. Motor cortex excitability is increased bilaterally after stroke and decreases concomitantly with recovery. Motor cortex excitability changes are related to both alterations in local excitatory-inhibitory circuits and changes in afferent input. Fluent sensorimotor integration, which is closely coupled with excitability changes, seems to be a key factor for motor recovery.

Approximately 75% of stroke survivors suffer from permanent disability; thus, stroke causes significant human suffering and poses a major economic burden on the society.1 Recovery from stroke is based on brain’s plasticity. Studies in both animals and humans have shown that a period of enhanced plasticity occurs 1-4 weeks after stroke.25 After this sensitive period, the effectiveness of poststroke rehabilitation diminishes dramatically. Recently, there have been promising attempts to prolong or enhance the sensitive period with pharmacological manipulations68 or with noninvasive brain stimulation,9,10 both aiming at changing the cortical excitation-inhibition balance. However, patients with initially similar clinical symptoms may recover differently, possibly because the underlying neurophysiological changes vary between these patients. Thus, understanding and monitoring recovery-related neurophysiological mechanisms and their temporal evolution is crucial for developing efficient, personalized rehabilitation.

Fluent upper limb motor function is important for independency in daily life. Integration of proprioceptive and tactile input with motor plans forms the basis of smooth and precise movements.11 Afferent input mediates its effect on motor functions by modulating the motor cortex excitability.12 Accordingly, our previous study in healthy subjects indicated that proprioceptive input strongly modulates the ~20-Hz motor cortex rhythm, causing an initial suppression followed by a strong and robust rebound.13 Prior studies have suggested that the ~20-Hz rebound reflects deactivation or inhibition of the motor cortex.1417 Moreover, a combined magnetiencephalography (MEG) and magnetic resonance spectroscopy study showed that the ~20-Hz rebound strength is associated with the concentration of the inhibitory neurotransmitter GABA (γ-aminobutyric acid).18

To study alterations in motor cortex excitability after stroke and its association with motor recovery, we measured the dynamics of ~20-Hz motor cortex oscillations during passive movement of the index fingers in 23 stroke patients at the acute phase and during 1-year recovery. The motivation of this study was to understand the neurophysiological mechanisms underlying stroke recovery, which is instrumental for developing novel therapeutic interventions.

Continue —> Strength of ~20-Hz Rebound and Motor Recovery After Stroke – Feb 04, 2017


Figure 1. (A) Setup for passive movement. (B) Representative signals of 1 patient at T0 (1-7 days), T1 (1 month), and T2 (12 months) after stroke. Two upper rows: Magnetoencephalography signals from a single gradiometer channel (raw and filtered to 15-25 Hz over the primary sensorimotor cortex. The ~20-Hz modulation is observable even to a single movement. Third row: Magnitude of acceleration. Total duration of the movement highlighted in gray.

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[Abstract] Effect of functional electrical stimulation on the proprioception, motor function of the paretic upper limb, and patient quality of life: A case report – Journal of Hand Therapy


Functional electrical stimulation (FES) has shown to improve motor function of the affected side in stroke patients; however, the effects of FES on proprioception, the functional recovery of the paretic upper limb, and the patient quality of life (QoL) are not clear. The aim of the current case report was to determine whether FES can improve joint position sense and the scores on measurements of upper limb function and a QoL survey. The participant was assessed before and after 10 consecutive intervention sessions; in addition, the patient performed the training tasks in the workstation assisted by the FES device. Improvements in angles and time only in the affected wrist and enhancement in the Action Research Arm Test scores for both upper limbs were found after FES intervention. In addition, the patient’s health-related QoL measurements improved. FES could ameliorate the proprioceptive deficit and the activity limitations of a stroke survivor.

Source: Effect of functional electrical stimulation on the proprioception, motor function of the paretic upper limb, and patient quality of life: A case report – Journal of Hand Therapy

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[Abstract] Effect of functional electrical stimulation on the proprioception, motor function of the paretic upper limb, and patient quality of life: A case report – Journal of Hand Therapy

Functional electrical stimulation (FES) has shown to improve motor function of theaffected side in stroke patients; however, the effects of FES on proprioception, thefunctional recovery of the paretic upper limb, and the patient quality of life (QoL)are not clear. The aim of the current case report was to determine whether FES canimprove joint position sense and the scores on measurements of upper limb functionand a QoL survey. The participant was assessed before and after 10 consecutive interventionsessions; in addition, the patient performed the training tasks in the workstationassisted by the FES device.


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Source: Effect of functional electrical stimulation on the proprioception, motor function of the paretic upper limb, and patient quality of life: A case report – Journal of Hand Therapy

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[ARTICLE] Improving proprioceptive deficits after stroke through robot-assisted training of the upper limb: a pilot case report study – Neurocase


The purpose of this study was to determine whether a conventional robot-assisted therapy of the upper limb was able to improve proprioception and motor recovery of an individual after stroke who exhibited proprioceptive deficits.

After robotic sensorimotor training, significant changes were observed in kinematic performance variables. Two quantitative parameters evaluating position sense improved after training. Range of motion during shoulder and wrist flexion improved, but only wrist flexion remained improved at 3-month follow-up.

These preliminary results suggest that intensive robot-aided rehabilitation may play an important role in the recovery of sensory function. However, further studies are required to confirm these data.

Source: Improving proprioceptive deficits after stroke through robot-assisted training of the upper limb: a pilot case report study – Neurocase –

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[ARTICLE] The Effect of Transcutaneous Electrical Nerve Stimulation (TENS) Applied to the Foot and Ankle on Strength, Proprioception and Balance: A Preliminary Study – Full Text PDF


Background: Transcutaneous electrical nerve stimulation (TENS) promotes upper motor neuron excitability which has the potential to improve function. As a precursor to clinical trials, we investigated the potential efficacy of TENS on strength, proprioception and balance in healthy older adults.


  • Design: A paired-sample randomized crossover trial. No stimulation was the control.
  • Intervention: A one-off session of TENS (Modulated frequency: 70-130Hz, 5 second cycle) via a conductive sock.
  • Participants: 25 healthy older volunteers with no pre-existing balance or mobility limitations or contra-indications to TENS.
  • Outcomes: Dorsiflexor and plantarflexor strength and proprioception using an isokinetic dynamometer and balance (postural sway and forward reach test).
  • Analysis: Paired t-tests

Results: None of the parameters showed any significant changes with TENS (p>0.05).

Conclusions: The stimulation of cutaneous sensory nerve endings of the foot with the application of TENS showed no immediate effect on the ankle proprioception, lower leg muscle strength, and postural stability. The concern that TENS would have a distracting impact on sensation and balance was not supported according to these results.

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[ARTICLE] The effects of ramp gait exercise with PNF on stroke patients’ dynamic balance – Full Text PDF

[Purpose] This study examined the effects of ramp gait training using lower extremity patterns of proprioceptive neuromuscular facilitation (PNF) on chronic stroke patients’ dynamic balance ability.

[Subjects and Methods] In total, 30 stroke patients participated in this study, and they were assigned randomly and equally to an experimental group and a control group. The experimental group received exercise treatment for 30 min and ramp gait training with PNF for 30 min. The control group received exercise treatment for 30 min and ground gait training for 30 min. The interventions were conducted in 30 min sessions, three times per week for four week. The subjects were assessed with the Berg balance scale test, timed up and go test, and functional reach test before and after the experiment and the results were compared.

[Results] After the intervention, the BBS and FRT values had significantly increased and the TUG value had significantly decreased in the experimental group; however, the BBS, FRT, and TUG values showed no significant differences in the control group. In addition, differences between the two groups before the intervention and after the intervention were not significant.

[Conclusion] In conclusion, ramp gait training with PNF improved stroke patients’ dynamic balance ability, and a good outcome of ramp gait training with PNF is also expected for other neurological system disease patients.

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via The effects of ramp gait exercise with PNF on stroke patients’ dynamic balance.

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[WEB SITE] 12 Ways to Build Ankle Strength for Top Performance

What’s in the ankle? A physically active body must achieve a stable balance around each active joint for top performance. Ligaments connect the bones to each other, and provide much of the joint’s stability. Muscles are connected to bone by tendons, allowing for movement at the joints.

Although the ligaments connecting the bones in the ankle are necessary for proper function, there are several muscles that also help support the ankle during any type of activity. Building strength and proprioception, or special awareness, in these muscles helps to prevent injury and improve performance.

Why is it important to keep the ankle strong? When an athlete performs any movement–whether running or jumping–the ankle and surrounding muscles are put under a great deal of stress. If the ankle musculature is strong, the athlete can withstand greater force before an injury is sustained. In addition to decreasing ankle injuries, strengthening lower leg muscles will help prevent chronic conditions such as shin splints and Achilles tendonitis.

Proprioception Proprioception is the body’s ability to realize its place in space. If an athlete is moving into a position that could sprain his or her ankle, increased proprioception can decrease the risk by alerting the athlete to the danger. Proprioception can also increase an athlete’s performance. An athlete with superior balance and awareness will be able to control his or her body more effectively. This is especially true in sports like basketball and soccer, but valuable in all sports or training. Proprioceptive training is done with balance exercises.

Balance Training

  1. Standing on one leg: Hold for 30 seconds, working up to one minute per leg.
  2. Balance and catch: Standing on one leg, catch and throw a ball with a partner. Make certain to throw the ball right, left, high, low. Perform three sets of 30.
  3. One leg mini squats: On one leg do a half squat with the opposite leg out front for 10 reps, out to the side for 10 reps and behind for 10 reps. Repeat three times.

more —>  12 Ways to Build Ankle Strength for Top Performance | ACTIVE.

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